L  I  E)  R.AR_Y 
OF  THE 
U  N  I  VE:R.5  ITY 
or  ILLINOIS 

en. 03 

As3l 


THE 

INTERNATIONAL  ENCYCLOPAEDIA 

SUEGERY. 


VOL.  IV. 


Digitized  by  the  Internet  Archive 
in  2015 


https://archive.org/details/internationalenc04ashh_0 


THE 

INTERNATIONAL  ENCYCLOPiEDIA 

OF 

SUEG-EET 


A  SYSTEMATIC  TREATISE 

ON  THE 

THEORY  AND  PEACTICE  OF  SURGERY 

BY 

•  AUTHOES  OF  yARIOUS  l^ATIOT^S 

EDITED  BY 

JOHIS"  ASHHURST,  Jr.,  M.B. 

PROFESSOR  OF  CLINICAL  SURGERY  IN  THE  UNIVERSITY  OF  PENNSYLVANIA,   SURGEON   TO  THE 

PENNSYLVANIA  HOSPITAL,  ETC. 


ILLUSTRATED  WITH  CH ROMO-LITHOGRAPHS  AND  WOOD-CUTS 


m  SIX  VOLUMES 
VOL.  IV. 

REVISED  EDITION 


WILLIAM 


NEW  YORK 

WOOD  &  COMPAl^Y 
1889 


WILLIAM 


Copyright  : 
WOOD  & 
1  8  8  7. 


COMPANY, 


I 

THE  IITERNATIOML 
ENCYCLOPAEDIA  OF  SURGERY. 


ARTICLES  CONTAINED  IN  THE  FOURTH  VOLUME. 

Injuries  of  Bones.  By  John  H.  Packard,  M.D.,  Surgeon  to  the  Pennsyl- 
vania Hospital  and  to  St.  Joseph's  Hospital,  Philadelphia.         Page  1. 

Injuries  of  the  Back,  including  those  of  the  Spinal  Column,  Spinal 
Membranes,  and  Spinal  Cord.  By  John  A.  Lidell,  A.M.,  M.D., 
Late  Surgeon  to  Bellevue  Hospital,  ^^ew  York;  also  Late  Surgeon 
U.S.  Yolunteers  in  charge  of  Stanton  U.S.  Army  General  Hospital,  In- 
spector of  the  Medical  and  Hospital  Department  of  the  Army  of  the 
Potomac,  etc.  Page  261. 

Malformations  and  Diseases  of  the  Spine.  By  Frederick  Treves, 
F.R.C.S.,  Assistant  Surgeon  to,  and  Senior  Demonstrator  of  Surgery  at, 
the  London  Hospital.  page  487 

Injuries  and  Diseases  of  the  Eyes  and  their  Appendages.  By  E.  Wil- 
liams, M.D.,  Professor  of  Ophthalmology  in  Miami  Medical  College, 
Cincinnati.  Page  561. 

Injuries  and  Diseases  of  the  Ear.  By  Albert  H.  Buck,  M.D.,  of  is^ew 
York.  Page  681. 

Diseases  and  Injuries  of  the  ^s'ose  and  its  Accessory  Sinuses.  By  George 
M.  Lefferts,  M.A.,  M.D.,  Clinical  Professor  of  Laryngoscopy  and  Dis- 
eases of  the  Throat  in  the  College  of  Physicians  and  Surgeons,  Medical 
Department  of  Columbia  College,  '^qw  York ;  Consulting  Laryngoscopic 
Surgeon  to  St.  Luke's  Hospital,  etc.  ■  Page  751. 

(V) 


vi 


THE  INTERNATIONAL  ENCYCLOPEDIA  OF  SURGERY. 


Injuries  and  Diseases  of  the  Face,  Cheeks,  and  Lips.  By  Alfred  C. 
Post,  M.D.,  LL.D.,  Emeritus  Professor  of  Clinical  Surgery  in  the  Uni- 
versity of  the  City  of  ^ew  York  ;  Consulting  Surgeon  to  the  i^ew  York 
Hospital,  St.  Luke's  Hospital,  the  Presbyterian  Hospital,  and  the 
Woman's  State  Hospital.  Page  849. 

Injuries  and  Diseases  of  the  Mouth,  Fauces,  Tongue,  Palate,  and  Jaws. 
By  Christopher  Heath,  F.R.C.S.,  Holme  Professor  of  Clinical  Surgery 
in  University  College,  London,  and  Surgeon  to  University  College  Hos- 
pital. Page  885. 


Surgery  of  the  Teeth  and  Adjacent  Parts.  By  jSTorman  W.  Kingsley, 
M.D.S.,  D.D.S.,  Late  Professor  of  Dental  Art  and  Mechanirsm  in  the 
l^ew  York  College  of  Dentistry.  Page  943. 


ALPHABETICAL  LIST  OF  AUTHORS. 

(VOL.  IV.). 


ALBERT  H.  BUCK, 
GEORGE  E.  FENWICK, 
CHRISTOPHER  HEATH, 
NORMAN  W.  KINGSLEY, 
GEORGE  M.  LEFFERTS, 
JOHN  A.  LIDELL, 
JOHN  H.  PACKARD, 
ALFRED  C.  POST, 
FREDERICK  TREVES, 
E.  WILLIAMS. 


/4 


I 


CONTENTS. 


PAGE 

List  of  Articles  in  Vol.  IY.         .  .  .  .  .  »  v 

Alphabetical  List  of  Authors  in  Vol.  IV.         ,  ,  .  ,  vii 

List  of  Illustrations  .  .  «  .  .  .  .  xxi 


INJURIES  OF  BONES. 
By 

JOHN  H.  PACKARD,  M.D., 

surgeon  to  the  PENNSYLVANIA  HOSPITAL  AND  TO  ST.  JOSEPH'S  HOSPITAL,  PHILADELPHIA 

Fractures  .  .  .  .  .  .  .  .  .  1 

Causes  of  fracture  2 
Immediate  causes  .  .  .  .  .  .  .  .3 

Predisposing  causes  .......  3 

Spontaneous  fractures         .  .  .  .  .  .  .12 

Mechanism  of  the  production  of  fractures  .  .  .  .  .13 

Varieties  of  fracture       .  .  .  .  .  .  .  .16 

Simple  and  compound  fractures      .  .  .  ,  .  -  16 

Multiple,  comminuted,  and  impacted  fractures       .  .  .  .17 

Transverse,  oblique,  and  longitudinal  fractures      .  .  .  .18 

Varieties  of  incomplete  fracture     .  .  .  .  .  .19 

Epiphyseal  separations  or  disjunctions       .  .  .  '        .  .21 

Complicated  fractures        .  .  .  .  ,  .  .  21 

Intra-uterine  fractures       .  .  .  ,  .  .  .22 

Phenomena  and  symptoms  of  fracture    ......  24 

Constitutional  symptoms  accompanying  fracture  .  .  .  .28 

Diagnosis  of  fracture     .  .  .  .  .  .  .  .29 

Consequences  of  fracture  .  .  .      '     .  .  .  .30 

Thrombosis  and  embolism  .......  31 

Fat-embolism        .  .  ,  «  .  .  .  .31 

Stiffening  of  neighboring  joints  32 
Atrophy     .........  33 

Necrosis     .........  33 

Development  of  morbid  growths     .  .  .  .  .  .33 

Greneral  prognosis  of  fractures  34 
Repair  of  fractures        ...  .  .  .  ,  35 

(ix) 


X 


CONTENTS. 


PAGE 

Defects  in  the  process  of  repair  of  fractures      •  •  .  •  ,42 

Delayed  union       .           .           .           ,  ,  ,  ,  ,  43 

Dissolved  union      .           .           ,           ,  ,  ,  ,  •    .  45 

Fibrous  union        .           .           »           ,  ►  ,  ,  ,46 

Complete  separation  .  .  .  .  ,  ,  .46 
False  joint  or  pseudartlirosis  47 

Union  with  deformity        .           .           ,  ►  .  ,  ^  ,47 

General  treatment  of  fractures  50 

First  attentions  to  the  patient        •          ,  ,  ,  •  .  •  50 
Reduction  51 
Dressing  the  fracture  53 
Solidifying  dressings  54 

After-treatment  of  fractures          .          ,  •  »  ,  ,66 

Treatment  of  delayed  union  and  false  joint  ►  •  •  ,  58 

Treatment  of  union  with  deformity          •  .  »  ,  ,  65 

Fractures  of  special  bones  67 

Fractures  of  bones  of  face        .          .          .  ,  »  ,  .67 

Fractures  of  the  zygoma    .          ,          ,  ,  ,  ,  .       68  • 

Fractures  of  the  malar  bone        *  ,          .  ►  ,  »  ,  69 

Fractures  of  the  upper  jaw  ,  ,  ,  ,  ,  ,69 
Fractures  of  the  nasal  bones  70 

Fractures  of  the  lower  jaw           ,          .  ,  »  »  ,71 

Fractures  of  the  laryngeal  apparatus     .          ,  ,  ,  ,  .79 

Fractures  of  the  hyoid  bone          .          .  .  ,  .  ,79 

Fractures  of  the  laryngeal  cartilages         .  ,  ,  ,  ,  80~ 

Fractures  of  the  ribs,  costal  cartilages,  and  sternum     .  ,  .  ,  82 

Fractures  of  the  ribs         .          .          ,  ,  ,  ,  .82 
Fractures  of  the  costal  cartilages   ......  86 

Fractures  of  the  sternum  88 

Fractures  of  the  pelvis  ........  90 

Fractures  of  the  acetabulum  93 

Fractures  of  the  sacrum  .  ,  ,  .  ,  ,  ,93 
Fractures  of  the  coccyx  94 

Fractures  of  the  crista  ilii  .  ,  ,  ,  ,  ,94 
Fractures  of  the  ischium    .......  94 

Fractures  of  the  clavicle          .          .          .  ,  .  ,  .98 

Fractures  of  the  scapula           .           ,          .  .  .  .  .  113 

Fractures  of  the  humerus         .          ,          ,  .  ,  ,  ,117 

Fractures  of  the  upper  end  of  the  humerus  .  ,  ,  .  119 

Fractures  of  the  shaft  of  the  humerus       .  .  .  .  .125 

Fractures  of  the  lower  end  of  the  humerus  ,  ,  .  .  133 

Compound  fractures  of  the  lower  end  of  the  humerus  .  .146 

Fractures  of  the  bones  of  the  forearm  .           .  .  .  .  .147 

Fractures  of  the  olecranon            .           ,  .  ,  .  .148 

Fractures  of  the  coronoid  process  of  the  ulna  .  .  ,  .153 

Fractures  of  the  head  of  the  radius          ,  .  .  .  .155 

Fractures  of  the  elbow  ,  .  .  .  ,  .  .156 
Fractures  of  the  shaft  of  the  ulna             .....  158 


CONTENTS. 


XI 


Fractures  of  the  bones  of  the  forearm — 

Fractures  of  the  radius 

Fractures  of  the  lower  portion  of  the  radius 

Fractures  of  both  bones  of  the  forearm 
Fractures  of  the  hand  . 

Fractures  of  the  carpal  bones 

Fractures  of  the  metacarpal  bones 

Fractures  of  the  phalanges 
Fractures  of  the  lower  extremity 
Fractures  of  the  femur  . 

Fractures  of  the  upper  part  of  the  femur 

Separation  of  the  upper  epiphysis  of  the  femur 
Fracture  of  the  trochanter  major 
Fracture  of  the  lesser  trochanter 

Fractures  of  the  shaft  of  the  femur 

Separation  of  the  lower  epiphysis  of  the  femur 

Fractures  of  the  condyles  of  the  femur 
Fractures  of  the  patella 

Compound  fractures  of  the  patella 
Fractures  of  the  bones  of  the  leg 

P>actures  of  both  bones  of  the  leg 
Compound  fractures  of  the  leg 

Fractures  of  the  tibia 

Fractures  of  the  fibula 
Fractures  of  the  bones  of  the  foot 

Fractures  of  the  tarsal  bones 

Fractures  of  the  metatarsal  bones  . 

Fractures  -of  the  phalanges  of  the  toes 
Other  injuries  of  bones  . 


161 
165 
177 
182 
182 
183 
184 
185 
186 
187 
197 
198 
200 
200 
216 
217 
221 
236 
237 
238 
250 
251 
253 
255 
255 
258 
259 
259 


INJURIES  OF  THE  BACK, 
INCLUDING  THOSE  OF  THE  SPINAL  COLUMN,  SPINAL 
MEMBRANES,  AND  SPINAL  CORD. 

By 

JOHX  A.  LIDELL,  A.M.,  M.D., 

LATE  SURGEON  TO  BELLEVUE  HOSPITAL,  NEW  YORK  ;  ALSO  LATE  SURGEON  U.  S.  VOLUN- 
TEERS IN  CHARGE  OF  STANTON  U.  S.  ARMY  GENERAL  HOSPITAL  ;  INSPECTOR  OF  THE 
MEDICAL  AND  HOSPITAL  DEPARTMENT  OF  THE  ARMY  OF  THE  POTOMAC,  ETC. 


Injuries  of  the  back  ...... 

Injuries  of  the  soft  parts.  .  .  .  .  » 

Incised  and  punctured  flesh-wounds  of  the  back 

Incised  or  punctured  flesh-wounds  of  back  of  neck 
Incised  or  punctured  flesh-wounds  between  shoulder-blades 


261 
263 
263 
263 
268 


xii 


CONTENTS. 


PAGE 

Contusions  and  contused  wounds  of  the  back  ^  .  •271 

Lacerated  flesh-wounds  of  the  back  •  •  .  •  ,  273 

Gunshot  (small-arm)  flesh-wounds  of  the  back      *  ^  ,  .276 

Sprains,  twists,  and  wrenches  of  the  back  •  .  .  ,  280 

In  the  cervical  region  .  .  .  ^  ^  .282 

In  the  dorsal  region    .  .  .  ,  ,  ^  .280 

In  the  lumbar  region  .......  288 

Inflammation  of  vertebral  articulations  from  sprains,  twists,  or  wrenches  290 
Haematuria  from  contusions  and  sprains  of  the  back    .  .  .294 

Hemorrhage  into  the  vertebral  canal  from  sprains,  violent  flexures, 

and  twists,  or  wrenches  of  the  back  .  .  ,  .  300 

Injuries  of  the  vertebral  column  .  ,  .  ,  ,  303 

Dislocations  of  the  vertebrae  .....  303 

Dislocations  in  cervical  region  .....  307 

Dislocations  in  dorsal  and  lumbar  regions      ....  330 

Fractures  of  the  vertebrae  ......  340 

Gunshot  injuries  of  the  vertebrae    .....  ,  365 

Gunshot  contusions  of  the  spinal  column       ,  .  ,  .  360 

Gunshot  fractures  of  the  vertebrae      .  .  ,  .  .  368 

On  trephining  (so-called)  or  resection  of  the  spinal  column  .  .  378 

Injuries  of  the  spinal  membranes,  spinal  cord,  and  spinal  nerves  .  .  380 

Injuries  of  the  theca  vertebralis  and  meninges  of  the  spinal  cord  .  .  380 

Injuries  of  the  spinal  cord  and  spinal  nerves         .  .  .  .381 

Concussion  of  the  spinal  cord  .  .  .  .  .  382 

Contusion  of  the  spinal  cord  .  .  .  .  .  .  335 

Compression  of  the  spinal  cord  .  .  .  .  .  389 

Wounds  of  the  spinal  cord      .  .  .  ,  ,  ,  393 

Injuries  of  *the  spinal  nerves  .  .  ,  .  .  .  399 

Traumatic  inflammation  of  the  membranes  and  substance  of  the  spinal  cord  400 
Traumatic  spinal  meningitis    ......  401 

Traumatic  myelitis     .  .  .  .  .  ,  .  409 

Sacro-gluteal  eschars,  and  other  so-called  bedsores  arising  from  lesions  of 

the  spinal  cord  and  spinal  nerves  .  .  .  .  .417 

Disorders  of  the  urinary  organs  arising  from  lesions  of  the  spinal  cord     .  436 
Paralysis  of  the  bladder         .  .  .  .  .  .436 

Alterations  of  the  urinary  secretion    .....  439 

Inflammation  of  the  urinary  organs    .....  440 

Tympanites  arising  from  lesions  of  the  spinal  cord  .  .  .  445 

Priapism  in  consequence  of  spinal  injuries  .  .  .  .  447 

Injuries  of  the  sacrum  and  coccyx        ......  45O 

Fractures  of  the  sacrum     .......  450 

Gunshot  fractures  of  the  sacrum         .  .  .  .  .  453 

Simple  fractures  of  the  coccyx      .  ,  .  ...  460 

Gunshot  fractures  of  the  coccyx    o  .  .  .  ,  .  4Q2 

Coccygodynia  462 
Remote  effects  of  spinal  injuries,  railway-spine,  etc.      ....  463 

Railway-injuries  of  the  spine         ......  475 

Table  of  cases  of  resection  of  the  spinal  column  ....  486 


CONTENTS. 


xiii 


MALFOKMATIONS  AND  DISEASES  OF  THE  SPINE. 


ASSISTANT  SURGEON 


Bv 

FREDERICK  TREVES,  F.R.C.S., 

"O,  AND  SENIOR  DEMONSTRATOR  OF  ANATOMY  AT,  Till 
HOSPITAI.. 


Spina  bifida  .... 
False  spina  bifida 
Congenital  sacro-coccygeal  tumors 
Attached  foetus 

Congenital  tumors  with  foetal  remains 

Congenital  cystic  tumors 

Congenital  fatty,  fibrous,  and  libro-cellular  tumors 

Caudal  excrescences 
Antero-posterior  curvatures  of  the  spine  . 

Cyphosis  .... 

Lordosis  .... 

Rachitic  spine 
Spondylitis  deformans 
Caries  and  necrosis  of  the  spine  . 
Intervertebral  arthritis  . 
Pott's  disease  of  the  spine 

Etiology      .  .  .  . 

Pathological  anatomy 

Symptoms  of  Pott's  disease  . 

Diagnosis  of  Pott's  disease  . 

Progress,  prognosis,  etc. 

Treatment  of  Pott's  disease  . 
Disease  of  the  atlo-axoid  region  . 
Additional  remarks  on  spina  bifida  and  Pott's  disease 


LONDON 
PAGE 

487 
4DG 
497 
497 
498 
499 
501 
502 
502 
502 
506 
508 
509 
512 
513 
514 
515 
518 
530 
538 
541 
543 
551 
560 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR 

APPENDAGES. 

By 

E.  WILLIAMS,  M.D., 

PROFESSOR  OF    OPHTHALMOLOGY  IN  MIAMI    MEDICAL  COLLEGE,  CINCINNATI. 

PAGE 

Anatomy  of  the  eye       .  .  .  .  .  .  .  .561 

Diagnosis  of  ocular  affections  without  the  use  of  the  ophthalmoscope        .  .  577 


xiv 


CONTENTS. 


PAGE 

Injuries  and  diseases  of  the  orbit          ,  ,          -          ,  .581 

Tumors  of  the  orbit           .           -  ,           .                     *           „  584 

Injuries  of  the  eyeball    .           .           *  «           .           ,          ,           ,  ggQ 

Foreign  bodies  in  the  eye  .          «  .          ,          .          ,  .590 

Accidental  wounds  of  the  eyeball   .  .          ,           .           .  .592 

Penetrating  wounds  of  the  eye  593 

Sympathetic  ophthalmia     .          .  .          ,          ,          ,          ^  599 

Treatment  of  wounds  of  the  eyeball  •           •           .          .          .  604 

Diseases  of  the  conjunctiva       ......  ,  608 

Conjunctivitis        .           .           .  .           ,           ,         ^          ,  608 

Conjunctivitis  granulosa ;  granulous  lids ;  trachoma  •          .          ,  613 

Diseases  of  the  cornea   .          .          .  .          ,          ,          .  .619 

Keratitis     .           .           .           ,  ,           .          ,           ,          ^  gX9 

Staphyloma  625 

Diseases  of  the  iris        .           .           .  ,          «          ,          ,          ,  g27 

Malformations  of  the  iris    ,          .  •          *          ,          ,  .627 

Iritis  627 

Tumors  of  the  iris  630 

Cataract           .           .           .         '  .  .          ,          ,          ,          .  631 

Congenital  cataract  633 

Senile  cataract       .           .           .  ,          ,          ,          ^  .634 

Traumatic  cataract  635 

Treatment  of  cataract        •          .  ♦          .          ,          ,           .  635 
Glaucoma          •••...«•.  644 

Simple  glaucoma  646 

Acute  glaucoma     .          .          .  .          ,          ^          ,          ,  647 

Chronic  inflammatory  glaucoma     •  .          .           ,          .          ,  647 

Secondary  glaucoma          .           .  .          ,           ,          ^  .648 

Hemorrjiagic  glaucoma      .           .  .          ,           ^          ,  .648 

Treatment  of  glaucoma  648 

Strabismus        .  g^Q 

Definition  and  varieties      .  .          ,           ,          .           .  g^Q 
Causes  of  strabismus          .......  651 

Treatment  of  strabismus     .           .  .          .           *          .           ,  653 

Diseases  of  the  eyelids    .           .           .  ,          ,           ,          ,          ^  ggO 

Blepharitis            .           .           .  ,           .           ,          ,  -660 

Chalazion  662 

Sebaceous  tumors  of  the  eyelids     •  .          ,           ,          .          .  663 

Lagophthalmus  663 

Ptosis        .           .           .          .  ^ ,          •           .          .          ,  664 

Entropium  and  trichiasis  665 
Canthoplasty         ........  667 

Ectropium  ....  .          •           .          .          ♦  667 

Symblepharon        .           .           ,  .           ,           ,           ,  .668 

Erectile  tumors  of  the  eyelids        .  .          ,           ,          .          ,  669 

Diseases  of  the  tear-passages      .           .  ,          .          .           ,          ,  670 

Sipiphora  670 

Dacryocystitis  and  lachrymal  fistula  .          .          ,          ,  ,671 


CONTENTS. 


XV 


PAGE 

Ophthalmoscopic  diseases  .  .  •  .  •  •  .0/5 

Intra-ocular  tumors  .  .  .  .  •  •  •  .  G78 

Retinoscopy :  the  shadow  test     .  .  .  •  •  •  .  G79 

Explanation  of  plates  illustrating  Injuries  and  Diseases  of  the  Eyes        .  .  680 


INJURIES  AND  DISEASES  OF  THE  EAR. 

By 

ALBERT  H.  BUCK,  M.D., 

OF  NEW  YORK. 

Examination  of  the  patient  681 
Tests  of  the  hearing  power           .          .          .          .          •  .681 

Instruments  and  methods  of  examination   .  •  •  •  >  683 

Diseases  and  injuries  of  the  auricle       ......  687 

Eczema  of  the  auricle        .......  687 

Simple  diffuse  inflammation  of  the  auricle  .....  688 

Perichondritis  of  the  auricle  ......  688 

New  growths  of  the  auricle  ......  689 

Contusions  and  wounds  of  the  auricle        .  .  •  ..  .  690 

Deformities  of  the  auricle  .  .  .  .  •  •  •  f'91 

Frost-bite  and  burns  of  the  auricle  .  .  •  •  •  ,  ('»91 

Diseases  and  injuries  of  the  external  auditory  canal  ....  692 
Impacted  cerumen 

Furuncles  or  boils  of  the  external  auditory  canal    .  .  .  •  693 

Diffuse  inflammation  of  the  external  auditory  canal  .  .  .  694 

Ulcers,  polypoid  growths,  and  bone-caries  .  .  .  .  f  697 

Syphilitic  ulcers  and  condylomata 

Foreign  bodies  in  the  auditory  meatus       .  .  .  .  .  697 

Wounds  of  the  auditory  meatus      ......  698 

New  growths  of  the  external  auditory  canal  ....  699 

Methods  of  examining  the  middle  ear    .  .  .  .  .  .  699 

Diseases  of  the  middle  ear         .......  '^^^^ 

Non-suppurative  inflammation,  or  simple  catarrh    ....  '^^06 

Acute  purulent  inflammation  of  the  middle  ear       .  .  .  .711 

Chronic  purulent  inflammation  of  the  middle  ear   ....  719 

Diseases  of  the  mastoid  process  .  .     '      .  ...  •  •  "^^^ 

Subacute  condensing  mastoid  osteitis         .....  732 

Acute  diffuse  mastoid  osteitis         ......  733 

Chronic  ulcerative  inflammation  of  the  mastoid  antrum     .  .  .  738 

Significance  of  certain  phenomena  occasionally  met  with  in  diseases  of  the 

mastoid  process  .  .  •  •  •  •  .739 

Fractures  of  the  temporal  bone  .  .  .  •  •  •  .740 

Miscellaneous  conditions  of  the  ear  743 

Atrophy  of  the  membrana  tympani  .....  743 


xvi 


CONTENTS 


Miscellaneous  conditions  of  the  ear — 

Rupture  of  the  drum-membrane  ,  ,  ,  .  ,  .744 
Otalgia  745 

Affections  of  the  auditory  nerve  ,  .  ,  ,  ,  .745 

Explanation  of  plates  representing  appearances  of  membrana  tympani  in  health 
and  disease 


DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS 
ACCESSORY  SINUSES. 

By 

GEORGE  M.  LEFFERTS,  M.A.,  M.B., 

CLINICAL  PROFESSOR  OF  LARYNGOSCOPY  AND  DISEASES  OP  THE  THROAT  IN  THE 
COLLEGE   OF   PHYSICIANS   AND   SURGEONS,  MEDICAL  DEPARTMENT  OF 
COLUMBIA  COLLEGE,  NEW  YORK  ;    CONSULTING  LARYNGOSCOPIC 
SURGEON  TO  ST.  LUKE'S  HOSPITAL,  ETC. 


Introduction  ;  description  of  instruments,  etc.    .           .           .  ,  .751 

Instruments  for  examination  of  the  nasal  cavities  .  ,  ,  .751 

Anterior  rhinoscopy          .           .           .           ,  ,  .754 

Posterior  rhinoscopy          .           «          .           .  »  ,          ^  755 

Instruments  for  treating  affections  of  the  nasal  cavities  .  .  .758 
Methods  and  instruments  of  medication     .....  760 

Diseases  of  the  nasal  passages    .          .          ,          ,  ^  ^  .764 

Acute  coryza  764 

Idiosyncratic  coryza  767 

Chronic  coryza  768 

Hypertrophic  nasal  catarrh           ,          ,          •  .  ,  .770 

Atrophic  nasal  catarrh       .           .           ,          ^  ,  ,           ,  773 

Ozaena        .           .           .           .           ,           ,  ,  ,  .780 

Syphilitic  affections  of  the  nasal  passages   .          .  ,  ,          ,  782 

Ulcerative  diseases  of  the  mucous  membrane  of  the  nose  •  .          •  784 

Glanders    .....           .  •  •          ,  785 

I^upus        .........  785 

Tuberculosis  of  the  nasal  mucous  membrane          .  •  .          .  786 

Submucous  inflammation  and  abscess  of  the  nasal  cavity  .  .          .  787 

Profuse  watery  discharge  from  nostrils      .          ,  ,  ,          ,  787 

Epistaxis          .....          ;  .  ,  .788 

Stenosis  of  the  nasal  passages  794 

Closure  of  the  nostrils               .          ,           »          ,  ,  .  ,796 

Affections  of  the  septum           -          .          »          ,  ,  .          ,  797 

Extravasations  of  blood  in  septum  .  ,  .  .  .  797 
Abscess  of  septum  ...•».,.  797 

Syphilitic  induration  of  septum  798 

Submucous  infiltration  of  septum    .           ,          ,  ,  ^          ,  799 


CONTENTS.  xvii 
i 

pa(;e 

Affections  of  the  septum — 

Deflection  or  deviation  of  septum   .  .  •  •  ,  .71)9 

Fractures  and  dislocations  of  septum         .  .  •  •  ,801 

Tumors  of  septum  ......  801 

Congenital  occlusion  of  posterior  nares       .....  802 

Bifid  septum  ........  804 

Foreign  bodies  in  the  nasal  passages      ......  804 

Nasal  calculi,  or  rhinolites  80G 
Parasites  of  the  nasal  cavity      .......  808 

Tumors  of  the  nose       .  .  .  .  ,  .  .  .810 

External  tumors    .  .  .  .  .  .  .  .810 

Tumors  of  the  nasal  passages         .  .  ,  .  ,  .810 

Mucous  polypus,  or  myxoma         .  .  .  .  .  ,813 

Fibrous  polypus     .  .  .  .  .  .  .  ,817 

Cartilaginous  growths       .......  824 

Osseous  growths     .  .  .  .  .  ,  .  ,824 

Sarcomatous  growths         .  ,  .  .  .  ,  ,825 

Carcinoma  ........  825 

Other  nasal  tumors  82(5 
'  Neuroses  of  the  nasal  passages  •  .  .  ,  .  ,  ,826 

Anosmia    .........  827 

Hyperaesthesia       .  .  .  ,  .  .  ,  .829 

Sternutatio,  or  excessive  sneezing  .  .  ,  ,  ,  .  829 

Spasmodic  twitching  of  the  nose    ......  830 

Paralysis  of  the  nostrils     .......  830 

Nasal  cough,  and  the  existence  of  a  sensitive  reflex  area  in  the  nose  .  830 
Injuries  to  the  nose       .  .  .  .  .  .  ,  .831 

Fractures  of  the  nasal  bones          .  .  .  .  .  .831 

Dislocations  of  the  nasal  bones       ......  833 

Wounds  of  the  nose  .......  833 

Injuries  to  the  nose  with  lodgment  of  foreign  bodies         ...  833 
Burns  and  scalds  of  the  nose  834 
Deficiencies  and  deformities  of  the  nose  834 
Injuries  and  diseases  of  the  frontal  sinus  .....  83(> 

Fractures  of  the  frontal  sinus  836 
Inflammation  and  abscess  of  the  frontal  sinus        ....  y;3G 

Dropsy  of  the  frontal  sinus  .  .  .  .  .  .837 

Tumor  of  the  frontal  sinus  .  ,  .  .  .  ^  337 

Foreign  bodies  in  the  frontal  sinus  *  •  .  .  .  839 

Diseases  of  the  ethmoidal  cells  .......  839 

Diseases  of  the  antrum  of  Highmore      ......  840 

Inflammation  and  abscess  of  the  antrum    .  .  .  ,  .840 

Effusions  of  blood  in  the  antrum    ......  843 

Tumors  of  the  antrum        .......  843 

Diseases  of  the  skin  and  subcutaneous  tissues  of  the  nose  ,  .  .  843 

Note  on  pathology  of  hay -fever  .  .  .  .  .  ,  ,843 

Appendix :  Rhinoplastic  operations.  (By  the  Editor.)  ^  .  .  .  844 

VOL.  IV.— B. 


xviii 


CONTENTS. 


INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS, 

AND  LIPS. 


/  By 

ALFRED  C.  POST,  M.D.,  LL.D., 

EMERITUS  PKOFESSOU  OF  CLINICAL  SURGEKY  IN  THE  UNIVERSITY  OF  THE  CITY 
OF  NEW  YORK  ;   CONSULTING  SURGEON  TO  THE  NEW  YORK  HOSPITAL, 
ST.  LUKE'S  HOSPITAL,  THE  PRESBYTERIAN  HOSPITAL,  AJ^D 
THE  woman's  STATE  HOSPITAL. 


Wounds  of  the  cheek 
Facial  paralysis 

Salivary  fistula  .... 
Facial  neuralgia  or  tic  douloureux 
Burns  of  the  lips  and  cheeks 
Frostbite  of  the  lips  and  cheeks  .  . 
Facial  erysipelas 
Malformations  and  deformities  of  the  cheeks  and  lips 
Harelip  .  .  .  .  . 

Wounds  of  the  lips 
Furuncle  and  carbuncle  of  the  lips 
J'issures  of  the  labial  margin,  or  cracked  lips 
Ulcers  of  the  cheeks  and  lips 
Cancer  of  the  lip  .  .  . 

Telangeiectasis  of  the  lips 
Port-wine  marks 
Cysts  of  the  lips 
Tumors  of  the  lips 

Hirsuties  .... 
Cheiloplastic  operations 


PAGE 

841) 
850 
850 
851 
853 
853 
854 
854 
856 
860 
861 
861 
861 
862 
863 
864 
865 
865 
865 
865 


INJURIES  AND  DISEASES  OF  THE  MOUTH,  FAUCES, 
TONGUE,  PALATE,  AND  JAWS. 

By 

CHRISTOPHER  HEATH,  F.R.C.S., 

HOLME  PROFESSOR  OF  CLINICAL  SURGERY  IN  UNIVERSITY  COLLEGE,  LONDON,  AND 
SURGEON  TO  UNIVERSITY  COLLEGE  HOSPITAL. 

Injuries  of  the  mouth,  fauces,  and  tongue  .....  885 

Wounds  of  the  tongue  885 
Wounds  of  the  fauces         ....  iiiip. 


CONTENTS. 


XIX 


PAGE 

Injuries  of  the  mouth,  fauces,  and  tongue — 

Wounds  of  tlie  pharynx      .  .  .  .  .  .  .  88G 

Foreign  bodies  in  tiie  pharynx       ......  886 

Diseases  of  the  mouth  and  fauces  ......  886 

Inflammatory  affections  of  the  mouth  and  fauces    ....  886 

Stomatitis  .........  887 

Tonsillitis  .........  887 

Pharyngitis  ......  .  .  888 

lirysipelas  of  the  fauces  and  pharynx        .....  888 

Hyi)ertrophy  of  the  tonsils  .......  888 

Hypertrophy  of  the  uvula  .......  890 

Ulceration  of  the  tonsils     .  .  .  .  .  .  .801 

Tumors  of  the  tonsils         .  .  .  .  .  ...  801 

Follicular  disease  of  the  pharynx   ......  802 

Tumor  of  the  pharynx       .......  80.') 

Diseases  of  the  tongue  ........  803 

Tongue-tie  ........  893 

Ranula      .........  803 

Inflammatory  swelling  beneath  the  tongue  .  .  .  .  g<)4 

Hypertrophy  with  prolapse  of  the  tongue,  or  macroglossia  .  .  .  804 

Atrophy  of  the  tongue       .  .  .  .  .  .  .  895 

Naevus  of  the  tongue         .......  805 

Congenital  tumor  of  the  tongue      ......  895 

Lymphangeioma  of  the  tongue       .  .  .  .  .  .  805 

Glossitis     .........  895 

Abscess  of  the  tongue        .......  89(> 

Gummata  of  the  tongue     .....  .  .  896 

Chronic  glossitis     ........  896 

Alterations  in  the  cuticle  of  the  tongue      .....  897 

Simple  ulcer  of  the  larynx  .......  898 

Syphilitic  ulceration  of  the  tongue  ......  898 

Tubercular  ulceration  of  the  tongue  .  .  .  .  .  899 

Cancerous  ulceration  of  the  tongue  .....  899 

Operations  for  removal  of  the  tongue  .  ....  900 

Malformations  and  diseases  of  the  palate  .  .  .  .  .  907 

Cleft  palate  ........  907 

Staphyloraphy  .......  999 

Uranoplasty    .  .  .  .  .  .  .  .911 

Ulceration  of  the  palate      .  .  .  .  .  .  .913 

Nodes  of  the  hard  palate    .  .  .  .  .  .  .913 

Necrosis  of  the  hard  palate  .  .  .  .  .  .913 

Tumors  of  the  palate         .  .  .  .  .  .  .914 

Diseases  of  the  gums     .  .  .  .  .  .  .    •       .  915 

Hypertrophy  of  the  gums   .  .  .  .  .  .  .915 

Naevoid  condition  of  the  gums       ......  91.3 

Gingivitis  or  inflammation  of  the  gums      .  .  .  .  .916 

Spongy  condition  of  the  gums       .  .  .  .  .  .016 

Transparent  hypertrophy  of  the  gums        .  .  .  .  .910 


XX 


CONTENTS. 


Diseases  of  the  gums — 

Epulis  .... 

Myeloid  tumors  of  the  gums  • 

Papilloma  of  the  gums 

Ulceration  of  the  gums      ,  , 
Diseases  of  the  jaws 

Inflammatory  deposit  in  the  lower  jaws 

Alveolar  abscess 

Chronic  abscess  of  the  lower  jaw  . 
Suppuration  or  empyema  of  the  antrum 
Periostitis  and  necrosis  of  the  jaws  . 
Hyperostosis  of  the  jaws 
Odontoma  .... 
Cysts  of  the  jaws  . 
Tumors  of  the  jaws 

Fibroma  of  the  jaws  . 
Enchondroma  of  the  jaws 
Osteoma  of  the  jaws  . 
Pulsating  tumors  of  the  jaws  . 
Cystic  sarcoma  of  the  jaws 
Sarcoma  of  the  jaws 
Carcinoma  of  the  jaws 
Operations  on  the  jaws  . 

Removal  of  the  upper  jaw  .  , 
Removal  of  the  lower  jaw  , 
Closure  of  the  jaws        .  .  , 


917 

917 

917 

917 

918 

918 

918 

919 

919 

921 

923 

923 

924 

927 

927 

928 

928 

929 

929 

930 

933 

934 

935 

937 

938 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


By 

KORMAE^  W.  KimSLEY,  M.D.S.,  D.D.8., 

LATE  PROFESSOR  OF  DENTAL  ART  AND  MECHANISM  IN  THE  NEW  YORK  COLLEGE  OF 

DENTISTRY. 


Surgery  of  the  deciduous  teeth  * . 

Lancing  the  gums  . 

Extraction  of  deciduous  teeth 
Surgery  of  the  permanent  teeth 

Extraction  of  permanent  teeth 

Irregularities  of  the  teeth 

Dental  caries 

Toothache  . 

Alveolar  abscess 

Cystic  tumors  of  the  jaw 
Prothetic  dentistry 

Mechanical  treatment  of  lasions  of  the  palate 


943 
943 
944 
945 
945 
946 
949 
953 
954 
954 
955 
960 


LIST  OF  ILLUSTRATIONS. 


CHROMO-LITHOGRAPHS. 


PLATE 

XXVII.  Morbid  conditions  of  the  eye  . 
XXVIII.  Morbid  conditions  of  the  eye  as  seen  by  the  ophthalmoscope 
XXIX.  Normal  and  morbid  appearances  of  membrana  tympani 
XXX.  Normal  and  morbid  appearances  of  membrana  tympani 
XXXI.  Epithelioma  of  the  face  ,  ,  • 


PAGE 

670 
676 
747 
748 
861 


WOODCUTS. 


FIG. 

802.  Diagram  supposed  to  represent  extra-capsular  fracture  of  the  cervix  fem 

oris.    An  impossible  line  of  fracture 

803.  Comminuted  fracture  .... 

804.  Transverse,  oblique,  and  longitudinal  fractures 

805.  Longitudinal  fracture  of  tibia 

806.  Voluminous  callus  in  fractured  femur 

807.  Diagram  of  false  joint  .... 

808.  Smith's  apparatus  for  ununited  fracture  of  the  leg 

809.  Smith's  apparatus  for  ununited  fracture  of  the  thigh 

810.  Pancoast's  screw  for  ununited  fracture  .    .  • 

811.  Improved  drill  for  ununited  fracture 

812.  Blandin's  bone-director  .... 

813.  Taylor's  osteoclast  .  .  •  • 

814.  Fractures  of  the  lower  jaw 

815.  Comminuted  and  fissured  fracture  of  lower  jaw  . 

816.  Fracture  of  lower  jaw  at  angle 

817.  Fracture  of  lower  jaw  at  symphysis  and  angle 

818.  Fracture  of  sternum  .... 

819.  Multiple  fracture  of  the  pelvis 

820.  T-fracture  of  the  ilium  .... 

821.  Fracture  of  clavicle  with  downward  displacement  of  outer  fragment 

822.  Levis's  apparatus  for  fracture  of  the  clavicle 

823.  Sayre's  dressing  for  fractured  clavicle  ;  application  of  first  strip 

(  xxi 


J4 
17 
18 
19 
37 
47 
59 
59 
61 
61 
62 
65 
72 
73 
75 
75 
89 
92 
94 
101 
110 
111 


xxii 


LIST  OF  ILLUSTRATIONS. 


FIG. 

824. 
825. 
826. 
827. 


828. 

829. 
830. 

831. 

832. 
833, 
834. 
835. 
836, 
838. 

839. 
840. 
841. 
842. 
843. 
844. 
845. 
846. 
847. 
848. 
849. 
850. 
851. 
852. 
853. 
854. 
855. 
856. 
857. 

858 
859. 
860. 
861. 
862. 
863. 
864. 
865. 
866. 


Sayre*s  dressing  for  fractured  clavicle  completed.    Front  view 
The  same.    Back  view     .  .     "  , 

Fracture  of  the  scapula     •  .  .  .  . 

Application  of  compress  and  adhesive  plaster  to  overcome  deformity 

fracture  of  surgical  neck  of  humerus 
Diagram  illustrating  tilting  of  lower  fragment  in  fracture  of  humerus  near 

elbow    .  . 
Splint  of  binder's  board  for  fracture  of  lower  part  of  humerus 
Diagram  showing  transverse  fracture  of  lower  end  of  humerus  and  line  of 
epiphyseal  disjunction  ....... 

Diagram  of  T-fracture  of  lower  end  of  humerus  with  lines  of  fracture  of 

internal  condyle,  epitrochlea,  and  internal  condyle 
Fracture  of  lower  end  of  humerus 
Hinged  splint  for  elbow,  with  Stromeyer's  screw 
Bond's  splint  for  fracture  of  the  radius 
Coover's  splint  for  fracture  of  the  radius  . 
837  Levis's  splint  for  fractured  radius 

Ligamentous  bands  beneath  synovial  capsule  of  hip-joint.    (After  Ames 

bury.)     .  .  . 

Diagram  showing  lines  of  fracture  in  upper  part  of  femur 
Shortening  of  cervix  femoris  consecutive  to  fracture 
Diagram  showing  a  femur  united  by  a  bridge  of  callus 
Smith's  anterior  splint  for  treatment  of  fractured  thigh 
Hodgen's  suspension  splint  for  treatment  of  fractured  thigh 
Deformity  in  "  Pott's  fracture" 
Fracture-box  with  movable  sides  . 
Frame  for  suspending  fracture-box 
Wire  frame  for  suspending  leg  . 
Mode  of  supporting  leg  with  strips  of  bandage  . 
Side  splint  for  making  extension  in  fractures  of  the  leg 
Extension-splint  adjusted  .... 
Posterior  view  of  vertebral  column,  ribs,  etc.    (Sibson  ) 
Knife  -wound  of  dorsal  spine 

Arrow-head  impacted  in  fourth  dorsal  vertebra  . 
Shell-wound  of  the  back  .... 
Shell-wound  of  lumbar  and  gluteal  regions 
Cicatrix  of  same  wound  nine  years  afterwards 

Distribution  of  occipitalis  major,  occipitalis  minor,  and  auriculo-temporal 

nerves  to  scalp.    (Hilton.)  ... 
Course  of  sixth  and  seventii  dorsal  nerves.  (Hilton.) 
Forward  luxation  of  fourth  cervical  vertebra 
Fracture  witliout  displacement  of  fifth  cervical  vertebra 
Thermograph  of  fatal  case  of  fracture  of  fifth  cervical  vertebra 
Transverse  fracture  of  first  lumbar  vertebra 

Fractures  of  fifth,  sixth,  and  seventh  cervical  vertebrae.  (Hilton.) 
Caries  of  cervical  vertebrae  from  gunshot  contusion 
Gunshot  fracture  of  ninth  dorsal  vertebra 
Gunsliot  fracture  of  third  lumbar  vertebra 


LIST  OF  ILLUSTRATIONS.  Xxili 

FIG.  PAGE 

867.  Gunshot  perforation  of  first  lumbar  vertebra  ....  SiV.) 

868.  Interior  view  of  vertebrae  shown  in  preceding  illustration  .           ,  370 

869.  Gunshot  perforation  of  lumbar  vertebrae  .....  370 

870.  Gunshot  fracture  of  dorsal  vertebrae  .   *        .           .           .  .371 

871.  Musket-ball  in  spinal  canal  .           .           ...           .  ,371 

H72.  Gunshot  fracture  of  seventh  dorsal  vertebra         .           .           .  .371 

873.  Pistol-ball  lodged  in  last  dorsal  vertebra    .....  372 

874.  Gunshot  fractures  of  last  dorsal  and  first  lumbar  vertebrae  .           .  372 

875.  Musket-ball  imbedded  in  intervertebral  substance  .          .          •  372 

876.  Gunshot-fracture  of  second  lumbar  vertebra  .          .           .  .376 

877.  Spinal  cord  and  roots  of  spinal  nerves,  etc.  ....  382 

878.  Musket-ball  compressing  cord  in  lumbar  region    ....  393 

879.  Laceration  of  spinal  membranes  from  fracture  of  first  lumbar  vertebra    .  397 

880.  Pistol-ball  lodged  in  spinal  foramen  of  fourth  lumbar  vertebra     «  .  404 

881.  Efi'ects  of  traumatic  spinal  meningitis  and  myelitis  .          .          ,  407 

882.  Sacro-gluteal  eschar  of  neuropathic  origin  ....  422 

883.  Penetration  of  sacral  canal  by  bed-sores  ,  .          .          .  .431 

884.  Shot-fracture  of  sacrum  and  ilium  .....  455 

885.  Shot  perforation  of  sacrum  ......  455 

886.  Gunshot  fracture  of  sacrum  .          .          .          .          .          .  455 

887.  Sacrum  grooved  by  musket-ball    ......  455 

888.  Sacrum  grooved  transversely  by  musket-ball  -          .          -  .456 

889.  Ball  impacted  in  left  upper  sacral  foramen  -          .          .          .  456 

890.  Posterior  view  of  same  specimen  .  .  v         .          .          «          .  456 

891.  Sacrum  with  ball  impacted  ......  457 

892.  Shot  fracture  of  sacrum    .......  457 

893.  Shot  penetration  of  sacral  canal    ......  458 

894.  Gunshot  perforation  of  sacrum      ......  458 

895.  Ball  lodged  in  spinal  canal  .           .                     .          .  .459 

896.  Conoidal  ball  extracted  from  sacrum  with  ramrod  .           .           .  460 

897.  Distribution  of  nerves  to  sacrum,  coccyx,  etc.    (Hilton.)  .          .  462 

898.  Lower  part  of  spinal  cord  and  distribution  of  spinal  nerves.    (Swan  and 

Hilton.)  ........  466 

899.  Taylor's  apparatus  for  treatment  of  Pott's  disease  of  spine  .           .  545 

900.  Suspension  of  patient  for  application  of  rigid  jacket  by  Sayre's  method   .  546 

901.  Tripod  for  suspending  patient  in  applying  rigid  jacket     .  .           .  546 

902.  Jury  mast  for  support  of  head  in  cases  of  Pott's  disease  above  the  third 

dorsal  vertebra  550 

903.  Frontal  section  of  adult  skull  through  middle  of  orbit.    (After  Merkel.)   .  562 

904.  Horizontal  section  through  orbit  of  adult  male.    (After  Gerlach.)  .  563 

905.  Transverse  section  of  optic  nerve.    (After  Merkel.)  .           .           .  564 

906.  Longitudinal  section  of  entrance  of  optic  nerve  into  eyeball.  (After  Merkel.)  564 

907.  Cross-section  of  optic  nerve  at  point  of  passage  through  lamina  cribosa. 

(After  Merkel.)  .  .  .  .  .  .  -564 

908.  Diagram  showing  shape  of  eyeball.     (After  Merkel.)       .  .           .  565 

909.  Sagittal  section  of  eyeball.    (After  Merkel.)  ....  567 

910.  Meridional  section  of  anterior  half  of  eyeball.    (After  Gerlach.)  .  .  567 

911.  Ciliary  muscle.    (After  IwanofF and  Arnold.)      ....  568 


xxiv 


LIST  OF  ILLUSTRATIONS. 


FIG. 

912. 

913. 

914. 

915. 

916. 

917. 

918. 

919. 
920. 
921. 

922. 
923, 
925. 
926, 
928. 
929. 
930. 
931. 
932. 
933. 
934. 
935. 
936. 
937. 
938. 

93a. 

940- 
941. 
942. 
943. 
944. 
945. 
946. 
947. 
948, 
950. 
95L 
952. 
953. 
954. 
955. 
956. 
957. 
958. 
959. 
960. 
961. 
962. 


Equatorial  section  of  eyeball,  posterior  segment.    (After  Merkel  ) 
Diagrammatic  section  of  retina.    (After  Shultze  and  Schwalbe  ) 
Diagrammatic  horizontal  section  of  eye.    (After  Merkel  ) 
Eye  in  normal  situation  in  orbit,  seen  from  in  front.    (After  Merkel  ) 
Eyehds  closed  ;  skin  removed  to  show  tarsal  glands.    (After  Merkel  ) 
Orbicularis  and  neighboring  muscles.    (After  Merkel.) 


Fibro-sarcoma  of  orbit  causing  exophthalmus 
.  Spud  for  removing  foreign  bodies  from  cornea  '. 
Broad  needle  for  removing  foreign  bodies  from  cornea 
Liebreich's  spring-stop  speculum  for  separating  eyelids 
Fixation  forceps  . 

924  Bowman's  stop-needles,  curved  and  straight 
Grooved  needle  for  fluid  cataract  . 
927  Jaeger's  keratomes    .  .  • 

Cystotome 

Paracentesis  needle  and  curette  . 
Graefe's  cataract  knives  . 
Graefe's  tortoise-shell  spoon 
Different  forms  of  iris  forceps 
Iris  scissors 

Wecker's  scissors,  modified  by  Keyser 
Strabismus  hooks 
Strabismus  scissors 
Sands's  needle-holder 
Ring-forceps  for  tumors  of  eyelid  . 
Weber's  probe-knife 
Bowman's  probes  . 
Williams's  bulb-pointed  probes 
Section  of  eyeball  showing  intra-ocular  tumor 
Wilde's  ear-speculum 
Forehead-mirror  . 
Forehead-mirror ;  profile  view 
Forehead-mirror  in  actual  use 
Angular  forceps  . 
949   Curette  and  slender  probe  . 
Auricle.    (After  Urbantschitsch.) 
Politzer's  apparatus 
Hard-rubber  curved  nose-piece 
Eustachian  catheter 
Ear-douche 

•  • 

Hard-rubber  pronged  ear-nozzle  . 
Middle-ear  pipette 
Blake's  snare 

Proper  method  of  holding  Blake's  snare 
Mastoid  process  of  ciiild  . 
Mastoid  process  of  adult  . 
Extensive  distribution  of  mastoid  cells 
Relations  of  facial  canal  to  middle-ear  and  mastoid  cells 


LIST  OF  ILLUSTRATIONS. 


XXV 


963.  Henle's  diagram  showing  relations  of  parts  of  temporal  bone 

964.  Strong  periosteum  knife    .  .  •  •  • 

965.  Mastoid  drills 

966.  Forehead-reflector  .  .  -  •  • 

967.  Illwminating  apparatus  for  rhinoscopy 

968.  Robert  and  Collin's  nasal  speculum 

969.  Fraenkel's  nasal  speculum  .  .  .  - 

970.  Nasal  speculum 

971.  Elsberg's  nasal  speculum  ,  .  .  -  • 

972.  Thudichum's  nasal  speculum        .  .  -  - 

973.  Rhinoscopic  mirror  .  .  •  '  - 

974.  Turck's  tongue-spatula      .  -  -  '  • 

975.  Anterior  rhinoscopy         .  •  -  -  - 

976.  Posterior  rhinoscopy         .  .  .  •  - 

977.  The  rhinoscopic  image      .  .  -  •  - 

978.  The  rhinoscopic  image      .  •  •  •  ' 

979.  Vault  of  pharynx  as  seen  by  posterior  rhinoscopy  . 

980.  ■  Nasal  douche 

981.  Nasal  spray -apparatus       .  .  •  •  ' 

982.  Posterior  nasal  syringe      .  .  •  -  • 
983*.  Posterior  nasal  tube  fitted  to  Davidson's  syringe  . 

984.  Compressed-air  atomizer  or  spray-producer 

985.  Spray-tube  with  patent  cut-off      .  .  -  - 

986.  Atomizer  throwing  spray  downward 

987.  Another  form  of  atomizer  .  .  -  -  - 

988.  Insufflator  for  anterior  nares  .  .  .  - 
089.  Insufflator  for  posterior  nares        .           *  -  - 

990.  Robinson's  tube  for  insufflation  of  nares  . 

991.  Smith's  guarded  canula  for  applying  nitric  acid  to  nasal  passages 

992.  993  Nasal  electrodes        .  .  .  .  • 

994.  Jarvis's  wire  ecraseur       .  .  .  •  • 

995.  Nasal  curette 

996.  Double  lip.    (After  Agnew.)        .  .  • 

997.  998   Operation  for  harelip  with  divergent  margins 
999,  1000.  Malgaigne's  operation  for  harelip 

1001,  1002.  Operation  for  harelip  with  marked  irregularity  of  sides 

1003.  Telangeiectasis  of  lip  strangulated  with  pins  and  ligature  . 

1004.  Application  of  subcutaneous  Hgature 

1005. "  Telangeiectasis  of  lip  strangulated  by  ligatures  crossing  each  other 

angles 

1006.  1007.  Dieffenbach's  operation  for  restoration  of  upper  lip  . 
1008,  1009.  Sedillot's  operation  for  restoration  of  upper  lip 
1010,  1011.  Buchanan's  operation  for  restoration  of  louver  lip  . 
1012,  1013.  Buck's  operation  for  restoration  of  lower  lip. 
1014,  1015,  1016.  Buck's  operation  for  restoration  of  upper  lip  . 
1017,  1018.  Cheiloplasty  of  lower  lip.    (After  Serre.)  . 
1019,  1020.  Cheiloplasty  of  loAver  lip  and  angle  of  mouth.    (After  Serre.) 
1021,  1022.  Cheiloplasty  of  lower  lip  and  angle  of  mouth.    (After  Serre.) 


at  rl<r 


ht 


PAGE 

734 

736 

737 

752 

752 

752 

752 

752 

753 

753 

753 

753 

754 

755 

757 

758 

758 

758 

759 

760 

760 

761 

762 

762 

762 

763 

763 

764 

774 

776 

777 

777 

855 

858 

859 

859 

863 

863 

864 
867 
867 
868 
870 
871 
872 
872 
873 


xxvi 


LIST  OF  ILLUSTRATIONS. 


FIG. 

1023, 
1025, 
1027, 
1029, 


1031, 
1033, 
1035, 
1037, 
1039, 
1041, 
1043, 
1045, 
1047, 
1049, 
1051, 
1053, 
1055, 
1057, 
1059, 
1061, 

1063. 

1065. 
1066. 
1067. 
1068. 
1069. 
1070. 
1071. 
1072. 
1073. 
1074. 


1024.  Restoration  of  lower  lip.    (After  Serre.)         .  . 
1026.  Restoration  of  left  half  of  edge  of  lower  lip.    (After  Serre.) 
1028.  Operation  for  growth  involving  right  commissure  of  lips.  (After  Serre.) 
1030.  Operation  for  cicatricial  contraction  of  right  angle  of  mouth.  (After 

Serre.)  ..... 
1032.  Restoration  of  upper  lip  and  ala  nasi.    (After  Serre.) 
1034.  Reconstruction  of  buccal  orifice.    (After  Serre.) 
1036.  Burow's  plastic  operation    .  .  .  , 

1038.  Restoration  of  edge  of  lower  lip.    (After  Szymanowski.) 
1040.  Restoration  of  whole  loAver  lip.    (After  Szymanowski.) 
1042.  Restoration  of  lower  lip.    (After  Szymanowski.) 
1044.  Restoration  of  lower  lip.    (After  Szymanowski.) 
1046.  Reconstruction  of  lower  lip.    (  After  Szymanowski.). 
1048.  Reconstruction  of  lower  lip.    (After  Szymanowski.) 
1050.  Restoration  of  border  of  lower  lip.    (  After  Szymanowski.) 
1052.  Restoration  of  lower  lip  and  angle  of  mouth.    (After  Szymanowski.) 
1054.  Operation  for  fissure  of  upper  lip.    (After  Szymanowski.) 
1056.  Restoration  of  upper  lip.    (Modified  from  Szymanowski.) 
1058.  Operation  for  cleft  of  upper  lip.    (After  Szymanowski.) 
1060.  Restoration  of  both  lips.    (After  Szymanowski.)  . 
1062.  Restoration  of  parts  of  both  lips  and  angle  of  mouth.    (After  Szy- 
manowski.)        .  . 

1064.  Mode  of  repairing  deficiency  of  edge  of  lower  Jip.    (After  Szyman- 
owski.) .  .  . 
Volsella  forceps 
Fahnestock's  tonsillotome  . 
Billings's  tonsillotome 
Gross's  tonsil  ecraseur 
Uvula  scissors 
Wire  ecraseur 
Chain  ecraseur 

Mears's  mouth-gag  for  staphylorraphy 
Tubular  needle 
Coghill's  wire-twister 


PAGE 

873 
874 
874 


THE  INTERNATIONAL 


ENCYCLOPEDIA  OF  SURGERY. 


INJURIES  OF  BONES. 

BY 

JOHN  H.  PACKARD,  M.D. 

SURGEON  TO  THE  PENNSYLVANIA  HOSPITAL  AND  TO  ST.  JOSEPH'S  HOSPITAL,  PHILADELPHIA. 


Fractures. 

The  main  function  of  the  bony  skeleton  and  of  its  accessory  cartilages  is 
passively  mechanical.^  They  constitute  a  framework  for  the  suspension  and 
protection  of  the  viscera,  and  for  the  utilization  of  muscular  force  in  the  per- 
formance of  all  voluntary  movements,  as  well  as  in  the  automatic  function  of 
breathing.  By  their  construction  and  arrangement,  the  bones  and  cartilages 
are  adapted  to  bear  all  the  strain  put  upon  them  in  the  ordinary  course  of 
life,  but  they  are  sometimes  subjected  to  violence  beyond  their  power  of 
resistance,  and  fracture  or  breakage  is  the  result. 

A  very  large  proportion  of  the  cases  which  present  themselves  to  the  surgeon, 
whether  in  hospital  or  in  private  practice,  are  those  of  broken  bones  ;  and  for 
this  reason,  as  well  as  on  account  of  the  gravity  of  the  conditions  often  in- 
volved, and  the  probable  permanency  of  any  untoward  result,  it  is  a  matter 
of  much  moment  that  this  subject  should  be  thoroughly  studied,  and  in  the 
most  practical  manner.  An  accurate  acquaintance  with  normal  anatomy  is 
essential ;  and  no  opportunity  of  examining  fractures,  whether  in  the  living 
body  or  in  the  dead,  in  recent  or  in  old  specimens,  should  be  neglected.  Clin- 
ical experience,  such  as  is  gained  in  hospitals,  is  of  great  value,  as  are  also 
mechanical  ability  and  dexterity  in  the  adaptation  and  application  of  appa- 
ratus. The  habit  of  gentleness  of  touch,  and  of  firm  and  skilful  handling  of 
injured  parts,  should  be  sedulously  cultivated. 

It  may  be  said  further,  that  out  of  no  other  class  of  cases  have  arisen  so 
many  suits  for  malpractice.    The  reason  of  this  is  not  difficult  to  perceive. 

1  Rindfleiscli  lias  recently  pointed  out  the  important  part  taken  by  the  marrow  of  bones  in  the 
formation  of  the  red  corpuscles  of  the  blood  ;  but  this  has  not  yet  been  shown  to  have  any 
surgical  interest. 

VOL.  IV. — 1  (  1  ) 


2 


INJURIES  OF  BONES. 


Lameness  m  the  lower  extremity  or  disability  iu  the  upper,  will  fix  the  atten- 
tion of  the  patient,  and  attract  the  notice  of  others.  Sometimes  the  surgeon 
may  have  indiscreetly  promised,  during  the  treatment,  perfect  recovery  or 
may  have  over  ooked  restlessness,  or  even  disobedience,  on  the  part  ot"  the 
patient.  Sometimes  the  latter  is  struck  with  the  more  favorable  result  of 
other  cases  as  compared  with  his  own  ;  and  sometimes,  unfortunately  the 
idea  of  bringing  suit  is  suggested  to  him  by  meddling  friends  or  pettifogging 
lawyers.  But  whatever  may  be  the  origin  of  such  proceedings,  thefail 
always  annoying  and  vexatious,  often  expensive,  and  generally  injurious  to 
the_  surgeon,  even  if  the  verdict  should  be  in  his  favoi?  Hencl  it  is  highly 
desirable  that  they  should  be  avoided,  as  far  as  possible,  by  th^  exercise  of 
the  utmost  skill,  care,  and  discretion,  in  the  management  of  the  injuries  now 
111  Question. 

There  are  some  fractures  which  are  serious  by  reason  of  the  danger  of  loss 
or  impairment  of  the  function  of  the  bone  itself,  and  in  which,  therefore  the 
main  object  of  the  surgeon  s  treatment  must  be  the  most  perfect  possible 
restoration  of  the  normal  form  and  relations  of  the  bone.  SAch  are  those  of 
the  humerus,  the  femur,  and  the  bones  of  the  leg  or  fo*-earm 

Others  derive  their  gravity  chiefly  from  the  risk  of  involvement  of  con- 
tained viscera ;  such  are  those  of  the  skull,  vertehr*,'  ribs,  and  pelvis.  Even 
i  e  bones  there  are  sometimes  such  injuries  inflicted  upon 

the  ne  ghbonng  soft  parts  bloodvessels,  or  nerves,  or  both,  as  to  produce  the 
gravest  results  Cases  of  this  kind  will  be  noted  in  connection  with  fractures, 
especially,  of  the  clavicle,  femur,  and  bones  of  the  leg 

somlhn  ^^l  ^'"^^     "^^"f  *°  fv^ctnre;  but,  as  will  further  appear, 

some  bones  are  much  more  exposed,  and  much  more  frequently  broken,  than 
others  And  just  as  the  normal  function  of  these  organs  is  carried  on  in  exact 
accordance  with  the  laws  of  mechanics,  so  in  their  fractures  the  workin^of 
the  same  laws  may  be  traced.  In  the  general  discussion  of  the  whole  subTect, 
hactures  of  the  long  bones  will  be  kept  in  view,  not  only  because  they  are 
moie  frequent  but  because  they  aflbrd  the  best  and  most  convenient  illustra- 
tions of  the  phenomena  presented. 

r>.Z^  P^'^^jfo'".  study  in  regard  to  these  injuries  are:  their  causes;  the 
mechanism  of  their  production;  their  varieties ;  the  phenomena  and  symptoms 
attending  them their  diagnosis;  their  consequences;  their  complications; 
the  mode  of  their  repair  and  deficiencies  in  this  process;  their  prognosis; 
and  the  principles  of  their  treatment.  All  these  topics  will  be  first  taken  up 
111  a  general  way,  and  they  will  subsequently  be  considered  in  reference  to  the 
severa  hones. 


Causes  op  Fkacture. 


Fractures  are  always  caused  by  force,  and  by  adequate  force ;  althouo-h 
under  certain  circumstances  it  may  and  does  seem  as  if  the  bones  gave  wav 
as  It  were  of  themselves  Hence  the  term  "spontaneous"  has  been  used! 
out,  as  will  be  hereafter  shown,  it  is  not  strictly  correct. 

The  causes  of  fracture  may  be  divided  into  immediate  and  predisposing. 
Under  the  former  head  are  embraced  the  various  forms  of  violence  under 
which  bones  give  way  while  under  the  latter  belong  all  conditions,  whether 
of  the  body  at  large,  of  the  skeleton,  or  of  the  individual  bones,  which  expose 
tne  latter  to  fracturing  forces,  or  make  them  more  ready  to  yield. 

i,erv!.''!^o,'r«  "i  *''",f °f       ^'■'''^■■^       '°  8«n«™lly  attended  with  lesions  of  the  great 

interest    hat  tl---^^^  "«  'V'T''''""'       ^""'^  magnitude  and  such  special 

interest,  ttiat  these  subjects  will  be  hereafter  dealt  with  in  separate  articles. 


CAUSES  OF  FRACTURE. 


3 


Immediate  Causes.— It  would  be  vain  to  try  to  enumerate  all  the  special 
forms  of  violence  by  which,  in  the  complicated  conditions  of  human  life,  bones 
are  broken.  But  they  may  be  classilied  under  four  general  heads :  direct  and 
indirect  violence,  muscular  action,  and  avulsion. 

Direct  violence  is  that  wdiich  is  inflicted  upon  the  bone  at  the  point  where 
the  fracture  occurs ;  such  as  a  blow  with  a  stick  or  a  stone,  the  passage  of  a 
wheel  over  a  limb,  or  the  fall  of  a  heavy  body  upon  it.  Here  the  momentum 
of  the  impinging  mass  is  expended  in  overcoming  the  resistance  of  a  portion 

of  the  bony  tissue.  .         ,        ,  i  x-  ^-u 

Indirect  violence  is  that  which  is  transmitted  through  some  length  ot  the 
bone,  which  becomes  an  overtaxed  lever ;  as,  for  example,  when  a  man  falls 
from' a  height,  alighting  upon  his  feet,  and  the  femur  gives  way  at  some  por- 
tion of  its  shaft.  Here  the  resistance  of  the  ground,  acting  through  the  loot 
and  leo-,  fixes  the  low^er  end  of  the  femur,  while  the  momentum  of  the  body 
continues  to  drive  the  upper  end  of  this  bone  downward ;  and  the  natural 
curve  of  the  shaft  is  increased  until  its  texture  gives  way.  ^  ^ 

As  will  presently  be  further  shown,  there  is  often  also  an  element  of  twisting 
added  to  the  leverage.  .  -,     ,  ^      -  ^  ^ 

Muscular  action,  when  it  causes  fracture,  must  either  be  extremely  violent 
and  sudden,  as  in  cases  of  convulsion  or  very  powerful  effort,  or  the  bone  must 
be  taken  at  a  disadvantage,  as  wdll  be  further  explained  in  speaking  of  the 
mechanism  of  fractures  generally,  as  well  as  of  those  of  special  bones.  _ 

Fractures  by  avulsion  are  those  in  which  a  small  fragment  of  bone  is  torn 
away  by  the  stress  put  upon  ligamentous  structures  attached  to  it.  They  are 
more  generally  known  at  present  as  "sprain-fractures,"  and^  the  observations 
to  be  made  concerning  them  will  be  found  in  connection  with  fractures  close 
to  the  joints,  especially  of  the  knee  and  ankle.  ^ 

So  many  illustrations  of  the  foregoing  statements  will  be  given  m  dis- 
cussing the  mechanism  of  fractures,  as  well  as  in  describing  these  injuries  as 
affecting  special  bones,  that  I  shall  dwell  no  further  upon  them  here ;  only 
sayins:  that  in  very  many  cases  the  agency  of  indirect  force  is  greatly  aided 
by  the  occurrence  of  muscular  contraction  at  the  moment  of  its  application. 

Predisposing  Causes.— Among  the  general  diseases  which  have  been  thus 
ranked  by  authors,  there  are  some  which  admit  of  much  doubt.  Thus,  in 
regard  to  gout,  rheumatism,  and  scurvy,  there  seems  to  be  no  evidence  that  they 
render  the  bones  more  fragile ;  although  they  may  possibly,  by  crippling  or 
weakening  the  limbs,  make  their  victims  clumsy,  and  less  able  to  avoid  falls 
or  escape  violence.  Yet  it  must  be  remembered  that  persons  so  diseased  are 
obliged  to  take  care  of  themselves,  and  to  abstain  from  the  active  pursuits 
which  would  involve  exposure  to  the  usual  fracturing  forces. 

Scrofula  has  been  placed  by  some  writers  in  this  category,  but  there  is  really 
no  evidence  that  it  belongs  here.  Its  subjects  are  sometimes  ill-nourished 
and  feeble,  and  very  probably  their  bones,  like  their  tissues  generally,  are  weak 
in  texture.  But  many  of  the  scrofulous  are  strong  and  active,  and  in  these 
there  is  no  sign  of  fragility  of  the  bones  unless  they  are  actually  affected 
with  caries,  and  not  alwavs  then.  After  healing  has  taken  place,  the  osseous 
tissue  hceras  to  be  condensed  and  peculiarly  firm,  although  the  constitutional 
disorder  may  be  still  progressing. 

Syphilis  has  been  assigned  by  some  as  a  cause  of  fragility  of  the  bones,  and 
many  cases  are  on  record  in  support  of  their  views.  Berkeley  Hill^  mentions 
a  case  in  which  a  child  six  weeks  old,  already  affected  with  snuffles  and  pem- 
phigus, sustained  a  fracture  of  the  left  humerus  by  the  mother  "  catching  the 

1  Syphilis  and  Local  Contagious  Disorders,  2d  ed.    London,  1881. 


4 


INJURIES  OF  BONES. 


arm  in  a  hole  in  the  towel  with  which  the  child  was  being  dried.  When  the 
child  was  examined,  the  right  clavicle  was  bent  and  thickened  with  callus 
near  its  middle,  where  it  had  been  broken  at  some  time  unknown  to  its 
mother.  The  fractured  bone  united  in  the  usual  manner."  He  also  speaks 
ot  fractures  occurring  in  syphilitic  children  during  their  birth,  quoting  a  case 
recorded  by  Porak  ;i  and  says  that  "  in  adults  the  bones  occasionally  give  way 
under  a  trifling  strain."  Gross^  mentions  the  case  of  a  man  aged  31,  whose 
humerus  gave  way  as  he  threw  a  small  chip  at  a  dog.  He  had  had  syphilis 
seven  years  before,  and  was  at  the  time  subject  to  nocturnal  pains  in  the  arm 
and  forearm.  Prof  Chiari,  of  Prague,^  maintains  that  the  occurrence  of 
"gummous  osteomyelitis,"  or  central  gummata,  in  the  medullary  structure  of 
the  long  bones,  is  not  rare,  and  may  afi:brd  an  explanation  of  these  cases  of 
apparently  spontaneous  fracture.  But  when  we  consider,  first,  the  immense 
number  of  syphilitic  patients  constantly  under  observation,  and  the  rarity  of 
Iractures  among  them,  and  secondly,  the  fact  that  in  many  persons  presumably 
free  from  any  such  taint  the  bones  give  way  to  seemingly  inadequate  force 
it  must  be  admitted  that  the  basis  of  the  theory  that  syphilis  weakens  the 
bony  structures  is  but  a  slight  one.  Only  a  very  few  instances  have  been 
reported  m  which  fractures  have  taken  place  at  the  seat  of  the  so-called 
tertiary  lesions.* 

Cancer  is  another  malady  which  has  lons^  had  the  reputation  of  affecting: 
the  strength  of  the  osseous  system.  But  here  also  the  fact  would  seem  to  be 
that  It  IS  only  when  local  manifestations  of  the  constitutional  taint  occur  in 
the  bones,  that  these  organs  show  any  unusual  fragility.  At  least  we  may 
say,  as  m  the  case  of  syphilis,  that  in  view  of  the  great  number  of  cases  of 
cancer  constantly  under  the  eyes  of  the  profession,  it  is  strange  that  fractures 
without  local  deposit  should  so  seldom  occur,  if  the  pathological  change  in 
the  bones  were  really  an  element  in  the  natural  history  of  the  disease. 

It  is  otherwise  with  regard  to  certain  disorders  of  the  nervous  system,  which 
are  attended  with  such  degeneration  of  the  nerve  centres  as  to  affect  the 
trophic  innervation  of  many  organs,  and  especially  of  the  skeleton.  Perhaps 
the  bones  betray  this  influence  the  more  readilv  by  reason  of  their  low  grade 
of  organic  activity.  Attention  seems  to  have  been  first  drawn  to  this  subject 
by  Davey,^  who  reported  the  case  of  an  insane  person,  an  autopsy  upon 
whom  disclosed  six  so-called  "spontaneous"  fractures— three  in  the  two 
femora,  and  three  in  the  humerus,  radius,  and  clavicle  respectively.  At  a 
later  period,  the  frequency  with  which  fractures  of  the  ribs  were  found  in 
patients  dying  in  lunatic  asylums,  attracted  notice;  it  was  thought  that  these 
lesions  were  due  to  maltreatment  by  attendants,  until  the  publication  of 
numerous  observations  by  Pedlar ,6  Hearder,^  and  others,  showed  softening  of 
the  bones  to  be  one  of  the  elements  of  a  tabetic  condition  apt  to  occur  in  the 
later  stages  of  insanity.  The  bones  of  two  insane  persons  dying  with  frac- 
tured ribs,  are  said  by  Ormerod^  to  have  been  dark,  wet,  greasy,  easily 
decomposed,  enlarged,  and  with  thin  outer  walls ;  under  the  mfcroscope  they 
showed  much  fatty  matter,  and  a  granular  condition  like  ossifying  cartilage. 

According  to  T.  L.  Eogers,^  the  organic  constituents  of  the  bones  in  a 

'  (raz.  Med.  de  Paris,  1877,  p.  538. 

«  System  of  Surgery,  vol.  i.  p.  898,  6th  ed.,  1882. 

3  Phila.  Med.  Times,  Feb.  10,  1883,  from  Vierteljahrsschr.  fur  Dermatoloffie  uiid  Syphilis. 
*  Arnott,  London  Med.  Gazette,  June  5,  1840. 

6  Medical  Times,  Dec.  24,  1842.  6  West  Riding  Lunatic  Asylum  Report,  1871. 

7  .Journal  of  Mental  Science,  .Tan.  1871.  ^  i-  > 
'  St.  Bartholomew's  Hospital  Reports,  vol.  vi.  1870. 

»  Liverpool  Med.  and  Surg.  Reports,  vol.  iv.  1870. 


CAUSES  OF  FRACTURE. 


5 


similar  case  were  in  larger  amount,  and  the  proportion  of  lime  to  phosphoric 
acid  less,  than  normal ;  the  bones  resembling  those  of  the  fcetus.  Moore^ 
placed  upon  record  a  case  of  "  osteo-malacia"  in  a  woman,  aged  70,  the  sub- 
feet  of  acute  mania,  who  had  had  at  different  times  four  fractures,  and  who 
died  soon  after  the  fourth.  He  does  not  appear,  however,  to  have  recog- 
nized this  "breaking  down  of  the  bone-tissue"  as  dependent  upon  the  disease 
of  the  central  nervous  system. 

In  1867  I  made  an  autopsy  in  the  case  of  the  late  Dr.  Pennock,^  who  had  been  long 
a  paralytic  ;  the  bones  were  all  so  soft  as  to  be  easily  cut  with  a  knife,  and  presented 
much  the  same  appearance  as  those  above  mentioned,  although  no  fracture  had  taken 
place. 

Dr.  Weir  Mitchell,  in  1873,^  in  an  article  on  "Rest  in  Locomotor  Ataxia," 
said  :  "  It  naturallv  occurs  to  ask  why  so  many  ataxies  have  chanced  to  break 
limbs  ?  and  as  to  this  I  should  answer,  first,  that  no  people  are  so  awkward 
or  fall  so  much  ;  and,  next,  that  in  some  of  the  cases  it  seemed  to  me  that  the 
habitual  abruptness  of  the  muscular  acts  had  a  share  in  the  calamity,  and 
that  I  have  suspected,  what  has  not  yet  been  proved,  that  the  bones  in  ataxics 
may  suffer  some  impairment  of  their  nutrition,  and  hence  of  their  strength." 

Charcot^  reported  a  very  remarkable  case,  in  which  several  fractures 
occurred  in  the  person  of  an  ataxic  woman ;  and  referred,  with  assent,  to  the 
suo:gestion  of  Mitchell,  just  quoted.  Further  observations  were  communicated 
to  "the  Pathological  Society  of  London,  in  1880,  by  Buzzard,^  and  the  subject 
was  discussed  by  Hutchinson  and  others. 

A  lady,  about  60  years  of  age,  was  under  my  care  in  1879,  who  had  long  been 
paraplegic,  and  who,  by  catching  her  foot  against  a  cushion  as  she  was  lifted  into 
a  carriage,  sustained  a  fracture  of  both  bones  of  the  right  leg ;  just  about  a  year  pre- 
viously siie  had  broken  the  other  leg  from  an  equally  slight  cause.  A  very  similar  case, 
in  a  man  of  65,  was  placed  on  record  by  Mr.  Busk.*' 

Professor  Bruns,  of  Tubingen,  has  published  a  very  interesting  paper,^  based 
upon  the  case  of  an  ataxic"  woman,  set.  57,  who  had  sustained  fractures,  at 
different  times,  of  both  forearms  ;  the  right  without  known  cause,  the  left  in 
lifting  a  plate.  He  gives  a  long  list  of  references  to  articles,  by  various  authors, 
bearing  upon  the  subject,  and  defines  the  change  which  occurs  in  the  bones  as 
an  eccentric  atrophy,  with  rarefaction  of  the  compact  substance,  and  filling 
of  the  widened  marrow-spaces  with  fat.  Eoss,^  speaking  of  tropho-neuroses, 
says : — 

"  Spontaneous  fractures  have  attracted  the  attention  of  surgeons  from  a  remote  period, 
but  these  accidents  were  attributed  to  the  influence  of  certain  diatheses,  such  as  gout, 
rheumatism,  scrofula,  and  cancer.  Larrey  drew  special  attention  to  the  fact  that  a  cer- 
tain form  of  paralysis  of  the  lower  extremities  was  associated  with  a  strong  predisposi- 
tion to  fractures  of  their  bones.  In  the  record  of  this  case,  however,  it  is  mentioned 
that  the  so-called  paralytic  symptoms  were  associated  with  amaurosis  and  great  exalta- 
tion of  the  sensibility  of  the  lower  extremities,  which  renders  it  almost  certain  that  the 
symptoms  were  not  due  to  paralysis,  but  to  ataxia.  In  1873,  Weir  Mitchell  drew 
attention  to  the  frequency  of  spontaneous  fractures  in  locomotor  ataxia,  and  suggested 

»  St.  George's  Hospital  Reports,  1871-2. 

«  See  American  Journal  of  the  Medical  Sciences,  July,  1868.  »  Ibid.,  July,  1873. 

*  Arch,  de  Physiologic,  Janvier,  1874. 

5  Brit.  Med.  Journal,  Feb.  14,  1880.  The  reader  may  refer  with  advantage  to  another  article 
by  Buzzard,  "On  the  Affection  of  the  Bones  and  Joints  in  Locomotor  Ataxy,"  in  the  British 
Medical  Journal  for  March  5,  1881. 

6  London  Medical  Gazette,  April  10,  1840. 

'  Spontan-fracturen  bei  Tabes.    Berl.  klin.  Wochenschr.,  March  13,  1882. 
8  Treatise  on  Diseases  of  the  Nervous  System,  1881,  vol.  i.  p.  224. 


6 


INJURIES  OF  BONES. 


that  during  the  progress  of  the  disease  the  bones  had  undergone  nutritive  changes  which 
greatly  diminished  their  resistance.  This  subject  was  subsequently  investigated  by 
Charcot  and  his  followers,  with  their  usual  thoroughness  and  success.  The  period  of 
fracture  is  usually  preceded  by  two  or  three  paroxysms  of  lancinating  pain  ot"  unusual 
severity ;  and  at  the  same  time  the  limb  is  found  swollen,  and  with  all  the  symptoms  of 
osteo-periostitis,  and  fracture  occurs  on  the  slightest  movement  of  the  limb,  or  in  "the 
entire  absence  of  any  movement  or  other  external  cause.  The  femur  is  more  frequently 
fractured  than  any  other  bone,  the  seat  of  fracture  being  frequently  the  neck  of  the 
ormer  ;  but  the  bones  of  the  leg,  arm,  forearm,  and,  indeed,  almost  every  bone  of  the 
hmb  and  trunk,  have  been  found  fractured,  including  the  vertebral  column.  Multiple 
fractures  in  the  same  patient  are  by  no  means  uncommon,  and  in  a  case  published  by 
Charcot,  the  patient,  towards  the  close  of  life,  could  scarcely  move  in  bed  without  frac- 
turing some  one  or  other  of  the  few  bones  which  had  not  been  already  fractured. 
Damaschino  has  drawn  attention  to  the  fact  that  the  spontaneous  fractures  of  ataxics 
reunite  very  readily  and  rapidly,  with  an  enormous  formation  of  callus." 

Dr.  Debove,  in  a  communication  to  the  Paris  Hospital  Society,  observed 
that  m  his  practice  at  the  Bicetre,  he  had  frequent  occasion  to  see  fractures 
in  the  subjects  of  hemiplegia,  these  fractures  always  occurring:  on  the  hemi- 
plegic  side,  there  bemg  every  reason  to  believe  that  changes  took  place  in 
such  cases  m  the  osseous  tissue,  rendering  it  more  fragile.  In  one  case  of 
chronic  hemiplegia  he  found  that  not  only  the  fractured  bone  itself,  but  all 
the  bones  on  the  same  side,  had  undergone  such  change.  They  were  less 
heavy  than  on  the  sound  side,  the  medullary  canal  was  larger,  and  the  sub- 
stance of  the  diaphysis  was  less  compact.  Examined  histologically,  the 
Haversian  canals  were  found  much  dilated,  and  the  bone  porous.  Chemical 
examination  also  showed  that  the  diaphysis  contained  a  larger  quantity  of  fat 
ihese  fractures  usually  consolidated  rapidly,  the  callus'' bein^  somewhat 
voluminous.^ 

It  would  seem  clear,  from  the  foregoing,  that  there  is  in  many  forms  of  cen- 
tral nervous  disease,  including  hemiplegia,  paraplegia,  locomotor  ataxia,  gen- 
eral paralysis  of  the  insane,  and  perhaps  other  allied  conditions,  a  state  of 
detective  nutrition  brought  about  in  the  bones,  whereby  they  are  rendered 
either  softer  or  more  brittle,  and  which  causes  them  to  yield  very  readily  to 
slight  fracturing  forces.  Very  possibly,  further  study  of  the  subject  may 
throw  additional  liglit^  upon  the  whole  series  of  changes ;  but  the  statement 
just  made  is  an  embodiment  of  what  is  now  known  with  regard  to  it. 

Rachitis,  or  rickets,  a  disease  supposed  by  most  w^riters  to  be  almost  wholly 
unknown  m  this  country ,2  has  been  not  unfrequently  observed  as  a  predispos- 
ing cause  of  fracture  by  British  and  Continental  surgeons.  It  affects  children 
chiefly,  and  is  manifested  by  softening  and  distortion  of  the  bones,  with  en- 
largement of  their  articular  extremities.  It  may  be  that  such  cases  often 
occur  among  the  lower  classes  of  our  negroes,  the  parents  being  ill-fed,  poorly 
clothed,  and  often  strumous  or  syphilitic ;  and  that  the  deformed  limbs  so 
commonly  seen  in  that  race  among  us,  are  the  traces  of  con2:enital  rickets. 

Hamilton^  mentions  a  case  seen  by  him  in  1853,  in  which,  in  an  infant 
four  days  old,  born  of  a  healthy  mother  and  at  full  time,  "nearly  all  of  the 

1  Medical  Times  and  Gazette,  Oct.  29,  1881  ;  from  Gaz.  des  Hopitaux,  20  Oct.  1881 

^i^cP^.*"  I^achitis,  by  Dr.  J.  Lewis  Smith,  Vol.  I.  p.  251.  In  the  American  Journal 
of  the  Medical  Sciences  for  January  and  April,  1872,  the  reader  may  find  an  admirable  discussion 
of  this  disease  by  the  late  Dr.  John  S.  Parry,  who  says  he  ''has  been  irresistibly  forced  to  the 
conclusion  that  rachitis  is  scarcely  less  frequent  in  Philadelphia  than  it  is  in  the  large  cities  of 
Great  Britain  and  the  continent  of  Europe,  and  that  it  should  occupy  just  as  important  a  place 
in  our  mortuary  lists  as  Hillier  conceives  that  it  should  in  those  of '  the  registrar-general  of 


Practical  Treatise  on  Fractures  and  Dislocations,  6'th  ed.,  1880,  p.  33. 


CAUSES  OF  FRACTURE.  i 

lono-  bones  were  separated  and  movable  at  their  epiphyses,  the  motion  being 
o-enerally  accompanied  with  a  distinct  crepitus.  The  bones  were  also  much 
enlaro-ed  in  their  circumference ;  the  bones  of  the  forearm  and  the  temur 
were  greatly  curved;  the  fontanelles  were  unusually  open;  and  the  clavicles 
were  entirely  wanting.  The  child  was  of  full  size,  hut  looked  teeble.  It 
died  in  a  condition  of  marasnms  six  months  after  birth  ;  at  which  time  some 
deo-ree  of  union  had  taken  place  at  several  of  the  i)oints  of  separation,  the 
limbs  havino-  been  supported  constantly  with  pasteboard  splints  and  rollei-s." 

A  case  was  reported  by  Collins  to  the  Manchester  Medical  Society m 
which  a  condition  allied  to  rickets  seemed  to  have  been  brought  about  m  a 
child  by  the  deficiency  of  casein  in  the  mother's  milk.  The  child  was  born 
January  2,  1882  ;  when  first  seen,  January  13,  the  left  femur  presented  every 
appearance  of  having  been  fractured  and  recently  united.  On  the  30th,  the 
left  humerus  was  found  to  be  broken;  on  February  20,  the  right  humerus,, 
and  on  February  24,  the  right  femur.  Each  fracture  was  at  the  centre  of  the 
shaft,  and  there  was  in  no  i'nstance  any  evidence  of  violence  or  injury.  There 
was  no  history  of  syphilis  ;  the  child's  bones  were  curved.  All  the  fractures 
united  readily. 

As  illustrative  of  the  more  pronounced  cases  of  rickets,  1  may  quote  trom 
Malgaigne^  a  case  recorded  by  Jacquemille:  •• 

The  patient  was  "  born  of  healthy  parents,  but  affected  from  his  first  year  with  gene- 
ral rachitis,  which  liad  flattened  his  ribs,  distorted  his  spine,  and  curved  all  the  long 
bones  except  tlie  humerus.  He  could  not  walk  till  five  years  old,  and  remained  always 
excessively  small  and  feeble.  Toward  the  age  of  twelve,  in  climbing  a  wood-pile,  he 
fell  and  broke  the  right  arm  at  the  middle.  The  fracture  was  simple,  and  united  per- 
fectly. At  fifteen,  trying  to  get  up  behind  a  carriage,  he  lost  his  footing,  and  fractured 
both  thighs  ;  which  uniting  with  deformity,  he  was  permanently  crippled  on  the  right 
side.  At  seventeen,  he  broke  the  left  arm.  At  twenty-eight,  he  broke  the  left  thigh, 
at  a  different  point  from  before.  Finally,  at  thirty-two,  he  again  broke  the  right  thigh, 
likewise  at  a  new  point.    The  case  was  now  lost  sight  of." 

Mr.  R.  Barwell^  lately  showed  to  the  Pathological  Society  of  London— 

A  f^irl,  aged  17,  but  apparently  very  much  younger,  who  presented  a  most  extraordi- 
nary "series"  of  deformities.  Her  family  history  threw  no  light  on  her  condition, 
which  was  not  congenital.  In  her  mental  development  she  was  juvenile  rather  than 
weak,  and  she  had  not  reached  puberty.  Very  few  of  her  bones  were  free  from  deform- 
ity. Both  humeri  were  much  bent,  but  especially  the  right ;  so  that,  on  that  side, 
whereas  the  humerus  measured  seven  inches  and  a  half,  the  length  of  the  arm  from 
acromion  to  olecranon  was  only  four  inches  and  a  quarter ;  again,  the  right  tibia  meas- 
ured nine  inches  and  a  half,  but  the  length  of  leg  was  only  four  inches  and  a  half.  This 
was  owing  to  the  bone,  at  about  the  lower  fourth,  being  bent  back  on  itself,  so  that  it 
ran  upwards  and  parallel  to  the  rest  of  the  bone.     The  left  olecranon  process  was 

greatly  lengthened,  and  placed  at  an  obtuse  angle  to  the  shaft  of  the  bone  The 

bones,  a  few  years  ago,  had  been  remarkably  brittle,  and  still  remained  so,  but  to  a  less 
degree.  Between  the  ages  of  9  and  13,  she  had  broken  her  arms  four  times,  and  her 
lower  limbs  on  several  occasions.  There  was  no  bending  of  the  ribs,  nor  any  enlarge- 
ment of  the  epiphyses.' 

Mr.  Barwell  did  not  think  that  the  case  could  be  classed  either  with  rickets 
or  with  osteo-malacia.  He  had  had  under  his  care,  some  years  ago,  a  boy 
who  presented  similar  deformities,  but  less  marked,  and  he  had  endeavored 
to  straighten  the  femur.  On  cutting  down  to  it,  however,  he  found  that  on 
the  slightest  force  the  chisel  sank  through  the  whole  structure  of  the  bone, 


1  Brit.  Med.  Journ.,  May  13,  1882. 

8  Traite  des  Fractures  et  des  Luxations,  tome  i.  p.  20  ;  Translation,  p.  33. 
»  Brit.  Med.  Journ.,  Dec.  9,  1882. 


8 


INJURIES  OF  BONES. 


and  about  five  fluidounces  of  liquid  fat  flowed  out.  Both  of  these  patients 
suttered  from  pam  referred  to  the  convex  side  of  the  distorted  boiie  He 
thought  that  there  was  hypertrophy  of  the  medulla  at  the  expense  of  the 
bone  proper. 

J.  Cloquet^  says:  "M.  Esquirol  possesses,  in  his  anatomical  collection,  the 
skeleton  of  a  rachitic  female,  in  whom  nearly  all  the  bones  of  the  limbs  and 
trunk  are  covered  with  the  traces  of  fractures  more  or  less  well  united  •  seve- 
ral of  them  are  broken  in  two,  three,  or  four  points  of  their  length  These 
fractures,  more  than  two  hundred  in  number,  appear  to  have  occurred  at 
different  times,  judging  from  the  varying  states  of  the  callus."    It  is  not  easy 
to  say  what  was  the  real  nature  of  this  remarkable  case,  but  it  is  scarcely 
likely  that  it  was  one  of  ordinary  rachitis  ;  more  probably  it  belonged  among- 
the  now  recognized  tropho-neuroses.  * 
As  a  general  rule,  when  rachitic  children  survive  the  period  of  the  second 
dentition,  the  skeleton  acquires  firmness,  and  even  becomes  remarkably  dense 
and  strong.   Hence  it  might  be  questioned  whether  the  adult  cases  iust  quoted 
should  fairly  be  regarded  as  belonging  under  this  head..  But  the  condition 
known  as  moUities  ossium,  malacosteon,  or  osteo-malacia—'' mitQiim^  of  the 
bones,   in  plain  English— would  seem  really  to  differ  very  little  from  that 
which  m  children  goes  by  the  name  of  rickets  ;  and  Jacquemille's  patient  may 
have  simply  passed  from  one  into  the  other.    Rickets,  then,  would  be  the  mol- 
lifies ossium  of  children,  mollifies  ossium  the  rickets  of  adults  ;  an  idea  lon^  aero 
suggested.   But  this  view  must  not  be  too  implicitly  accepted,  since  in  rickets, 
although  the  pathological  changes  noted  in  the  bones  are  more  those  of  sub- 
acute inflammation,  there  is  little  or  no  pain  ;  while  in  the  mollifies  ossium  of 
adults,  a  disorder  m  which  fatty  degeneration  seems  to  be  a  very  important 
element,  the  pains  are  excessive.    The  tendency  of  the  former,  under  anything 
like  favorable  circumstances,  is  toward  spontaneous  cure ;  recovery  from  the 
latter  ha^  never  yet  been  recorded.    Of  the  published  cases  of  mollifies,  the 
subjects  have  been  for  the  most  part  females.    In  some,  large  amounts  of  phos- 
phates and  of  "animal  matters"  are  said  to  have  been  excreted  with  the 


urme. 


^  Further  reference  need  hardly  be  made  to  mollifies  ossium,  especially  as  it 
is  highly  probable  that  the  cases  hitherto  ranged  under  this  head  may  be 
found  to  belong  properly  among  the  trepho-neuroses  before  spoken  of  the 
changes  connected  with  the  bony  skeleton  being  altogether  subordinate  to. 
those  affecting  the  central  nervous  system.  Such  would  seem  to  be  the  ex- 
planation, in  the  light  of  the  science  of  our  day,  of  the  classical  cases  recorded 
by  Curling,  Solly ,3  Saviard,^  and  others. 

^  I  ought,  however,  to  remark  that  in  some  instances  the  softening  is  limited 
m  extent ;  thus  in  a  case  reported  by  the  late  Dr.  is'eill,*  one  femur  only 
seemed  to  be  affected.  The  theory  of  the  neurotic  origin  of  the  disease  is 
not  here  set  aside,  but  we  have  simply  to  suppose  that  a  portion  only  of  the 
central  nervous  system  has  undergone  pathological  change,  and  that  as  a  re- 
sult there  is  degeneration  of  that  part  of  the  skeleton  which  is  dependent 
upon  the  tract  so  involved. 

^  Fragilitasossmm,  or  brittleness  of  the  bones,  differs  from  the  already  men- 
tioned predisposing  causes  of  fracture  in  being  not  as  much  a  disease  as  a 

>  Article  "Fractures,"  Diet,  de  Medecine.    Paris,  1824. 

2  Solly,  Med.-Chir.  Trans.,  vol.  xxvii.  p.  443  ;  Maclntyre,  ibid.,  vol.  xxxiii.  ;  Chambers,  ibid., 

v01«  XXXVll. 

!  H"""^^"^'  Transactions,  vol.  xx.  ;  Solly,  ibid.,  vol.  xxvii. 

*  Malgaigne,  op.  cit.,  tome  i.  p.  21  ;  Translation,  p.  33. 
^  Am.  Journal  of  the  Med.  Sciences,  July,  1874. 


CAUSES  OF  FRACTURE. 


9 


peculiarity.  Sometimes  it  is  seen  in  old  people,  as  one  of  the  changes  inci- 
dent to  their  time  of  life  ;  but  it  has  also  been  observed  as  a  congenital  con- 
dition, and  in  rare  instances  as  a  matter  of  heredity,  so  that  many  members  of 
a  family,  and  even  several  generations,  may  manifest  it.  From  the  published 
accounts,  it  does  not  appear  that  the  bones  of  persons  affected  with  fragility 
are  always,  or  even  generally,  small  or  slight,  and  their  muscular  develop- 
ment would  seem  to  be  quite  equal  to  the  average  stanciard.  A  few  instances 
only  need  be  here  quoted  at  length. 

Dr.  F.  J.  Shepherd  reported  to  the  Medico-Chirurgical  Society  of  Montreal 
a  case  of  senile  atrophy  of  the  bones,  with  very  remarkable  fragility,  in  a 
woman  aged  between  80  'and  90. 

TyrrelP  thus  reports  a  remarkable  case  of  brittleness  of  bone  in  a  man 
whose  age  is  not  given  : — 

He  had  been  the  subject,  at  the  time  he  was  last  under  my  hands,  of  seventeen  frac- 
tures ;  and  when  I  last  saw  him,  tliree  or  lour  years  ago,  he  had  liad  five  more  frac- 
tures, making  in  all  twenty-two.  These  fractures  affected  the  femur,  the  tibia  and 
fibula,  the  upper  arm,  and  the  forearm — scarcely  a  cylindrical  bone  of  any  size  had 
escaped.  In  consequence  of  these  fractures  he  had  lost  in  height  from  seven  to  eight 
inches.  The  first  time  I  had  him  under  my  care  was  in  consequence  of  fracture  of  the 
thigh-bone,  and  the  other  had  been  fractured  once  or  twice  previously.  In  consequence 
of  indifferent  surgery,  that  limb  was  shorter  by  three  inches  than  that  for  which  he 
came  under  my  care.  He  had  worn  an  iron  to  make  up  for  the  difference  in  the  length 
of  the  two  limbs,  and  it  enabled  him  to  make  progression  with  some  inconvenience. 
Finding  this,  I  stated  that  it  was  possible  to  set  the  recently  broken  limb  to  the  same 
length  as  the  one  formerly  broken,  and  at  his  wish  I  did  so.  I  made  an  angular  union 
of  the  second  limb,  reduced  it  to  the  same  length  as  the  other,  and  he  was  enabled  after- 
wards to  make  progression  more  easily  and  rapidly.  Hence  I  was  the  instrument  of 
taking  off  three  or  four  inches  from  his  height,  by  shortening  the  limb  to  that  extent. 

It  may  not  be  anticipating  too  much  to  say  here  that  it  is  difficult  to  see 
how  walking  could  have  been  facilitated  by  making  the  leg  crooked ;  and 
the  experiment  is  certainly  one  which  surgeons  of  the  present  day  would 
hesitate  to  try. 

Gibson^  gives  the  following  case  of  his  own  : — 

A  patient  of  mine,  a  Mr.  Green,  residing  near  Trenton,  J.,  has  a  son  now  nine- 
teen years  of  age,  who,  from  infancy  up  to  the  present  period,  has  been  subject  to  frac- 
tures from  the  slightest  causes,  owing  to  an  extraordinary  brittleness  of  the  bones.  The 
bones  of  the  arm,  forearm,  thigh,  and  leg,  have  all  been  broken  repeatedly,  even  from 
so  trivial  an  accident  as  catching  the  foot  in  a  fold  of  carpet  whilst  walking  across  the 
room.  The  clavicles  have  suffered  more  than  any  other  bone,  having  been  fractured 
eiglit  times.  What  is  remarkable,  the  boy  has  always  enjoyed  excellent  health,  and 
the  bones  have  united  without  much  difficulty  or  much  deformity.  The  above  was  pub- 
lished in  1824  ;  since  then  this  patient  died,  in  the  twenty-third  year  of  his  age.  .  .  . 
Altogether  he  had  experienced  twenty -four  fractures. 

Stanley^  speaks  of  a  boy  aged  ten,  under  the  care  of  Mr.  Earle,  in  St.  Bar- 
tholomew's Hospital,  "  who  had  suffered  eight  fractures,  six  in  one  tibia,  and 
two  in  the  femur.  Each  fracture  of  the  tibia  occurred  in  a  different  part  of 
the  bone,  and  had  united  within  the  usual  period." 

In  a  case  reported  by  Arnott,^  a  girl  aged  fourteen  years  was  under  treat- 
ment for  her  thirty-first  fracture ;  the  right  thigh  having  been  broken  seven 

'  Medical  News,  Nov.  18,  1882. 

2  St.  Thomas's  Hosp.  Reports,  vol.  i.  1836. 

3  Institutes  and  Practice  of  Surgery,  8th  ed.  (1850),  vol.  i.  p.  234. 
*  A  Treatise  on  Diseases  of  the  Bones.    London,  1849. 

s  London  Med.  Gazette,  June  15,  1833. 


'  INJURIES  OF  BONES. 


t  mes,  the  eft  six  ;  the  right  leg  nine  times,  the  left  once ;  the  right  arm  four 
times,  the  left  three;  and  the  left  forearm  once.    Her  sister  six  veare  oM 
had  had  nine  fractures  since  the  age  of  eight  months.   NeTer  of  her  pare.S 

z£:':£^^i^i:;z^  ^-^'^  '^--^''^^  ^^^^^ 

Agnew'  mentions  a  child  seen  by  him  who  had  twice  broken  the  same 
thigh  ;  he  was  one  of  a  family  of  six  children,  every  one  of  whom  had  sut 
fered  from  fracture  two  of  these  three  times  eack  The  f^thei  had  had 
TnS':k:Xg  '°  ''''  of  the  bones 

Gurlt^quotes  from  Axmann  another  case,  in  which  three  brothers  showed 
this  tendency  to  the  occurrence  of  fracture  oioiners  snowea 

Of  fragility  affecting  the  bones  in  several  generations,  a  very  few  instances 
have  been  given,  but  they  are  beyond  doubt.^  Goddard' saV  a ^0^8"  ed 
twelve,  who  had  had  fourteen  fractures,  all  from  slight  violence  •  his  moXr 
had  broken  her  right  rtiigh  once,  and  her  left  five  times;  and  her  brother  at 
thirteen  years,  had  suftered  two  fractures  of  one  thigh,  and  nine  of  the  other 
as  well  as  two  of  the  arm.  "  These  people,"  says  the  record  "  are  of  vevv 
short  stature,  and  have  small  bones."  ^  '  ^ 

wl^^^'T  ^/r'  ^^'^  ^''^'"'^        ^""."^'^y      t'^e  parish  of  Offenbach,  "  three  of 
whom  had  twice,  and  one  thrice,  broken  an  arm  and  a  leg,  while  one  had  five 
times  sutfered  fractures  of  one  or  another  limb,  slight  force  only  having  been 
as  a  rule  sufficient  o  produce  the  lesions.    Both  the  father  and  ^-Indfether 
had  had  bones  broken.    The  family  were  otherwise  healthy,  and  presented 
no  discoverable  dyscrasia.   It  is  remarkable  that  none  of  them  sustafned  frac 
tures  before  they  were  eight  years  of  age.   The  fractures  united  very  quickly 
so  that  the  callus  was  generally  perfectly  firm  by  the  end  of  three  weeks 
But  If  the  same  bone  was  broken  a  second  time,  union  did  not  take  place."  ' 
in  a  case  reported  by  Greenish,^  a  boy  aged  18  had  himself  had  thirteen 
fractures;  his  grandfather  had  had  "numlrous"  fractures;  his  fether  one 
his  uncle  two ;  his  five  cousins  (children  of  his  uncle),  eight  four,  fouT  fbur' 

ters  Slcaped  '''^  ^' '  ''^^  ''=^5' 

[The  editor  has  recorded  a  case  in  which,  without  apparent  reason,  seven- 
teen fractures  had  been  sustained  by  the  bones  of  the  right  lower  extremity-. 
Soped  ^n  ^Cr^J^l^r ''''''''  ""^''^^^^  -^hondromata  had  beJn 

the  Ji<*Hty  of  individuals  to  fracture;  they  are  so  closely  connected  in  this 
respect  that  they  may  be  considered  together 

and  ii,!lfr,-!\*'''  °i!  P"^^-^^''il^e  habits,  plays,  and  occupations  of  boys 
and  gills  are  veiy  much  alike,  and  one  might  naturally  suppose  that  their 
bones  would  be  broken  with  about  equal  frequency,  /et  according  to  Ma^l- 
gaigne,  from  two  to  five  years  of  age, "  the  number  of  girls  attected  lith  frac- 
ture was  nearly  double  that  of  the  boys  ;"  while  Gurlt^  gives  the  proport  on 
from  one  to  four  years  IJ  times  as  many,  and  from  five  to  eight  yea^S  times 

'  Principles  and  Practice  of  Surgery,  vol.  i.  p.  718. 

2  Ekraann's  case,  quoted  by  Gurlt  from  Acrplin«  fA   n  i^qq\ 
«.«  present  catego.;,\„t  to  Lre  Uen^lr^^Z' I^J^'^l^^^^^^^^^  be  ■„ 

vagueness  of  the  account  enables  one  to  judf^e.  ^euiiary  racniiis,  as  lar  as  the 

*  Gibson,  op.  cit.,  vol.  i.  p.  23G. 

*  Untersuchungen  und  Erfahrungen  im  Gebiete  der  Chirurc^ie  1844  •  nnotf^d  W  Pi^.u  Wo  v. 
der  Lehre  von  den  Knochenbruchen,  Bd.  i.  S.  149  '  ^         ^  Handbuch 

6  Brit.  Med.  Jouru.,  June  26,  1880.  "  e  Or^    u  * 

'  "  Op.  cit.,  table  on  p.  9. 


CAUSES  OF  FRACTURE. 


11 


as  many  boys  as  girls.  The  two  authors  just  quoted  agree  in  saying  that  be- 
tween the  fifteenth  and  twentieth  years  of  life  about  eight  times  as  many  frac- 
tures occur  in  males  as  in  females.  Malgaigne  thinks  that  the  disproportion 
then  steadily  diminishes,  until  "  beyond  seventy-five  years  there  are  nearly 
twice  as  many  fractures  in  women  as  in  men  ;"  but  Gurlt  makes  the  propor- 
tion between  twenty-one  and  thirty  10  times,  and  between  thirty-one  and 
forty  llj  times  as  many  male  as  female  cases.  Then,  according  to  the  latter 
author,  a  decrease  does  occur,  and  from  seventy-one  to  eighty  the  women  are 
2J  times,  and  from  eighty-one  to  ninety  7  times,  as  often  affected  with  frac- 
tures as  men.  I  shall  make  no  attempt  to  reconcile  or  explain  the  differences 
between  these  estimates,  coming  from  such  distinguished  sources. 

Children  sustain  fractures  mainly  as  the  result  of  falls ;  but  they  are  very 
liable  to  be  hurt  in  this  way,  partly  from  their  lack  of  muscular  strength, 
partly  from  their  heedlessness  and  love  of  adventure.  Occasionally  they  put 
themselves  in  danger  from  the  kicks  of  horses,  or  from  being  run  over ;  I 
once  had  to  amputate  the  arm  of  a  little  fellow,  only  seventeen  months  old, 
for  compound  fracture  caused  by  the  wheel  of  a  passenger  railway  car. 

After  puberty,  the  rougher  sports  of  boys  render  them  much  more  liable 
than  girls,  not  only  to  falls,  but  to  other  forms  of  violence ;  and  during  adult 
life,  many  of  the  occupations  followed  by  men  are  attended  with  numerous 
exposures  from  which  women  are  almost  wholly  exempt.  Our  hospital  wards 
attbrd  daily  evidence  of  the  liability  to  fracture  among  painters,  carpenters, 
masons,  drivers,  and  laborers  of  all  kinds. 

With  the  advent  of  old  age,  the  habits  of  the  two  sexes  become  again  much 
more  nearly  alike,  and  the  accidents  to  which  both  are  exposed  resemble 
those  which  are  apt  to  happen  to  children.  Senile  feebleness,  and  the  timi- 
dity which  comes  wdtli  it,  is  curiously  similar  in  its  effect,  in  this  way,  to 
the  ignorant  and  heedless  weakness  of  childhood.  And  the  slighter  frames 
of  women  yield  more  readily  to  sudden  strains,  so  that  the  excess  in  the 
number  of  their  fractures  is  not  a  matter  of  wonder. 

i^ot  only  is  the  frequency  of  fractures  influenced  by  the  causes  just  dis- 
cussed, but  their  character  also.  In  children  and  in  the  youth  of  both  sexes, 
we  have  to  deal  mainl}^  with  fractures  (sometimes  incomplete)  of  the  shafts  of 
the  long  bones,  and  with  epiphyseal  disjunctions.  In  adults  we  meet  with 
injuries  of  the  former  class,  and  (chiefly  in  the  male  sex)  with  fractures  by 
crushing,  as  in  mining,  railroad,  and  machinery  accidents,  and  falls  from 
heights.  Among  old  people,  the  bones  are  more  apt  to  give  way,  from  slight 
force,  at  weak  points  ;  thus  in  them  fractures  of  the  neck  of  the  femur  are 
very  common.    But  these  points  will  be  again  referred  to  more  particularly. 

Drunkenness  has  been  spoken  of  by  some  authors  as  a  source  of  immunity 
from  fracture ;  and  in  proof  of  this  idea  cases  are  adduced  in  which  persons 
have  fallen  from  considerable  heights,  while  under  the  influence  of  liquor, 
without  sustaining  any  injuries  beyond  contusions.  But  there  are  very  many 
instances  known  in  which  sober  people  have  likewise  escaped  fractures ;  and 
on  the  other  hand,  a  large  proportion  of  the  patients  admitted  into  hospitals, 
or  treated  in  private,  for  this  class  of  hurts,  have  received  them  while  drunk. 
The  only  way  in  which  intoxication  can  prevent  fracture  is  by  relaxing  the 
muscles,  and  thus  rendering  the  limbs  flaccid.  Under  such  circumstances 
one  of  the  conditions  of  indirect  force  as  a  cause  of  fracture  is  set  aside,  and 
the  bones,  if  broken,  yield  to  direct  violence  or  crushing. 

The  influence  of  season,  and  especially  of  cold  weather,  as  a  predisposing 
cause  of  fracture,  was  insisted  on  by  some  of  the  older  writers,  who  main- 
tained that  the  bones  were  more  brittle  in  winter.  This  idea  need  hardly  be 
gravely  refuted.    When  the  ground  is  frozen  hard,  and  rendered  slippery  by 


1^  INJURIES  OF  BONES. 


ice  and  snow  falls  upon  it  are  perhaps  more  apt  to  result  in  fracture  of  bones- 
but  on  the  otner  hand  in  milder  weather,  out-door  occupations  are  more  ex' 
tensively  carried  on,  whether  in  the  way  of  work  or  of  sport,  and  a  ^reat 
many  accidents  occur  to  those  engaged  in  them.  ^ 

Something  may  now  be  said  of  the  local  predisposing  causes  of  fracture 

Ihe  exposed  situations  of  certain  bones,  and  of  certain  portions  of  those 
bones  render  them  especially  liable  to  breakage.  Tables  are  ^iven  by  sys- 
tematic authors,  derived  mainly  from  hospital  records,  showino;  with  more 
or  less  accuracy  the  relative  distribution  of  fractures  over  the  skeleton  from 
a  comparison  of  large  numbers  of  cases.  Such  tables,  as  far  as  I  have  been 
able  to  hnd  and  compare  them,  agree  in  sustaining  the  following  general 
statement  of  the  comparative  liability  to  fracture  of  the  different  portions  of 
the  skekton:  The  greatest  number  of  fractures  occur  in  the  bones  of  the 
leg ;  then  follow  the  thigh,  the  arm,  the  forearm,  the  clavicle,  the  ribs  the 
lacial  bones  (including  of  course  the  lower  jaw),  and  the  patella.  A  iore 
detailed  exhibit  would  scarcely  be  of  practical  value  here,  but  can  be  found 
m  the  writings  of  Malgaigne,  Gurlt,^orris,  and  others,  by  those  who  may 
be  interested  m  the  matter.  - 

Inflammation  of  a  bone  has  been  assigned  as  a  cause  of  such  weakening  of 
Its  texture  as  to  render  it  apt  to  give  way.  Mcod's  two  cases,  quoted  by 
Malgaigne,!  seem  to  bear  this  explanation ;  in  each  the  patient  had  had  pains 
lor  about  a  month  m  the  humerus,  which  broke  under  very  slight  stress 

and  necrosis,  by  depriving  a  bone  of  a  portion  of  its  thickness,  may 
lead  to  the  snapping  of  the  remainder. 

Tubercle  of  bone  may  so  alter  it  as  to  make  it  unequal  to  the  resisting  of 
iracturing  lorces ;  and  m  a  very  few  instances  the  same  result  has  been  re- 
corded ol  cystic  or  hydatid  tumors.  For  details  of  five  such  cases,  the  reader 
IS  referred  to  Gurlt.^  With  regard  to  the  development  and  natural  history 
oi  sarcomata  of  the  long  bones,  by  which  they  have  sometimes  been  similarly 
attected,  much  information  may  be  found  in  a  paper  by  Dr.  S  W  Gross  ^ 
The  central  sarcomata  would  seem  to  be  those  most  apt  to  weaken  the  bony 
structures  so  as  to  predispose  them  to  fracture. 

Spontaneous  Yractvk^^.— Spontaneous  fractures,  so  called,  are  such  as  oc- 
cur without  any  apparently  adequate  cause.  Thus  Erichsen*  says  that  he 
knew  a  gentleman  a  little  over  fifty  years  of  age,  seemingly  in  perfect 
health,  whose  thigh  gave  way  with  a  loud  snap  as  he  turned  in  bed.  .Gross^ 
nientions  the  case  of  a  gentleman  aged  54,  who  broke  his  femur  in  pulling 
oil  a  boot.    Other  like  instances  are  on  record. 

In  a  larger  class  of  cases,  there  is  evidence  more  or  less  clear  of  a  precedent 
diseased  condition  of  the  bones ;  and  to  designate  these.  Prof.  Broca^  sug- 
gested "  pathological"  as  a  more  accurate  term.  Thus  there  may  have  been 
previous  complaint  of  pain  at  or  near  the  seat  of  fracture  ;  and  in  some  cases 
malignant  disease  has  been  present  at  the  time,  as  in  those  recorded  by 
Saltier  and  S.  Cooper?  Sometimes  there  is  a  local  development  of  the  disease 
in  the  bone,  i)revious  to  its  giving  way,  as  in  the  case  quoted  from  Petit  by 
Malgaigne  f  or  again,  the  fracture  is  the  first  sign  of  the  bone  becoming 

'  Op.  cit.,  tome  i.  p.  23  ;  Translation,  p.  34,  2  Qp.  cit.  S.  193. 

'  American  Journal  of  the  Medical  Sciences,  July  and  October,  1879.    *      *'  ' 

*  Science  and  Art  of  Surgery,  1873  (Am.  ed.),  vol.  i.  p.  303 

5  Op.  cit.,  vol.  i.  p.  899. 

6  Oaz.  des  Hopitaux,  15  Avril,  1876  ;  Med.  Times  and  Gazette,  May  13,  1876. 
^  Salter,  Med.-Chir.  Transactions,  vol.  xv.;  Cooper,  ibid.  vol.  xvii. 

^  Op.  cit.,  tome  i.  p.  13  ;  Translation,  p.  26. 


MECHANISM  OF  THE  PRODUCTION  OF  FRACTURES. 


13 


affected,  as  in  an  instance  recorded  by  myself.^  Hydatids  (cysticercus  cellu- 
losse)  are  sometimes  found  in  bone,  and  the  first  indication  of  the  disease  has 
sometimes  been  the  occurrence  of  fracture  without  apparent  cause.* 

Still  another  set  of  cases  are  thus  known,  in  which  the  bones  give  way  un- 
der abnormal  muscular  action,  as  in  epileptic  or  other  convulsions.  Lente^ 
has  recorded  an  instance  in  which  both  femora  were  so  fractured.  Van  Oven* 
reported  a  fracture  of  the  femur,  by  cramp  coming  on  during  sleep,  in  his 
own  person.  Many  other  cases  have  been  published,  some  of  which  will 
be  hereafter  referred  to  in  connection  with  the  special  bones  involved.  As  a 
general  rule,  if  the  muscular  action  be  not  clearly  pathological,  such  as  that 
exerted  in  epileptic  states,  it  is  sudden  and  forcible  ;  and  the  fact  can  often 
be  demonstrated  that  the  bones  thus  broken  are  taken  at  a  mechanical  dis- 
advantage. Sometimes,  as  I  shall  point  out  in  regard  to  certain  parts  of  the 
skeleton^  there  is  a  probability  of  leverage  being  the  true  explanation  of 
these  apparently  causeless  yieldings. 

It  will  therefore  be  seen  that  the  term  "  spontaneous,"  if  used  at  all,  should 
be  clearly  understood  either  to  refer  only  to  the  first  of  the  classes  of  cases 
just  enumerated,  or  to  have  a  simply  conventional  meaning,  namely,  that 
the  force  producing  the  fracture  is  not  obviously  adequate  to  the  breaking  of 
a  sound  bone.  For  it  cannot  be  imagined  that  turning  in  bed,  for  instance, 
or  throwing  a  chip,  should  involve  sufiicient  strain  upon  the  structure  of  a 
normal  femur  or  humerus  to  cause  the  fibres  to  give  way.  Indeed,  in  the 
first  class  of  cases,  it  may  be  regarded  as  almost  certain  that  some  pathological 
change  had  taken  place  in  the  bones,  although  undetected  ;  the  accounts  do 
not  state  whether  or  not  there  was  any  further  evidence  of  disease,  but  such 
a  thing  is  quite  possible. 

As  to  the  third  class,  any  one  familiar  with  the  fearful  force  of  muscular 
action  often  manifested  by  patients  afiected  with  epilepsy  or  tetanus,  will 
see  the  absurdity  of  applying  the  word  "  spontaneous"  to  fractures  occurring 
under  such  circumstances. 

^^"othing  ever  occurs  spontaneously,  either  in  normal  or  in  pathological 
phenomena ;  although  it  may  be  that  the  chain  is  not  traceable  without 
closer  observation  or  clearer  insight  than  is  brought  to  bear  upon  it. 

Mechanism  of  the  Production  of  Fractures. 

It  has  already  been  remarked  that  the  main  function  of  the  bony  skeleton, 
and  of  each  of  its  component  parts,  is  mechanical,  and  is  carried  on  in  accord- 
ance with  the  known  laws  of  mechanics.  Further  than  this,  each  bone  is  a 
member  of  a  system,  made  up  of  two  or  more  bones,  united  together  by 
ligaments,  and  moved  upon  one  another  more  or  less  freely  by  the  action  of 
muscles,  so  that  the  mechanical  conditions  involved  are  somewhat  complex, 
and  can  only  be  arrived  at  by  the  study  of  the  structure,  form,  and  connec- 
tions of  the  members  of  each  system.  When  the  strain  put  upon  a  bone  is 
beyond  its  power  of  resistance,  its  fracture  takes  place  in  obedience  to  the 
same  laws,  and  under  the  influence  of  the  same  conditions.  Hence,  if  any 
one  studies  a  large  number  of  fractures,  placing  them  in  series  according  to 
the  portion  of  the  skeleton  involved,  he  may  readily  note  a  certain  uniformity 
which  prevails  among  the  difierent  members  of  each  series.  Variations  do 
indeed  exist,  but  they  are  traceable  to  differences,  perhaps  slight,  in  the  char- 

'  Malgaigue,  Translation,  p.  26. 

2  Stanley,  op.  cit.,  pp.  190,  194  ;  Wickham's  case,  from  London  Medical  and  Physical  Journal, 
vol.  Ivii. 

3  Amer.  Med.  Times,  July  21,  1860.  *  Med.  Times  and  Gazette,  Dec.  25,  1852. 


14 


INJURIES  OF  BONES. 


Fig.  802 


Diagram  supposed  to  represent  extra-capsular 
fracture  of  the  cervix  femoris.  An  impossible 
line  of  fractui-e. 


acter,  direction,  or  exact  mode  of  application  of  the  fracturino-  force  or  In 
the  conditions  of  resistance,  or  perhaps  in  the  shape  of  the  bones 'them- 
selves. Ihe  dominant  lines  of  breakage  are  singularly  constant;  and 
although  they  have  been  pointed  out  in  regard  to  certain  special  fractures 
they  have  been  overlooked  in  the  general  study  of  these  injuries  ' 
m  such  uniformity  exists  in  the  case  of  china,  marble,  or  plaster.  A  bowl 
or  statue,  struck  or  thrown  down,  may  be  shattered  into  fragments  of  the 

most  fantastic  and  apparently-  capricious 
shapes.  Or  if  several  exact  models  of  a 
femur  were  made  in  plaster,  and  force  ap- 
plied to  them,  they  would  be  cracked, 
shivered,  or  broken  off  short,  in  the  most  ir- 
regular way.  The  annexed  outline  (Fig.  802) 
is  taken  from  a  cut  which  has  been  used  by 
eminent  authors  as  a  representation  of  ex- 
tracapsular fracture  of  the  cervix  femoris  ; 
but  I  Avill  venture  to  say  that  no  one  ever 
saw  such  a  fracture,  and  that  any  one  will 
be  convinced  of  its  impossibility  who  will 
look  at  a  vertical  section  of  the  head  and 
neck  of  the  femur.  What  the  dominant 
lines  really  are,  will  be  shown  when  the 
discussion  of  fractures  of  this  part  comes 
in  order. 

Only  a  brief  review  can  be  sfiven  here  of 
t,,,^  +1  1      •    •  1     ,  . .  mechanical  conditions  of  the  skeleton ; 

but  the  genera  principles  laid  down  will  be  found  to  be  verified  in  the 
case  of  special  bones  and  their  fractures. 

Upon  an  exterior  survey,  it  is  at  once  seen  that  the  long  bones  are  narrow 
n  their  shafts,  and  expanded  at  either  end  for  the  purpos^e  of  strengthening 
the  articulations  It  will  be  also  noted  that  they  are  almost  without  excep" 
tion  curved,  and  that  many  of  them  are  twisted  in  a  marked  degree.  These 
irregularities  of  form  are-more  pronounced  in  some  skeletons  than  in  others, 
borne  of  the  bones,  notably  the  lower  jaw  and  the  femur,  are  strongly  bent. 

Upon  making  sections-of  the  femur  for  instance,  this  bone  affbrdin-  the 
most  striking  example-it  will  be  seen  that  the  shaft  consists  of  a  tubc^vith 
1    "^r^  "^V"'^  gradually  pass  toward  either  end  into  a  thin 

shell,  filled  with  a  network  of  cancellous  bony  tissue,  of  which  more  will  be 
saic  presently  The  aggregate  of  osseous  substance  is  the  same  throughout ; 
so  that  an  inch  of  the  length,  taken  from  the  middle  of  the  shaft  of  the  femur 
will  weigh  about  the  same  as  an  inch  of  the  length  cut  near  either  end.  Sec- 
tions ot  the  pelvis  and  scapula  will  show  a  very  analogous  arrangement  be- 
tween their  flat  and  their  spongy  portions  ;  and  the  same  may  be^said  of  the 
yertebrf^  In  other  words,  the  structure  of  all  bones  is  adapted  to  the  bear- 
ing ot  either  strain  or  pressure,  or  both.  Where,  as  in  the  shafts  of  the  long 
bones,  strain  is  to  be  provided  for,  the  material  is  massed  in  tubes  of  ade- 
quate thickness  of  wall  ;  and  it  will  always  be  found  that  this  thickness  is 
greatest  on  the  concavity  of  curves.  On  the  other  hand,  where,  as  at  the 
articulating  ends,  pressure  is  io  be  sustained,  the  bony  substance  is  spread 
out  so  as  to  give  surface.  Allusion  was  just  made  to  the  backing  up  of  the 
thm  shell  thus  formed,  by  reticular  tissue  ;  and  this  deserves  special  notice. 

J^.verywhcre  in  the  spongy  bones,  as  well  as  in  the  articular  ends  of  the 
ong  bones  the  lamellae  forming  this  network  run  at  right  angles  to  the  sur- 
face, so  as  to  receive  the  pressure  directly  upon  their  extremitfes,  and  thus  to 


MECHANISM  OF  THE  PRODUCTION  OF  FRACTURES. 


15 


afford  the  greatest  possible  strength.  Sections,  vertical  or  transverse,  of  the 
bodies  of  the  vertebrae,  of  the  astragalus,  of  the  carpal  or  tarsal  bones,  or  even 
of  the  articular  ends  of  the  phalanges,  will  show  this  law  ;  aud  it  will  be  fur- 
ther-noticed that,  in  any  of  these  cases,  if  the  surface  to  receive  pressure  is 
concave,  the  shell  of  bone  is  thickened  accordingly.^ 

If  now  the  lines  of  muscular  traction  be  considered,  the  further  fact  will 
appear  that  it  is  invariably  exerted  so  as  to  bear  in  the  length  of  these  columns 
of  bony  tissue,  whether  of  the  shafts  or  of  the  extremities  of  the  long  bones, 
or  of  the  mass  of  those  more  or  less  cubical  in  shape.  The  ribs,  pulled  upon 
by  the  intercostal  muscles  at  their  upper  and  lower  margins,  are  tilled  from 
end  to  end  with  cancellous  tissue,  so  arranged  as  to  take  the  strain  thus 
imposed,  while  other  lamellae,  placed  transversely,  meet  the  effect  of  pressure ; 
hence  these  bones,  although  long  in  shape,  are  analogous  to  the  so-called 
thick  or  round  bones  in  structure.  In  looking  at  the  relations  of  the  ribs  to 
muscles,  it  must  not  be  forgotten  that  very  powerful  strain  is  brought  upon 
these  bones  by  some  of  the  muscles  acting  on  the  upper  extremity  ;  but 
it  will  be  found  that  in  this  respect  also  the  same  law  as  to  the  distribution 
of  stress  is  carried  out,  so  as  to  reduce  it  to  a  minimum  for  each  portion  of 
each  bone. 

The  lines  of  tension  of  the  muscles  always  form  more  or  less  acute  angles 
with  the  axes  of  strength  of  the  bones  acted  upon  by  them ;  and  this  rule  is 
more  close  and  definite  in  proportion  to  the  length  and  power  of  the  muscu- 
lar masses  concerned. 

From  what  has  now  been  said,  it  will  probably  be  apparent  that  the  arrange- 
ment of  the  bony  material  is  such  as  to  adequately  provide  for  meeting  all 
the  stress  to  which  it  is  normally  exposed.  Let  it  be  recalled,  however,  that 
each  bone  is  but  a  member  of  a  mechanical  system  of  levers,  and  hence  that 
the  force  brought  to  bear  upon  it  may  be  vastly  increased,  as  well  as  changed 
in  direction,  so  as  to  take  it  at  a  disadvantage.  Under  these  circumstances, 
its  texture  gives  way  to  what  is  called  in  mechanics  a  "  cross-breaking  strain." 
The  obliquity  of  most  fractures  with  regard  to  the  long  axis  of  the  portion 
of  bone  involved,  to  be  presently  noticed  as  almost  if  not  altogether  univer- 
sal, is  an  additional  proof  of  the  correctness  of  this  view. 

'^o\Y  the  prevalence  of  this  mechanism,  together  with  the  systemic  rela- 
tion of  each  bone,  above  recalled,  may  serve  to  explain  in  great  degree  the 
existence  of  the  dominant  lines  of  breakage  to  which  reference  has  been  made, 
and  which  will  be  further  spoken  of  in  connection  w^ith  special  fractures. 

A  bone  being  broken  across,  it  will  easily  be  seen  how^  in  very  many  in- 
stances one  of  its  fragments  may  engage  in  the  other,  and  act  as  a  w^edge  to 
split  it  into  two  or  more  smaller  fragments. 

The  natural  curves  of  the  long  bones,  and  the  slight  twist  which  is  pre- 
sented by  the  longitudinal  axes  of  many  of  them,  although  of  advantage  in 
their  normal  function,  may  render  their  fracture  easier  under  certain  circum- 
stances. 

Of  all  these  mechanical  conditions,  instances  will  present  themselves  in 
connection  with  special  fractures  ;  and  the  general  statements  now  made  may 
suffice  for  the  present. 

1  The  reader  will  find  this  subject  well  set  forth  and  illustrated  in  WagstaflFe's  Student's  Guide 
to  Haman  Osteology,  London,  1875  ;  and  by  Wyman,  Trans.  Am.  Med.  Assoc.  for  1850.  It  has 
been  almost  wholly  overlooked  by  systematic  writers  on  anatomy. 


16 


INJURIES  OF  BONES. 


Varieties  of  Fracture. 

A  good  many  terms  have  from  time  to  time  been  suggested  with  a  view  to 
the  designation  of  peculiarities  presented  by  these  injuries,  but  only  a  few  are 
or  need  be  retained.  Confusion  has  arisen  from  the  employment  of  some  of 
these  terms  in  different  senses  by  different  authors ;  it  is  therefore  especially 
necessary  to  define  them  as  they  will  be  used  in  the  following  pages.  With 
regard  to  some  of  the  varieties,  the  mere  definition  will  sufiice;  but  of  others 
I  shall  have  to  speak  more  at  length,  and  will  do  so  here  for  the  sake  of  con- 
venience. 

Simple  and  Compound  Fractures. — A  sim.ple  fracture  is  one  to  which  the 
atmosphere  does  not  find  access,  the  soft  parts  remaining  so  far  intact  as  to 
exclude  it.  _  There  may  be  very  extensive  injury  of  all  the  tissues,  and  the 
skin  not  divided  ;  or  there  may  be  a  gaping  wound  of  the  skin,  and  the  mus- 
cles and  fasciae  untorn;  but  in  either  case,  the  fracture  is  still  a  simple  one. 

When  the  external  air  is  admitted  to  the  broken  portion  of  bone,  whether 
by  the  action  of  the  fracturing  force  wounding  the  soft  parts  from  without, 
or  by  the  thrusting  of  the  fragments  through  the  skin,  the  injury  is  called  a 
compound  fracture. 

A  fracture,  at  first  simple,  may  become  compound  by  a  process  of  slough- 
ing or  ulceration,  or  by  suppuration ;  and  conversely,  a  fracture,  compound 
either  primarily  or  secondarily,  may  become  simple  by  the  healing  of  the 
external  wound  and  the  consequent  exclusion  of  the  air. 

Compound  fractures,  as  would  naturally  be  supposed,  vary  extremely  in 
severity ;  but  they  are  always  more  serious  than  the  same  amount  of  bone- 
injury  would  be  if  not  exposed  to  the  air.  Sometimes  the  opening  in  the 
skin  is  but  small,  yet  the  bone  is  very  extensively  crushed  and  splintered,  and 
the  other  soft  parts  have  been  torn  and  bruised  beyond  repair  ;  sometimes  the 
bone  suffers  very  largely,  while  the  soft  parts  are  very  little  injured  ;  some- 
times the  wounding  of  the  tissues  about  the  bone  is  greatly  in  excess,  the 
bone  itself  being  merely  broken  across ;  and  in  some  cases  a  formidable  lace- 
ration of  the  skin  may  attend  upon  comparatively  trifling  hurts  to  the  deeper 
soft  parts  and  to  the  bone  itself. 

Railroad,  machinery,  and  mining  accidents,  and  falls  from  heights,  are  the 
most  frequent  causes  of  compound  fractures,  which  may,  however,  be  produced 
by  much  less  formidable  forces.  I  have  several  times  seen  these  injuries,  so 
grave  as  to  require  amputation,  the  result  of  slight  falls.  An  attempt  to  rise 
and  walk  will  sometimes  convert  a  simple  fracture  of  the  leg  into  a  compound 
one,  by  the  ends  of  the  fragments  penetrating  the  skin.  Occasionally  the  seat 
of  fracture  is  laid  bare  secondarily  by  the  occurrence  of  suppuration  or  by 
sloughing  of  the  superjacent  soft  parts  ;  but  here  the  gravity  of  the  condition 
is  not  dependent  upon  the  mere  exposure  of  the  bone. 

Compound  fractures  are  more  serious  than  simple,  because  they  involve  as 
a  general  thing  more  severe  injury  to  the  bone  itself;  because  in  them  the 
tearing  of  the  periosteum,  an  almost  invariable  accompaniment  of  any  break- 
ing of  the  bone,  is  apt  to  be  greater,  whence  there  is  more  risk  of  impair- 
ment of  nutrition — recovery,  as  will  presently  be  further  shown,  being  thus 
hindered,  rendered  more  dififtcult,  or  prevented  ;  because  the  violence  done  to 
the  surrounding  soft  parts  is  greater ;  and  because,  independently  of  any  sep- 
tic influence  exerted  by  the  atmosphere,  subcutaneous  injuries  of  all  kinds 
are  repaired  more  readily  than  those  which  are  deprived  of  the  protection  of 
the  skin.    Suppuration  is  almost  sure  to  follow  upon  compound  fracture  :  it 


VARIETIES  OF  FRACTURE. 


17 


is  only  in  very  rare  instances  that  the  immediate  closure  of  the  wound  can  be 

effected.  .  ^       ^  j- 

It  is  in  compound  fractures,  more  frequently  than  m  any  other  class  ot 
injuries,  that  the  question  of  amputation  is  raised. 
For  the  discussion  of  the  conditions  requiring  it,  the 
reader  is  referred  to  the  article  on  Amputation.^ 
The  treatment  of  compound  fractures  not  calling  for 
the  removal  of  the  limb,  will  be  considered  iu  con- 
nection with  that  of  fractures  .generally. 

Multiple,  Comminuted,  and  Impacted  Fractures. 

 When  there  are  two  or  more  distinct  breakages, 

whether  of  the  same  bone  or  of  different  bones,  the 
case  is  said  to  be  one  of  multiple  fracture. 

When  there  are  several  fragments,  the  fracture  ia 
said  to  be  comminuted.  (Fig.  803.)  Sometimes 
there  is  one  main  line  of  breakage,  and  the  end  of 
one  or  of  both  fragments  is  split  or  shattered  into 
several  smaller  ones.    (See  Fig.  804,  d.) 

Impacted  fracture  is  said  to  exist  when  one  of  the 
fragments  penetrates  the  other,  and  is  so  wedged 
into  it  as  to  limit  or  prevent  their  mobility  upon  one 
another.  Usually  there  is  first  a  partial  separation, 
and  then  either  by  external  force  or  by  muscular 
contraction  the  wall  of  one  fragment  is  driven  into 
the  cancellous  structure  of  the  other. 


Comminuted  fracture. 


Multiple  fractures  are  generally  produced  by  very  great  violence,  such  as 
railroad  or  machinery  accidents,  or  falls  from  heights ;  forces  being  exerted 
either  at  the  same  moment,  or  successively,  upon  different  portions  of  a  limb 
or  of  the  body.  They  derive  their  gravity  either  from  the  amount  of  injury 
inflicted,  and  the  consequent  shock  to  the  system,  or  from  the  difiiculty 
involved  in  the  application  of  proper  dressings. 

Some  years  ago  a  man  was  brought  to  the  Episcopal  Hospital,  who,  while  drunk,  had 
been  run  over  by  a  "dummy"  engine  as  he  was  stooping  down  to  hunt  for  his  pipe  on 
the  ground.  Almost  all  the  bones  in  his  body  seemed  to  be  broken,  except  those  of  the 
head  ;  his  ribs  were  smashed  ;  his  pelvis  ground  up  so  that  it  felt  like  a  mass  of  loose 
stones,  and  his  extremities  could  be  twisted  about  in  any  direction.  He  died  about  an 
hour  after  the  alleged  time  of  the  accident. 

In  December,  1881,  a  colored  man,  aged  32,  was  brought  to  the  Episcopal  Hospital, 
having  been  injured  by  a  derrick  falling  upon  him.  He  presented  but  slight  symptoms 
of  shock,  but  died  in  about  two  hours.'  On  examination  it  was  found  that  eight  ribs  on 
the  left  side  were  broken,  and  seven  on  the  right ;  on  the  left  side  the  pleura  was 
wounded,  and  the  eighth  intercostal  artery  was  divided  by  a  spiculum  of  bone  ;  on  the 
right  side  four  of  the  ribs  had  injured  the  pleura,  and  two  had  penetrated  the  lung  also. 
In  each  pleural  cavity  there  were  a  number  of  spicula  of  bone.  Fractures  of  the  spinous 
and  transverse  processes  of  the  second,  third,  fourth,  and  fifth  lumbar  vertebra?,  and  on 
the  left  side  division  of  two  lumbar  arteries  by  spicula,  causing  large  hemorrhage  into 
the  areolar  tissue,  were  noted.  There  were  also  oblique  fractures  of  the  right  femur  in 
its  lower  third,  and  of  the  left  fibula  in  its  upper  third,  with  rupture  of  the  internal 
lateral  ligament  of  the  knee. 

Gross^  speaks  of  an  old  woman,  w^ho,  by  a  fall  from  a  third  story  window, 
sustained  no  less  than  eighty-three  fractures. 


»  Vol.  I.  p.  560. 
VOL.  IV. — 2 


2  Op.  cit.,  vol.  i.  p.  898. 


18 


INJURIES  OF  BOXES, 


Less  interest  attaches,  however,  to  eases  such  as  tho>e  just  o-iven  (the  list 
ot  which  might  he  almost  indefinitely  extended),  which  are  inevitably  fatal 
than  to  those  in  which  only  two  or  three  fractures  are  sustained,  and  in  which 
the  treatment  presents  points  of  much  ditficulty. 

In  April,  1882,  a  boy,  aged  14,  was  brought  to  St.  Joseph's  Hospital,  havintr  been 
carried  ten  times  around  a  revolving  shaft.    He  had  fractures  of  the  ric^ht  humerus 
radius  and  ulna,  and  temur,  and  of  the  left  radius  and  ulna  ;  also  dislocation  of  the  hip 
and  elbow  on  the  right  side.    There  was  marked  shock  ;  but  he  ultimately  made  a 
good  recovery. 

I  was  called,  in  1881,  by  Dr.  Downs,  of  Germantown,  to  a  young  man,  ao'ed  22, 
who  had  had  his  right  arm  caught  around  a  shaft,  and  had  sustained  fracturel  of  the 
humerus,  radius  and  ulna,  and  metacarpus.  The  swelling  of  the  whole  limb  and  shoul- 
der  was  so  great  as  to  mask  the  injuries  somewhat,  and  "to  interfere  with  the  manage- 
ment of  the  case  ;  but,  as  it  subsided,  we  succeeded  in  getting  the  bones  into  good 
position,  and  an  almost  perfect  restoration  of  all  the  functions  of  the  part  was  effected. 

When  a  part  contains  two  bones,  and  a  fracture  of  both  is  caused  by  the 
same  violence,  although  at  such  difl:'erent  levels  that  the 
two  lesions  are  quite  separate,  the  case  is  not  said  to  be 
one  of  multiple  fracture  •}  nor  is  the  term  applied  to 
cases  where  several  ribs  are  broken,  unless  the  injur\' 
should  afiect  both  sides,  or  be  not  only  at  different 
points,  but  due  to  forces  acting  distinctly" only  on  those 
points.  Two  or  more  separate  fractures"^  each  requiring 
special  attention  in  the  way  of  treatment,  must  exist  in 
order  to  brhig  the  case  properly  under  the  present  head. 

Of  course,  very  various  combinations  of  fractures 
may  present  themselves,  and  must  be  dealt  with  accord- 
ing to  the  best  judgment  of  the  surgeon.  Some  of  these 
combinations  will  be  referred  to  more  in  detail  in  speak- 
ing of  fractures  of  special  reo'ions. 

Traxsverse,  Oblique,  axd  Loxgitudixal  Fractures. 
—Fractures  are  further  divided  according  to  their  direc- 
tion, into  transverse,  oblique,  and  longitudinal ;  these  terms 
having  reference  to  the  relation  of  the  line  of  fracture 
to  the  longitudinal  axis  of  the  portion  of  bone  involved. 
(Fig.  804;  r/,  transverse :  oblique;  r-,  mixed  oblique 
and  longitudinal.) 

Transverse  fractures,  strictly  speaking,  are  extremely 
rare.  Occasionally  they  are  met  with  In  the  succuleiit 
bones  of  the  very  young,  and  sometimes  as  the  result 
of  extreme  violence,  f  once  saw  a  thigh-bone  broken 
directly  across  by  the  impact  of  a  heavy  chai'o-e  of  shot 
at  very  close  range.  But  as  an  almost  universal  rule,  a 
greater  or  less  amount  of  obliquity  may  be  looked  for 
in  fractures;  a  fact  which  has  already  been  alluded 
to  in  support  of  the  leverage  theory  of  "the  mechanism 
of  the  production  of  these  injuries. " 

Lono-itudinal  fractures  are  also  very  rare,  except  as 
subordinate  to  other  lines  of  breakage.     Fio-.  805 
copied  from  Holmes's  "System  of  Surgery,"  represents 

1  Non-professional  people  often  say  that  a  man  had  his  leg  "broken  in  two  place*  *"  when 
they  merely  mean  that  both  bones  were  broken. 


VARIETIES  OF  FRACTURE. 


19 


a  remarkable  instance  of  a  tibia  split  for  a  considerable 
portion  of  its  length.  Generally,  the  fractures  called 
longitudinal  are  merely  extremely  oblique,  so  as  to  be 
nearly  parallel  to  the  axis  of  the  bone.  It  almost 
always  liappens  that  the  fragments  are  serrated  along 
their  margins,  by  the  irregularity  with  w^hich  the  fibres 
o-ive  way.  Sometimes  the  serrations  are  fine  and  close, 
but  oftener  the  line  of  fracture  is  extremely  jagged,  and 
presents  several  strongly  marked,  tooth-like  processes. 
The  proper  coaptation  of  these  edges  may  be  very  difii- 
cult,  by  reason  of  their  interlocking ;  but  if  it  be  once 
eftected,  they  serve  to  prevent  the  reproduction  of  the 
displacement.  It  will  readily  be  perceived  that  project- 
ini>;  portions  of  the  fragments  are  apt  to  be  broken  off, 
an^l  that  they  may  occasionally  give  rise  to  much  trou- 
ble by  acting  as  foreign  bodies. 

Varieties  of  Incomplete  Fracture. — So  far,  refer- 
ence has  been  made  only  to  complete  fractures,  in  which 
the  whole  thickness  of  the  bone  is  broken  through.  It 
remains  to  say  something  of  incomjjlete  fractures — a 
term  which  embraces  a  variety  of  forms  of  injury. 

Fissures  or  cracks  need  hardly  be  formally  defined  here.  They  occur 
mostly  as  accessory  to  complete  fractures,  from  which  they  branch  off",  fre- 
quently in  a  spiral  course.  In  the  flat  bones,  and  especially^  in  those  of  the 
cranium,  they  are  often  met  with,  and  may  be  stellate,  radiating,  or  caine- 
rated.  Very  rarely,  they  exist  alone  in  the  long  bones,  as  the  result  of  vio- 
lence not  quite  sufficient  to  break  the  wdiole  thi^ckness  of  the  shaft ;  in  such 
cases  they  may  be  unsuspected  until  much  and  long-continued  mischief  has 
been  caused.  Some  of  the  recorded  instances  will  be  referred  to  in  connec- 
tion with  the  special  bones  concerned. 

Splintered  fractures  are  such  as  consist  in  the  detachment  of  a  small  por- 
tion, generally  an  edge,  of  a  bone,  the  main  body  of  which  is  left  intact. 
They  are  seen  occasionally  at  the  brim  of  the  pelvis,  or  at  the  spine  of  the 
tibia ;  but  for  obvious  reasons  they  may  readily  pass  unrecognized  unless 
attended  with  a  wound  making  them  compound. 

Perforations  of  bone  are  ahvays  compound  fractures,  and  almost  invariably 
the  result  of  gunshot  injury ;  the  reader  is  therefore  referred,  for  information 
concerning  them,  to  the  article  on  Gunshot  Wounds.^ 

Sprain  fractures  have  been  already  briefly  mentioned  under  the  head  of 
fractures  by  avulsion,"  as  those  in  which  small  fragments  of  bone  are 
pulled  away  by  excessive  stress  put  upon  the  ligamentous  fibres  attached  to 
them.  Thus  Bruce ^  has  published  a  case  in  wdiich,  by  a  fall  from  a  second 
story  window,  a  boy  aged  12,  had  a  piece  torn  out  of  the  right  tibia,  and  one 
out  of  the  left  femur,  in  each  instance  by  the  anterior  crucial  ligament.  And 
DitteP  is  reported  to  have  met  with  an  instance  in  Avhich  the  spine  of  the 
tibia  was  tlius  wrenched  away  in  a  man  who  w^as  violently  kicked  in  the  ham. 
Cases  are  referred  to  as  observed  by  Poncet,  and  one  at  the  University  College 
Hospital,  in  London,  in  a  boy  aged  11,  who  had  been  run  over  by  a  cart. 
Dittel  failed  to  produce  this  lesion  experimental!}^  on  the  dead  subject. 

Shepherd*  has  described  a  fracture  of  the  portion  of  the  astragalus  into 

1  Vol.  II.  pp.  121  et  seq. 

2  Trans,  of  the  Pathological  Society  of  London,  vol.  xviii.  1867. 

»  Med.  Times  and  Gazette,  Sept.  30,  1876  (from  Centralblatt  fur  Chirurgie). 
4  Med.  News,  June  10,  1882. 


Fig.  805. 


Longitudinal  fracture  of 
tibia. 


20 


INJURIES  OF  BONES. 


which  the  posterior  fascicukis  of  the  external  lateral  ligament  of  the  ankle 
joint  is  inserted,  which  probably  belongs  in  this  class.  He  exhibited  four 
specimens,  all  however  taken  from  bodies  in  the  dissecting-room,  and  with^ 
out  history. 

Callender,  who  I  believe  first  gave  the  name  of  "  sprain-fractures"  to  these 
injuries,!  suggests  that  the  bit  of  detached  bone  may  remain  held  by  its  liga- 
mentous connection,  but,  failing  to  unite,  may  act  as  a  foreio;n  body,  occa- 
sionally getting  caught  in  the  joint.  Of  this,  however,  there  is  no  known 
instance. 

I  have  recently  seen  a  case  in  which  the  tip  of  the  inner  malleolus  was 
torn  off  in  a  fall  on  the  ice ;  whether  it  united  or  not  I  cannot  say,  but  the 
injury  was  followed  by  very  intractable  lameness.  Yery  little  is  as  yet  known 
in  regard  to  this  form  of  fracture,  to  which  special  attention  has  only  re- 
cently been  attracted ;  but  the  injury  to  the  bone  adds  to  the  gravity  of  the 
case,  renders  recovery  much  slower,  and  may  even  cause  permanent*^  impair- 
ment of  the  functions  of  the  limb.  Such  cases,  there  can  be  no  doubt,  have 
often^  been  unrecognized.  Crepitus  may  sometimes  be  detected,  but  may  be 
wanting  by  reason  of  effusion  into  the  joint  or  into  the  tissues,  or  because 
the  small  fragment  is  separated  from  the  main  portion  of  the  bone. 

Any  case  of  sprain  or  other  injury  about  a  joint  should  be  carefully  ex- 
amined with  reference  to  the  existence  or  non-existence  of  this  form  of  frac- 
ture, and  its  possibility,  or  proof  of  its  presence,  should  influence  the  surgeon 
in  making  and  expressing  a  prognosis. 

_  Partial  fractures  are  those  in  which  a  bone  is  so  acted  upon,  either  by 
direct  or  by  indirect  violence,  that  some  of  its  fibres  are  broken,  while  the 
rest  are  only  bent.  Sticks  are  often  broken  in  this  way,  especially  when 
they  are  green  and  tough  ;  hence  the  name  "  green-stick" 2  or  willow"  frac- 
ture has  been  given  to  this  form  of  injury.  And  fractures  of  this  kind  are 
especially  apt  to  be  met  with  in  the  tough  and  resilient  bones  of  the  young,  in 
whom,  moreover,  the  periosteum  is  proportionately  thicker  and  less  apt  to  he 
torn  through  than  in  later  life.  Otto^  says  that  he  has  seen  incomplete  frac- 
ture in  the  radius  of  a  lion,  as  also  in  the  bones  of  animals  of  the  deer  kind. 

Reference  may  be  best  made  here  to  the  subject  of  bending  of  hones,  about 
which  there  has  been  much  discussion,  some  surgeons  maintaining  that  it  is 
common,  and  others  that  it  is  impossible.  Without  going  into  the  history  of 
the  question,  I  may  say  that  cases  were  long  since  observed,  in  which,  generally 
in  the  forearm,  distortion,  or  rather  angular  deformity ,  was  noticed,  but  without 
any  of  the  other  signs  of  fracture  to  be  presently  described.  Sometimes, 
indeed,  there  was  pain,  and  always  more  or  less  loss  of  power ;  but  not  the 
helpless  dangling  of  the  limb  usual  in  fracture.  Hence  it  was  claimed  that 
the  affected  bones  were  not  broken,  but  only  bent.  Experience,  however, 
showed  that  whenever  dissections  were  made  in  such  cases,  the  lesion  was 
found  to  be  incomplete  or  partial  fracture,  as  above  described.  It  must  be 
admitted  that  Hamilton^  succeeded  in  bending  experimentally  the  bones  of 
young  animals ;  but  this  does  not  prove  the  possibility  of  such  a  thing  in  the 
human  subject ;  and  for  practical  purposes  it  is  better  to  regard  and  treat 
cases  of  apparent  bending  as  partial  fractures.  I  believe,  indeed,  that  this 
would  be  the  true  view  of  bending,  if  that  were  shown  to  exist ;  that  is,  that 

*  St.  Bartholomew's  Hospital  Reports,  vol.  vi.  1870. 

*  "  There  is  also  a  curvedness  which  may  be  reduced  to  a  fracture.   I  have  seen  it  in  children 

often  It  is  as  it  were  when  you  break  a  green  stick  ;  it  breaks,  but  separates 

not." — Wiseman,  "  Chirurgical  Treatises,"  vol.  ii.  book  vii.  p.  239,  6th  ed.  1734. 

'  Compendium  of  Human  and  Comparative  Pathological  Anatomy,  translated  by  South.  Lon- 
don, 1831. 

^  Op.  cit.,  p.  85. 


VARIETIES  OF  FRACTURE. 


21 


the  crumpling  up  of  the  bony  tissue  of  the  wall  on  the  concavity,  would 
amount  to  a  solution  of  continuity  equivalent  to  the  rupture  of  the  bony 
fibres  of  the  wall  on  the  convexity  in  the  usual  form  of  partial  fracture,  and 
that  the  difference  would  be  simply  that  in  the  former  case  the  convex  wall, 
and  in  the  latter  the  concave,  remained  unsevered.  Such  a  result  is  often 
produced  in  the  attempt  to  bend  metallic  tubes,  and  may  have  existed  in  the 
really  tubular  bones  which  were  experimented  upon  by  Hamilton,  as  above 
mentioned. 

Partial  or  "  willow"  fractures  are  generally  produced  by  moderate  force,  or 
by  great  force  acting  slowly.  Thus  in  many  of  the  recorded  cases  they  have 
been  the  result  of  slight  falls;  and  Hodge ^  and  Parkman^  have  seen  them 
in  young  men  carried  around  revolving  shafts.  Farquharson^  published  one 
in  a  young  man  of  18,  sustained  in  a  foot-ball  match.  Two  very  remarkable 
cases,  due  to  gunshot,  were  observed  during  our  late  war.*  They  affected 
the  right  ninth  rib  and  the  left  fourth  rib,  and  the  patients  were  aged  respec- 
tively 21  and  28  years. 

The  restoration  of  the  shape  of  the  limb  is  apt  to  be  very  difficult,  and  in 
its  accomplishment  the  fracture  is  often  rendered  complete.  Sometimes, 
however,  it  has  been  gradually  brought  about  by  nature,  apparently  as  the 
result  of  the  continuous  action  of  the  surrounding  muscles. 

Epiphyseal  separations  or  disjunctions,  met  with  only  in  the  young,  be- 
fore consolidation  by  bone  has  taken  place  between  the  diaphyses  and  the 
epiphyses,  do  not  differ  materially  from  fractures,  although  the  tissue  which 
gives  way  is  not  true  bone,  but  the  cartilage-like,  osteogenetic  matrix.  Some- 
times in  these  cases  the  line  of  separation  seems  to  be  very  nearly  if  not 
quite  transverse.  Union  generally  takes  place  readily,  but  the  subsequent 
growth  and  development  of  the  whole  bone  has  seemed  in  some  instances  to 
have  been  interfered  with. 

Hutchinson^  gives  instances  of  deficient  growth  in  bones  which  have  been 
the  seat  of  such  injuries,  and  Holmes^  says  that  he  has  several  times  noted  this 
after  fractures  in  the  neighborhood  of  the  wrist.  In  all  cases  the  child's 
friends  should  be  informed  of  the  probability  of  impaired  development  as  a 
result.  Holmes,  from  a  study  of  the  specimens  contained  in  the  Museum 
of  St.  George's  Hospital,  is  inclined  to  agree  with  some  of  the  French  sur- 
geons^ in  the  opinion  that  "the  line  of  fracture  seldom  runs  accurately  through 
the  epiphyseal  cartilage  in  its  whole  course." 

I  shall  have  occasion  to  refer  to  these  injuries  again  in  speaking  of  ordi- 
nary fractures  affecting  special  bones  in  the  neighborhood  of  their  articular 
extremities. 

Complicated  Fractures. — This  term  has  a  special  significance  in  surgery. 
According  to  ordinary  speech,  any  coincident  condition,  such  as  delirium 
tremens,  tetanus,  or  disease  of  the  liver  or  kidney — rendering  the  treatment 
more  difficult  and  the  prognosis  more  grave — might  be  said  to  complicate  a 
fracture;  and  so  also  would  the  existence  of  other  fractures  or  injuries,  even 
in  distant  regions  of  the  body.    But,  in  surgical  language,  a  complicated  frac- 

1  Proceedings  of  the  Pathological  Society  of  Philadelphia,  vol.  i.  p.  232. 

*  Am.  Journal  of  Med.  Sciences,  Oct.  1853. 
3  British  Med.  Journal,  Dec.  4,  1869. 

♦  Med.  and  Surg.  History  of  the  War  of  the  Rebellion.  First  Surgical  Volume,  pp.  567  and 
568. 

5  Transactions  of  the  Pathological  Society  of  London,  vols.  xiii.  and  xvii. 
^  Surgical  Treatment  of  the  Diseases  of  Infancy  and  Childhood,  1868,  p.  240. 
Grazette  des  Hopitaux,  1865. 


22 


INJURIES  OF  BONES. 


ture  is  one  along  with  which  there  is  some  serious  surgical  lesion  of  neigh 
boring  structures. 

Thus  there  may  be  extensive  wounding  of  the  soft  parts,  but  not  admitting 
the  air  to  the  broken  ends.  (Such  admission  of  air  would,  as  before  said, 
make  the  fracture  compound  ;  and  while  the  fact  of  its  being  compound  really 
constitutes  a  complication,  there  is  a  propriety,  as  well  as  convenience,  in 
limiting  the  use  of  these  terms.) 

Again,  the  original  violence  may  have  not  only  broken  the  bone,  but  also 
ruptured  the  adjacent  artery  or  a  vein  of  considerable  size,  or  lacerated  a  large 
nerve-trunk.  Such  rupture  or  laceration  may  also  be  caused  by  contact  with 
the  sharp  or  jagged  edge  of  one  of  the  fragments. 

Or,  besides  the  fracture,  there  may  be  luxation  of  the  neighboring  joint; 
or,  without  dislocation,  the  joint  may  have  been  seriously  damaged. 

Or,  in  certain  positions,  important  viscera  may  have  been  lacerated  or 
penetrated  by  the  fragments ;  thus  the  bladder  is  apt  to  be  ruptured  in  frac- 
tures of  the  pelvis,  and  the  lungs,  or  even  the  heart,  may  be  wounded  in  frac- 
tures of  the  ribs. 

The  amount  and  character  of  the  influence  exerted  by  these  other  lesions 
upon  the  course  of  a  case  of  fracture,  vary,  as  might  be  supposed,  very  greatly. 
Some,  as  wounds  of  the  soft  parts,  merely  embarrass  the  surgeon  in  his  treat- 
ment;  others,  like  luxations,  require  special  measures  for  their  relief;  or,  if 
uncorrected,  will,  in  a  marked  degree,  vitiate  the  ultimate  usefulness  of  the 
hmb.  Injuries  of  vessels  or  nerves,  superadded  to  fracture,  may  necessitate 
amjDutation. 

But  there  is  a  large  class  of  complicated  fractures— those  in  which  the  vis- 
cera are  wounded— in  which  the  gravity  of  the  complication  is  apt  to  be  such 
as  to  altogether  overshadow  that  of  the  fracture.  These  cases  may  be  ame- 
nable to  surgical  treatment,  as,  for  example,  when  the  bladder  is  ruptured  in 
fracture  of  the  pelvis,  and  success  depends  upon  preventing  the  escape  of  urine, 
either  into  the  surrounding  areolar  tissue  or  into  the  peritoneal  cavity;  or  they 
may  come  within  the  province  of  the  physician,  as  when  a  pleurisy  is  set  up 
by  a  broken  rib.  Sometimes  the  lesion  complicating  the  fracture  is  neces- 
sarily fatal,  as  in  the  case  of  a  wound  of  the  heart. 

Further  reference  to  these  various  complications  will  be  made  in  connection 
with  fractures  affecting  special  bones. 

There  is  still  another  class  of  complications  of  fracture — those,  namely, 
which  arise  secondarily,  from  the  occurrence  of  inflammation  in  neighboring: 
parts.  Thus  it  occasionally,  though  rarely,  happens  that  an  abscess  is  formed 
either  about  the  fragments,  in  the  soft  jDarts  close  by,  or  in  a  joint.  Under 
such  circumstances,  the  treatment  of  the  fmcture  itself  maybe  seriously  inter- 
fered with,  and  the  prospect  of  restoration  of  usefulness  to  the  limb  much 
impaired. 

Intra-uterine  Fractures. — ITotwithstanding  the  mobility  of  the  foetus, 
and  its  protection  by  the  amniotic  liquid  and  by  the  maternal  body,  its  bones 
are  occasionally  broken.  These  injuries  are  generally  due  either  to  blows  or 
to  other  violence  inflicted  from  without  through  the  belly  of  the  mother,  or 
to  abnormal  contraction  of  the  muscles  of  the  child  itself.  In  one  or  two  in- 
stances, one  of  twins  has  sustained  fracture  apparently  from  entanglement  of 
its  limbs  with  those  of  its  fellow. 

When  external  violence  is  the  cause  of  these  fractures,  the  effect  is,  of 
course,  limited  to  those  bones  on  which  it  falls.  Of  this  many  instances  have 
been  published,  and  are  quoted  by  Malgaigne  and  other  systematic  writers. 
Only  a  few  points  need  be  noted  here. 


VARIETIES  OF  FRACTURE. 


23 


Sometimes  union  has  already  taken  place  at  the  time  of  hirth ;  as  in  the 
case  reported  by  De  Luna.^  A  woman  aged  32,  at  the  middle  of  the  nmth 
month  of  pregnancy,  fell  down  stairs,  striking  her  belly  against  a  wooden  tub. 
Pain,  not  very  severe,  and  faintness  followed.  The  cliild,  when  seen  by  the 
reporter,  was  four  weeks  old,  and  had  "fracture  of  the  clavicle  near  the  acro- 
mial extremity,  united  by  bony  callus,  with  considerable  overlapping." 

In  one  case  recorded  by  Rodrigue,^  the  humerus  was  dislocated,  and  both 
bones  of  the  forearm  of  the  same  side  were  broken  and  firmly  united  at  an 
angle  of  about  45°. 

Sometimes  the  fragments  have  projected,  and  have  heen  felt  by  the  mother 
irritating  the  walls  of  the  womb. 

Although  the  bones  in  many  instances  have  become  solidly  united  before 
birth,  it  occasionally  happens  that  no  union  takes  place.  Thus,  a  case  is 
recorded  by  Mr.  II.  Smith^  in  which  the  tibia  and  fibula,  broken  within  the 
Avomb,  w^ere  still  ununited  when  the  child  was  seven  years  old.  One  curious 
instance  is  quoted  by  Gurlt,-*  from  Maeder,  in  wdiich  a  woman  seven  months 
pregnant  fell  from  the  top  of  a  ladder,  and  subsequently  lost,  at  first  blood, 
afterward  blood  and  water,  from  the  vagina ;  she  had  also  persistent  pains  in 
the  belly,  but  no  loss  of  general  health,  and  her  confinement  was  normal.  Her 
child,  a  strong  boy,  was  born  wanting  the  left  upper  extremity  from  the  mid- 
dle of  the  arm,  where  the  white  bone  protruded  through  a  reddish-brown, 
moist,  but  not  bleeding  or  suppurating  wound,  which  soon  healed  up.  The 
separated  limb  came  away  with  the  after-birth ;  it  seemed  to  have  undergone 
maceration.  This  case,  which  stands  alone,  as  far  as  I  can  ascertain,  admits 
of  only  one  explanation,  which  suggests  itself. 

It  is  scarcely  worth  wdiile  to  dwell  here  upon  the  cases  in  which  very  nume- 
rous fractures  have  been  seen  in  the  foetus,  as  in  most  of  them  there  is  no  ques- 
tion that  they  were  the  result  of  diseased  conditions  of  the  skeleton,  and  it 
is  probable  that  this  was  the  true  explanation  in  all.  Sometimes  it  is  clearly 
from  deficient  ossification  between  the  diaphyses  and  epiphyses. 

Thus,  Barker^  reported  a  case  in  which  all  the  long  bones  of  the  extremities 
were  broken,  and  the  frontal,  parietal,  upper  part  of  the  occipital,  and  squa- 
mous portion  of  the  temporal  were  absent.  On  examination,  the  skeleton  was 
found  deficient  in  inorganic  matter,  except  in  certain  enlarged  portions  which 
contained  an  excess. 

Brodhurst,^  in  a  paper  read  before  the  Royal  Medico-Chirurgical  Society, 
suggested  the  connection  between  these  lesions  and  other  congenital  defects, 
such  as  distortions  of  the  feet  and  hands.  In  the  discussion  which  followed, 
Messrs.  Little  and  Pollock  spoke  of  cases  which  they  had  seen  with  defi- 
ciencies of  fingers  and  toes  ;  and  Mr.  Adams  said  that  the  limbs  in  such  cases 
did  not  grow  normally. 

Davies^  has  reported  a  case  in  which  a  man,  grow^n  up  when  seen  by  him, 
had  had  an  intra-uterine  fracture  of  the  leg,  in  which  this  defect  of  growth 
was  very  marked. 

Of  fractures  sustained  during  birth,  very  little  need  be  said.  They  are  some- 
times' caused  by  the  powerful  expulsive  contractions  of  the  uterus ;  as  in  a 
case  reported  by  Vanderveer.^    But  they  are  for  the  most  part  due  to  the 


'  Am.  Journal  of  the  Med.  Sciences,  .July,  1873. 

2  Am.  Journal  of  the  Med.  Sciences,  January,  1854. 

3  Trans,  of  the  Pathological  Society  of  London,  vol.  xviii.  1867. 

4  Op.  cit.,  Bd.  i.  S.  222. 

5  British  Medical  Journal.  Sept.  26,  1857. 

°  Med.  Times  and  Grazette,  April  7,  1860  ;  Med.-Chir.  Transactions,  vol.  xliii. 

'  British  Medical  Journal,  Oct.  17,  1857. 

8  Am.  Journal  of  the  Med.  Sciences,  May,  1847. 


24 


INJURIES  OF  BONES. 


operations  of  the  accoucheur.  Gibson^  says  that  he  has  seen  the  clavicle  give 
way  from  an  ignorant  midwife  pulling  at  the  arm.  Malgaigne  mentions  a 
number  of  cases  of  epiphyseal  disjunctions  thus  produced ;  in  one,  the  lower 
epiphysis  of  the  femur  and  the  upper  epiphysis  of  the  tibia  were  separated 
at  the  same  time  by  traction  on  the  foot.  In  the  use  of  the  blunt  hook  such 
accidents  sometimes  occur,  and  cannot  always  be  avoided  even  by  the  most 
dexterous  and  careful  Operators.^ 


Phenomena  and  Symptoms  of  Fracture. 

When  a  bone  is  broken,  it  loses  more  or  less  completely  its  value  as  a  lever, 
and  the  muscles  of  the  part,  instead  of  acting  upon  it  as  a  whole,  act  upon  the 
fragments  separately.  The  periosteum  is  torn,  or,  in  rare  cases,  stretched.  The 
surrounding  soft  parts,  including  capillary  and  other  vessels  and  nerve  fibres, 
are  ruptured  and  lacerated  to  a  greater  or  less  degree,  and  pressed  upon  by 
the  ends,  jagged  or  pointed,  of  the  fragments.  Hence,  the  injury  gives  rise 
to  a  series  of  phenomena,  or  symptoms,  which  are  now  to  be  described. 

Sound. — Occasionally,  but  very  rarely,  the  patient  hears  a  distinct  sound 
attending  the  giving  way  of  a  bone ;  and  sometimes  it  is  even  perceived  by 
the  bystanders.  But  under  the  circumstances  of  excitement  usually  attending 
an  accident,  a  momentary  and  unlooked-for  noise  may  readily  escape  notice, 
even  if  it  were  one  which  would,  if  expected,  be  plainly  audible. 

Loss  OF  Function. — Almost  always  there  is  immediate  loss  of  power  in  the 
part  where  the  fracture  is  situated.  This  does  not  mean  that  the  muscles 
are  paralyzed,  although  we  often  hear  non-professional  persons  assert  that  an 
arm,  for  instance,  cannot  be  broken,  because  the  patient  can  move  his  fingers. 
But  the  value  of  the  aftected  bone,  as  a  lever,  is  destroyed ;  and  hence  the 
system  of  which  it  forms  a  part  is  useless. 

When,  however,  there  are  two  bones,  only  one  of  which  is  broken,  or  when 
the  injured  bone  is  braced  by  tissues  around  it,  there  is  sometimes  so  little 
disability,  for  a  time  at  least,  as  to  cast  doubt  upon  the  reality  of  the  fracture. 
Thus,  Hunt^  records  the  case  of  a  man  aged  26,  struck  by  a  falling  girder,  who 
walked  next  morning  to  a  steam-train,  got  off  at  Philadelphia,  and  into  a 
street-car  at  the  station  ;  from  the  car  he  walked  with  a  stick  some  two 
hundred  and  fifty  yards  to  the  Pennsylvania  Hospital  gate,  and  thence  up 
into  the  ward  in  the  third  story.  He  died  on  the  twenty-third  day,  from 
pelvic  abscess  and  pysemia,  and  it  was  found  that  "  the  neck  of  the  femur, 
immediately  behind  the  head,  was  broken  directly  across,"  the  line  of  fracture 
being  immediately  within  the  capsule  of  the  joint." 

In  1877,  I  saw  an  elderly  lady  who  broke  the  neck  of  the  femur  by  tripping  in  the 
carpet,  and  who  yet  walked  up  and  down  a  flight  of  stairs  several  times  a  day  during 
the  following  week.  She  died  exhausted  about  two  weeks  subsequently,  and  there  was 
found  extensive  fracture  of  the  bone  referred  to. 

1  Op.  cit.,  vol.  i.  p.  255. 

2  'Jlie  reader,  should  he  wish  to  pursue  this  subject  further,  will  find  valuable  information  in 
Bouchut's  Traite  Pratique  des  Maladies  des  Nouveaux-Nes,  etc.,  Paris  ;  also,  in  Delore's  article 
on  Fractures  in  the  Foetus,  in  tlie  Dictionnaire  Encyclopedique  des  Sciences  Medicales;  in  Kuest- 
iier,  Die  typischen  Verletzungen  des  Extrem.-knochen  des  Kindes  durch  den  Grebtirtshelfen, 
Ilalhi,  1877.  He  may  also  consult  with  advantage  an  article  by  Dr.  Alex.  Russell  Simpson,  "On 
Diastases  in  the  Bones  of  the  Lower  Extremity  of  the  Foetus,  produced  by  the  Accoucheur,"  in 
the  Edinburgli  Med.  Journal  for  June,  1880 ;  and  one  by  Ruge,  in  the  Zeitschrift  fiir  Geblirtsh. 
und  Frauenkrankheiten,  Berlin,  1876. 

^  Philadelphia  Medical  Times,  Oct.  26,  1872. 


PHENOMENA  AND  SYMPTOMS  OF  FRACTURE. 


25 


In  1876,  one  of  my  own  children  had  his  arm  broken  by  an  accidental  blow ;  tliere 
was  no  displacement,  and  no  sign  of  fracture  except  pain  and  loss  of  power,  until  two 
weeks  later,  when  he  had  a  fall,  and  tlie  fragments  at  once  became  freely  movable. 

Deformity  of  the  affected  part  ia  almost  always  one  of  the  results  of  frac- 
ture ;  not  invariably,  because  it  may  be  that  the  periosteum  remains  suffi- 
ciently intact  to  hold  the  fragments  in  place.  The  kind  and  degree  of 
deformity  vary  greatly  in  difierent  bones,  and  in  difterent  portions  of  the 
same  bone  ;  it  is  apt  to  be  less  where  the  fracturing  force  has  not  been  very 
violent,  where  only  one  of  two  parallel  bones  is  broken,  and  where  the  bone, 
if  single,  is  surrounded  by  a  large  mass  of  muscle. 

Deformity  may  be  owing  either  to  the  original  violence,  to  muscular  con- 
traction, to  the  weight  of  the  distal  part  of  the  limb,  or  to  incidental  causes, 
such  as,  in  case  of  the  femur,  the  pressure  of  the  bed-clothes  on  the  foot. 
When  the  fracturing  violence  is  direct,  it  simply  forces  the  fragments  apart 
after  breaking  them ;  and  they  may  be  held  thus  by  the  entanglement  of 
their  serrations,  by  muscular  contraction,  or  by  both  combined ;  when  it  is 
indirect,  the  leverage  afforded  by  one  or  both  fragments  will  be  readily  un- 
derstood. Muscular  contraction  may  drag  the  fragments  apart,  as  in  the  case 
of  the  patella  or  olecranon ;  or  may  pull  one  fragment  past  the  other,  as  when 
the  shaft  of  the  femur  is  broken  obliquely ;  or  may  rotate  one  fragment,  as  in 
fracture  of  the  cervix  femoris.  In  case  of  fracture  of  the  thigh  or  leg,  the 
slight  weight  of  the  foot,  perhaps  with  the  addition  of  that  of  the  bed-clothes, 
is  sufficient,  acting  through  a  long  bent  lever,  such  as  is  formed  by  the  distal 
part  of  the  limb,  to  produce  great  twisting. 

We  often  meet  with  expressions  such  as  "the  fragments  being  uncon- 
trolled," and  "the  fragments  assuming  bad  positions;"  but  these  are  incorrect, 
as  they  imply  that  the  fragments  are  not,  as  they  really  are,  absolutely  passive. 
It  is  not  generally  at  the  seat  of  injury  that  we  must  look  for  the  causes  of 
deformity  or  of  its  continuance. 

However  produced,  deformity  consists  in  a  change  in  the  relation  of  the  axes 
of  the  fragments.  This  change  may  consist  either  in  their  forming  an  angle 
with  each^other — angular  deformity  ;  or  in  the  rotation  of  the  distal  one — 
rotary  deformity ;  or  in  the  end  of  one  passing  by  the  end  of  the  other — lateral 
deformity,  over-riding,  over-lapping,  or  shortening.  Obviously  these  may  all 
be  presented  together  in  fracture  of  a  long  bone — the  femur,  for  example — or 
they  may  exist  singly.  And  either  of  them  may,  in  either  case,  be  very 
slight  or  very  pronounced ;  but  their  significance  does  not  depend  upon  their 
degree. 

Of  all  the  phenomena  attending  fractures,  the  deformity  is  the  most  im- 
portant, not  as  much  on  account  of  appearances  (although  in  women  this 
may  sometimes  be  a  matter  of  great  moment),  as  by  reason  of  the  disability 
which  it  is  apt  to  involve  if  it  is  uncorrected.  Even  a  slight  degree  of  angular 
or  rotary  displacement  may,  in  the  upper  extremity,  interfere  seriously  with 
the  complicated  movements  upon  which  the  free  use  of  the  hand  depends,  or, 
in  the  lower  extremity,  may  give  rise  to  awkward  lameness.  Hence  the  great 
end  and  aim  of  the  innumerable  appliances  which  have  been,  constantly  are, 
and  probably  will  always  continue  to  be,  proposed  for  the  treatment  of  frac- 
tures, is  the  keeping  of  the  fragments  in  their  normal  relation  until  they 
have  become  fixed  tlius  by  the  process  of  repair. 

The  degree  of  the  deformity  is  not  always,  or  indeed  generally,  an  index 
of  the  difficulty  of^its  correction ; -for  often  a  very  slight  displacement  can 
scarcely  be  overcome,  while  it  may  be  that  a  very  great  one  will  yield  at 
once.    But,  on  the  other  hand,  detcrmity  which  is  easily  corrected  is  apt  to 


26 


INJURIES  OF  BONES. 


be  reproduced  with  equal  readiness,  and  under  such  circumstances  all  the  re- 
sources of  the  surgeon  may  be  taxed  to  keep  the  fragments  in  proper  place. 

A  point  which  should  always  be  borne  in  mind,  is  that  the  pain  suffered  by 
the  patient  may  be  very  slight,  although  the  bones  are  in  very  bad  position. 
Hence  the  surgeon  should  by  no  means  be  satisfied  that  all  is  going  on  well 
because  no  complaint  is  made.  iTothing  but  actual  inspection  of  the  injured 
part  can  assure  him  of  its  safety.  This  remark,  however,  does  not  apply  to 
fractures  of  the  ribs,  or  to  such  other  fractures  as  are  serious  only  because  of 
the  involvement  of  contained  viscera. 

Pain  is  an  almost  invariable  attendant  upon  fracture.  It  is  due  in  part  to 
the  tearing  of  the  soft  parts,  and  to  the  inflammatory  condition  immediately  set 
up  thereby;  in  part  to  the  irritation  of  the  soft  parts  by  the  ends  of  the  frag- 
ments; and  perhaps  in  part  to  the  sensitiveness  of  the  fragments  themselves, 
or  at  least  of  the  medulla.  A  peculiar,  thrilling,  numb  pain,  extending  down 
along  the  limb  to  the  fingers,  is  often  complained  of  in  fracture  of  the  arm, 
from  pressure  of  the  lower  end  of  the  upper  fragment  against  the  nerve- 
trunks;  and  occasionally,  but  much  more  rarely,  an  analogous  pain  accom- 
panies fracture  of  the  leg. 

I  have  once  or  twice  seen  cases  in  which  the  persistent  pain  was  out  of  all 
proportion  to  the  severity  of  the  injury,  in  persons  of  very  sensitive  nervous 
systems,  and  liable  previously  to  attacks  of  neuralgia;  but  generally  the  pain 
is  not  very  violent,  and  subsides  steadily  with  the  redaction  of  inflammation. 
It  is  only  apt  to  remain,  under  proper  treatment,  when  the  fracture  is  in  a 
part  such  as  the  lower  third  of  the  forearm,  where  there  are  extensive  thecal 
serous  membranes ;  here  there  may  be  set  up  a  sort  of  rheumatoid  irritation, 
diflScult  to  overcome,  and  productive  of  much  suffering. 

A  notion  prevails  extensively  among  the  laity  that  fractures  are  most 
painful  when  they  are  "  knitting,"  and  that  the  ninth  day  is  the  time  when 
this  process  is  at  its  acme;  I  need  hardly  say  that  this  opinion  is  wholly 
without  foundation  in  fact. 

Persistent  pain,  or  rather  tenderness,  over  one  part  of  a  bone  may  become 
an  important  symptom  in  case  of  mere  fissure. 

Mobility.— A  greater  or  less  degree  of  mobility  at  the  seat  of  fracture  is 
nearly  always  observable,  and  is  more  distinct  the  nearer  the  lesion  is  to  the 
middle  of  a  long  bone.  Of  course  the  mobility  referred  to  is  passive,  and 
may  be  detected  either  upon  an  attempt  of  the  patient  to  use  the  part,  or  by 
grasping  the  two  portions  of  the  limb,  one  in  each  hand,  and  then  placing 
them  at  an  angle  with  one  another,  or  rotating  them  in  contrary  directions. 
It  is  upon  this  mobility  that  the  loss  of  pow'er  after  fractures  is  chiefly  de- 
pendent. 

Crepitus.— Along  with  the  mobility,  if  the  ends  of  the  fragments  be  in 
contact,  there  is  developed  a  peculiar,  rough,  crackling  or  clicking  sound, 
partly  heard  and  partly  felt,  known  as  crejpitus  or  crepitatioi} .  It  is  not 
always  equally  distinct,  being  sometimes  masked,  either  by  effusion  of  liquid 
or  by  the  entanglement  of  soft  parts  between  the  fragments,  sometimes  les- 
sened by  impaction.  It  is  not  present,  for  obvious  reasons,  in  incomplete 
fractures.  Bony  crepitus  should  be  carefully  distinguished  from  what  is 
known  as  soft  crepitus— the  crackling  of  dry  tendon-sheaths— and  from  a  very 
similar  but  smoother  sound  due  to  the  rubbing  of  the^islocated  head  of  a 
bone  over  the  surface  of  another  bone  covered  by  periosteum.  When  clearly 
heard  and  felt,  true  crepitus  is  proof  positive  of  fracture.  Yet  it  does  not 
always  indicate  accurately  the  degree  of  mobility.    It  may  be  quite  loud, 


PHENOMENA  AND  SYMPTOMS  OF  FRACTURE. 


27 


and  give  the  impression  of  loose  grating,  and  yet  the  fragments  may  be 
closefy  held  together.  I  recently  saw  an  instance  of  this  in  an  old  lady  of 
eighty-five,  who  died  some  weeks  after  sustaining  a  fracture  of  the  cervix 
femoris  ;  during  life  and  after  death,  the  crepitus  was  so  distinct  as  to  lead  to 
the  belief  that  the  fragments  were  very  movable,  yet,  when  the  bone  was  re- 
moved they  were  found  in  accurate  apposition,  and  hardly  any  sound  could  be 
elicited. 

Crepitus  is  of  course  wanting  when  the  fragments  are  not  m  contact,  as  m 
fractures  of  the  patella  and  olecranon,  if  one  portion  of  the  bone  is  drawn  up 
so  as  to  leave  a  wide  gap,  and  in  some  cases  of  overlapping. 

I  feel  constrained  here  to  enter  a  protest  against  the  employment  of  undue 
efforts  to  obtain  crepitus.  Should  it  not  be  readily  felt,  the  surgeon  should 
fall  back  upon  the  other  means  of  diagnosis  ;  as  by  persisting'in  the  attempt 
to  move  the  fragments  upon  one  another,  he  not  only  gives  present  pain  to 
the  patient,  but  may  do  harm  by  producing  or  increasing  displacement. 
When  once  the  surgeon  in  charge  has  perceived  it,  he  ought  not  to  unneces- 
sarily elicit  it,  again  and  again,  as  I  have  sometimes  seen  done,  to  satisfy 
either  himself  or  others. 

Swelling  is  very  apt  to  follow  upon  the  occurrence  of  fracture,  especially 
in  superficial  bones,  and  in  the  neighborhood  of  joints.  It  is  due  to  inflam- 
matory effusion,  and  takes  place  very  rapidly,  sometimes  almost  immediately. 

EccHYMOSis  nearly  always  shows  itself  in  the  vicinity  of  a  fracture,  and  is 
often  owing  to  the  rupture  of  small  vessels  in  the  soft  parts,  just  as  in  any 
other  bruise.  But  when  a  bone  is  broken,  its  vascular  medulla  is  torn  across  ; 
and  hence  there  comes  on  gradually  an  extravasation  of  blood,  sometimes 
stainins:  the  skin  a  deep  mottled  purple,  almost  black,  and  extending  along 
the  limb  for  a  great  distance.  This  secondary  effusion  of  blood  is  much  m^ore 
significant  than  that  which  shows  itself  within  the  first  few  hours  after  the 
injury.  It  is  usually  very  slowly  absorbed,  and  may  often  be  still  percepti- 
ble as  a  o-reen  and  yellow  discoloration,  even  after  the  fracture  has  been  alto- 
gether repaired. 

At  the  same  time  with  this  extravasation,  there  may  appear  upon  the  sur- 
face of  the  skin,  especially  in  weakly  patients,  hlehs  or  bullcE  of  various  size, 
sometimes  very  large,  distended  with  serum  more  or  less  stained  with  blood. 
These  are  often  a  source  of  great  alarm  to  the  patient,  and  even  to  the  inex- 
perienced surgeon ;  but  if  carefully  let  alone,  they  wdll  shrink  away  in  time, 
and  the  cuticle  either  becomes  re-attached,  or  a  new  cuticle  forms  before  the 
old  one  is  cast  off'.  It  is  a  bad  practice  to  open  them,  as  they  may  then  give 
rise  to  troublesome  and  intractable  sores,  interfering  with  the  treatment  of 
the  fracture  itself. 

ISTuTRiTivE  Changes. — Certain  local,  atrophic  changes  have  been  observed 
in  cases  of  fracture,  and  may  be  mentioned  among  the  phenomena  attending 
injuries  of  this  class,  although  they  are  by  no  means  constant  Curling^ 
speaks  of  atrophy  of  one  fragment  as  not  uncommon,  and  gives  a  list  of  twenty- 
four  specimens  illustrating  this  condition,  which,  however,  is  certainly  not 
often  present  in  such  a  degree  as  to  attract  attention.  Guenther^  claimed 
that  the  growth  of  the  nails  on  the  affected  limb  was  arrested  during  the  pro- 
cess of  union;  but  his  observation  has  not  been  substantiated  by  the  expe- 
rience of  others.    I  have  myself  reported^  two  cases,  one  in  the  leg  and  one 

'  Med.-Chir.  Transactions,  vol.  xx. 

2  Grazette  des  Hopitaux,  Nov.  24,  1842.  (Malgaigne.) 

8  Am.  Journal  of  the  Med.  Sciences,  April,  1874. 


V 


28 


INJURIES  OF  BONES. 


in  the  ring-finger,  in  which  the  nails  did  not  grow  on  the  injured  members ; 
but,  in  spite  of  careful  w^atching  for  other  similar  cases,  I  have  failed  to  meet 
with  them.  Muscular  wasting,  from  confinement  and  disease,  is  very  frequently 
seen  in  fractured  limbs ;  but  in  general  it  speedily  disappears  upon  the  re- 
sumption of  the  normal  functions  of  the  part,  as  does  also  the  oedema  which  ^ 
often  accompanies  it, 

From  what  has  now  been  said  of  the  general  phenomena  attending  frac- 
tures, the  symptoms  may  be  readily  learned.  These  are  divided  into  two 
classes, — the  rational,  and  the  physical  or  sensible. 

The  former  are  such  as  give  rise  to  a  reasonable  suspicion  of  the  existence 
of  fracture;  they  are  pain,  loss  of  power,  swelling,  and  ecchymosis.  To 
these  may  be  added,  when  it  is  present,  the  audible  crack  caused  by  the  snap- 
ping of  the  bone ;  but  this  would  not  be  conclusive,  because  very  much  the 
same  sound  niight  accompany  the  rupture  of  tendon,  muscle,  or  ligament. 

The  physical  or  sensible  signs  are  conclusive:  deformity,  preternatural 
mobility,  and  crepitus.  Sometimes  the  first  named,  striking  the  eye  of  the 
surgeon,  will  at  once  reveal  the  nature  of  the  case.  But  for  the  most  part  it 
is  from  the  combination  of  all  that  he  is  enabled  to  frame  his  opinion. 


Constitutional  Symptoms  AccoMPANYma  Fracture. 

Perhaps  it  will  have  been  noticed  that  nothing  has  as  yet  been  said  about 
the  constitutional  symptoms  attending  fracture.  In  very  many  cases  these  are 
very  slight,  and  might  readily  be  overlooked  by  an  inattentive  observer.  Yet 
they  always  occur,  and  are  in  proportion  to  the  severity  of  the  local  injury ; 
modified,  however,  by  the  idiosyncrasies  of  the  patients,  by  their  condition 
at  the  time  of  sustaining  the  hurt,  and  by  incidental  circumstances.  Thus, 
in  some  individuals,  the  nervous  system  is  very  sensitive,  and  even  a  simple 
fracture,  produced  by  slight  violence,  may  give  rise  to  marked  shock.  Such 
shock  may  be  the  more  severe  from  the  fact  of  previous  fatigue,  of  fright  at 
the  time  of  the  accident,  or  from  other  transient  circumstances.  Wagstafi:e,i 
in  an  article  on  temperature  in  shock,  in  surgical  cases,  notes  a  decided  lower- 
ing as  attendant  upon  compound  fractures ;  and  it  is  probable  that  a  propor- 
tionate degree  of  reduction  would  be  detected  in  less  serious  cases  by  careful 
observation. 

Following  upon  this  state  of  depression,  a  more  or  less  decided  febrile  rise 
is  often  noted,  especially  in  private  practice,  where  patients  are  apt  to  demand 
and  receive  more  attention  than  in  hospitals.  But  Stickler^  has  proved,  by 
a  series  of  carefully  tabulated  observations,  that  there  is,  as  a  rule,  a  tempo- 
rary febrile  rise  after  fractures  ;  it  reaches  its  maximum  during  the  first  three 
days,  when  the  local  inflammation  is  at  its  height. 

Upon  the  subsidence  of  this  febrile  movement,  the  system  at  large  generally 
ceases  to  manifest  any  disturbance,  and  the  whole  period  of  local  repair  may 
be  passed  through  without  any  other  trouble  than  perhaps  constipation,  and 
it  may  be  indigestion,  if  the  patient  is  prevented  from  taking  exercise,  and 
yet  indulges  his  appetite.  But  in  old  and  feeble  persons,  the  powers  may  be 
unequal  to  the  tax  upon  them,  and  a  condition  of  debility  may  ensue,  from 
which  recovery  is  impossible.  I  have  seen  a  simple  fracture  of  the  hume- 
rus prove  fatal  on  the  seventh  day,  in  a  lady  of  eighty-one ;  yet  Hender- 
son^  has  recorded  the  case  of  a  woman,  eighty-nine  years  old,  whose  femur, 

'  St.  Thomas's  Hosp.  Reports,  1870. 

2  New  York  Med.  Record,  Feb.  11,  1882.  8  London  Med.  Gazette,  Jan.  13,  1843. 


DIAGNOSIS  OF  FRACTUKE. 


29 


broken  near  the  middle,  was  found  firmly  united  on  the  forty-fourth  day ; 
Meachem*  one,  in  which,  in  a  woman  of  ninety,  a  fracture  of  the  lower  third 
of  the  leg  was  united  in  twenty-eight  days  ;  and  Lee^  one  of  union  of  a  frac- 
tured femur  in  a  man  of  ninety-eight.  These  cases  are  exceptional,  and  do  not 
set  aside  the  fact  that  old  age  makes  every  injury  more  formidable. 


Diagnosis  of  Fracture. 

This  ipattcr  has,  of  course,  been  to  a  certain  degree  dealt  with  in  speaking 
of  the  symptoms  of  these  injuries,  and  it  must  be  considered  again  in  refer- 
ence to  each  special  fracture ;  but  there  are  some  general  points  which  may 
be  made  here,  and  some  rules  laid  down,  in  order  to  save  repetition. 

The  earlier  an  examination  can  be  made  to  determine  whether  or  not  frac- 
ture exist,  and  its  seat,  if  present,  the  better ;  since  swelling  often  conies  on 
very  rapidly,  and  the  muscles  become  rigid,  so  as  to  mask  the  condition  of 
the  bone.  Hence,  if  the  surgeon  be  called  to  a  patient  who  must  be  moved  a 
long  distance  to  his  home,  or  to  a  hospital,  he  should,  if  possible,  ascertain  at 
once  the  character  of  the  injury,  by  as  careful  an  examination  as  the  circum- 
stances will  allow.  ^  .  n  . 

In  cases  of  injury  in  the  neighborhood  of  joints,  this  rule  is  especially  im- 
perative ;  since  here  the  question  is  apt  to  be  between  fracture  and  luxation, 
and,  if  the  latter  be  overlooked,  the  delay  involved  may  add  seriously  to  the 
difficulty  of  reduction.  Of  mistakes  of  this  kind,  instances  will  be  given 
hereafter.  .  . 

As  a  o-eneral  rule,  in  the  comparison  of  fractures  and  luxations,^  it  will  ^  be 
found  tlfat,  in  the  former  class  of  injuries,  the  degree  of  possible  passive  motion 
is  increased  beyond  the  normal,  while  in  the  latter  it  is,  in  certain  directions 
at  least,  materially  diminished.  On  the  other  hand,  in  luxation,  the  power 
of  rnovino-  the  limb  to  some  extent  is  apt  to  be  retained,  the  lever  affected  not 
beino-  broken,  but  having  merely  changed  its  bearing  point ;  while  in  frac- 
tures, as  before  stated,  the  limb  is  usually  altogether  disabled. 

From  the  study  of  normal  anatomy  certain  test  lines  have  been  derived,  by 
which  the  displacement  consequent  upon  fractures,  as  well  as  luxations,  may 
be  detected.  With  these  lines,  and  with  the  relation  of  the  normal  skeleton 
to  them,  the  surgeon  ought  to  render  himself  perfectly  familiar,  so  that  they 
may  serve  as  landmarks  in  his  examination  of  injured  parts.  They  will  be 
detailed  in  speaking  of  fractures  in  the  several  regions.  ^ 

The  diao-nosis  of  fracture  has  reference  not  merely  to  its  existence,  but  also 
to  its  exact  seat  and  direction.  The  latter  points  are,  indeed,  in  many  cases 
by  far  the  most  difficult  to  determine,  and  may  have  to  be  arrived  at  by  ex- 
clusion only.  The  general  symptoms  already  detailed  may  be  clear  enough, 
and  the  fact  of  fracture  be  absolutely  established,  yet  the  surgeon  may  be  in 
doubt  as  to  the  precise  line  of  breakage,  or  even,  when  a  joint  is  involved,  as 
to  which  of  the  bones  entering  into  it  has  suffered.  These  questions  can  only 
be  settled  by  careful  exploration,  with  a  skill  acquired  by  experience ;  in 
other  words,  with  the  educated  hand.  Occasionally,  the  observation  of  the 
effect  of  certain  passive  motions  will  go  far  to  solve  the  doubt ;  or  gentle  and 
dexterous  pressure  with  the  tips  of  the  fingers,  perhaps  with  the  nail,  may 
reveal  the  line  of  breakage. 

In  the  diagnosis  of  compoiind  fracture,  as  to  its  extent  and  severity,  the 
finger  is  always  better  than  any  other  probe ;  hut  even  this  should  be  used 


1  Am.  Med.  Times.  1861. 


2  St.  George's  Hospital  Reports,  vol.  iv.  1869. 


30 


INJURIES  OF  BONES. 


with  caution,  and  onlj  for  the  purpose  of  determining  such  points  as  the  sur- 
geon really  needs  to  know.  All  poking  about  to  satisfy  mere  curiosity,  at 
the  risk  of  disturbing  or  tearing  tissues  not  already  damaged,  and  all  wrench- 
ing of  the  fragments  to  get  at  the  deeper  parts  of  the  wound,  should  be 
abstained  from.  The  amount  of  injuiy  to  vessels  and  nerves  can  be  better 
ascertained  in  other  ways,  and  may  be  increased  by  meddlesome  and  indiscreet 
handling. 

Consequences  of  Fracture. 

While  it  is  quite  true  that,  in  general,  simple  fractures  progress  steadily 
toward  recovery,  it  is  also  true  that  they  sometimes  give  rise  to  very  grave 
and  even  fatal  symptoms.  These  symptoms  may  be  general  or  local,  imme- 
diate or  remote.  5lurray^  mentions  a  case  in  which  a  simple  comminuted 
fracture  of  the  thigh  was  folloAved  by  trauraatic  delirhim  ;  Hammick,^  one  in 
which  tetanus  ensued  upon  simple  fracture  of  the  thigh.  Pycemia^  not  a  very 
uncommon  sequence  of  compound  fracture,  has  been  seen  by  Hewett^  as  the 
result  of  simple  fracture  of  the  leg. 

The  occurrence  of  wounds  of  arteries veins ^  and  nerves^  has  been  already 
mentioned  {complicated  fractures)^  and  will  be  again  referred  to  in  connection 
with  fractures  of  special  bones.  Occasionally,  when  vessels  of  some  size  are 
\u]\xve^,  gangrene  comes  on,  or  the  hemorrhage  challenges  immediate  attention, 
and  either  ligation  or  amputation  must-  be  performed ;  but  sometimes  the 
symptoms  are  only  perceived  at  a  later  period,  Avhen  aneurism.,  true  or  false, 
has  developed  itself^  AVith  regard  to  nei^ves  also,  the  signs  of  the  lesion 'may 
appear  immediately,  or  may  be  postponed  until  they  show  themselves  in  the 
altered  nutrition  or  sensation  of  the  distal  parts.  In  several  instances  to  be 
hereafter  quoted,  it  was  to  the  callus  that  the  trouble  was  to  be  attributed, 
either  from  exuberance  of  this  formation,  or  from  entanglement  of  nerve- 
trunks  within  it.  is'erves  may  also  be  caught  and  pinched  between  the 
fragments ;  a  case  is  mentioned  by  Callender^  in  which  the  ulnar  nerve  was 
thus  entangled  in  a  fracture  separating  the  styloid  process  and  triangular 
ligament  from  the  rest  of  the  ulna.  The  same  author  saw  a  case  in  which  a 
compound  fracture  at  the  wrist  was  followed  by  gangrene  by  reason  of 
stretching  of  the  ulnar  and  median  nerves. 

Pre-existing  disease  may  become  fatal  when  complicated  with  fracture ; 
thus  Hunt'  has  placed  upon  record  a  case  in  which  a  man,  aged  29,  who  from 
the  age  of  four  years  had  had  chorea  and  partial  hemiplegia,  lost  his  life  from 
the  incessant  movement  of  his  arm,  broken  by  an  accident. 

There  are  some  instances  in  which  untoward  results  take  place  without 
any  apparent  reason.  In  one  of  his  clinical  lectures.  Prof.  Yerneuil  referred 
to  the  case  of  a  man,  60  years  of  age,  strong,  robust,  and  tall,  who  had  been 
in  hospital  for  two  months  and  a  half  for  a  fracture  of  both  bones  of  the  leg. 
He  was  treated  as  usual,  had^  exhibited  no  bad  symptoms  whatever,  and,  in 
fact,  was  just  about  to  be  sent  to  a  convalescent  hospital  prior  to  dismissal, 
when  (the  only  thing  that  had  excited  attention  having  been  some  alteration 
in  his  features)  he  suddenly  died,  his  face  havhig  a  violaceous  aspect.  Prof 
Verneuil  believed  that  this  must  have  occurred  from  embolism.,  which  is  not 
very  rare  after  fracture.    It  is  produced  by  tkrombosis  of  some  of  the  veins 

•  Edinb.  Med.  Journ.,  Feb.  1882.  2  On  Amputations,  Fractures,  etc.,  p.  74. 
'  Lancet,  1867,  vol.  i.  p.  (J28. 

*  For  much  valuable  information  on  this  subject,  with  details  of  27  cases,  the  reader  is  referred 
to  a  pamphlet  entitled  "  Des  Anevrysmes  compliquant  les  Fractures.  Par  Gerard  Laurent,  Doc- 
teur  en  Aledecine,  etc."    Paris,  1875. 

^  St.  Bartholomew's  Hosp.  Reports,  1870.  s  Pennsylvania  Hosp.  Reports,  vol.  ii.  18G9. 


CONSEQUENCES  OF  FRACTURE. 


31 


in  the  vicinity  of  the  fractured  bone,  which  is  the  cause  of  the  oedema  that 
so  commonly  accompanies  fracture  of  the  leg.  Through  a  sudden  movement 
or  muscular  effort,  one  of  the  clots  which  have  thus  formed  in  the  inferior 
veins,  and  whicli  are  not  usually  very  adherent,  may  become  detached,  and, 
cnterino-  the  femoral  and  iliac  veins,  and  eventually  reaching  and  obstructing 
one  or  more  of  the  branches  of  the  pulmonary  artery,  may  give  rise  to 
sudden  death,  as  in  asphyxia.  However,  in  thi-s  case  the  diagnosis  was  erro- 
neous, for  the  most  careful  examination  of  all  the  veins  and  of  the  pulmonary 
arteries  failed  to  show  the  existence  of  any  clot.  The  heart  was  absolutely 
empty,  and  the  brain,  minutely  examined,  exhibited  no  disease.^  Again, 
Hammick^  describes  the  case  of  a  man  with  simple  fracture  of  the  leg,  who 
was  very  despondent;  on  the  third  morning  he  "became  ill,  grew  very 
feeble,  and  in  four  hours  was  dead.  We  examined  with  the  minutest  dissec- 
tion every  part  of  the  body,  but  were  not  able  to  detect  anything  in  the 
remotest  degree  to  account  for  his  death."  It  seems  not  improbable  "that  this 
may  have  been  an  instance  of  fat  emholisya. 

Thrombosis  and  Embolism. — These  sometimes  ensue  upon  the  breaking  of 
a  bone.  Southam^  has  recorded  two  cases,  one  in  a  man  aged  60,  with  Pott's 
fracture  of  the  libula,  in  whom  thrombosis  appeared  on  the  17th  day,  and 
proved  fatal,  and  the  other  in  a  woman  aged  65,  also  with  fracture  of  the 
libula,  who  had  like  symptoms  on  the  16th  day,  and  died.  In  the  former 
case  the  diagnosis  was  verified  by  an  autopsy.  A  case  is  reported  by  Tyrrell, 
in  which  a  man  aged  49,  had  his  left  leg  fractured  for  the  sixth  time,  the 
other  leg  having  been  broken  once.  On  the  twelfth  day  he  had  symptoms  of 
cerebraf  disturbance,  followed  by  partial  paratysis  of  motion  on  the  left  side 
of  the  face  and  in  the  left  arm.  These  symptoms  were  ascribed  by  Tyrrell 
to  the  withdrawal  of  his  accustomed  stimulus,  but  should  rather,  perhaps,  be 
referred  to  embolism. 

Fat-embolism^  is  a  condition  first  observed  as  a  sequence  of  fracture  by 
Wagner  and  Zenker,  in  1862.  It  consists  essentially  in  the  passage  into  the 
veins  of  liquefied  fat,  which  is  carried  into  the  lungs,  brain,  and  spinal  cord, 
blocking  up  the  capillaries  of  those  organs. 

The  occurrence  of  free  oil  in  the  blood  had  been  pointed  out  by  E,.  W. 
Smith,  as  early  as  1836  f  and  in  1856  a  case  was  reported  by  Macgibbon,'^  in 
which  a  woman,  aged  35,  affected  with  delirum  tremens,  died  suddenly,  the 
immediate  symptoms  having  been  dyspnoea,  with  coma  and  marked  pallor ; 
the  autopsy  disclosed  fatty  degeneration  of  the  heart  and  other  organs,  and 
a  great  deal  of  free  oil  in  the  blood.  Wagner,  in  1865,  Busch,  in  1866, 
Bergmann,  in  1873,^  and  Czerny,  in  1875,^  made  important  investigations  on 
the  subject,  which  has  been  further  studied  by  Scriba.^^  Flournoy,  in  1878,^^ 
showed  that  three  conditions  were  needful  for  the  development  of  fatty  em- 
bolism after  fractures :  large  openings  in  the  veins  ;  free  fluid  fat ;  and  a  vis 

^  Med.  Times  and  Gaz.,  Oct.  22,  1881,  p.  486  ;  from  Gaz.  des  Hopitaux,  No.  86. 

«  Op.  cit.,  p.  74.  3  Lancet,  March  1,  1879. 

*  St.  Thomas's  Hospital  Reports,  voL  i.  1836. 

^  See  also  the  article  on  Shock,  Vol.  II.  p.  268. 

6  Stokes,  The  Diseases  of  the  Heart  and  the  Aorta,  p.  308.   Dublin,  1854. 

7  Am.  Journal  of  the  Med.  Sciences,  Jan.  1856. 

8  Berliner  klin.  Wochenschr.,  Aug.  18,  1873. 

9  Ibid.,  Nov.  1  und  8,  1875. 

'0  See  London  Med.  Record,  Oct.  22,  1873  ;  Med.  Times  and  Gazette,  Jan.  8,  1876,  and  British 
Med.  Journal,  May  22,  1880.  These  articles  were  reproduced  in  the  Am.  Journal  of  the  Med. 
{Sciences,  Jan.  1874,  and  July,  1880. 

Contrib.  a  I'etude  de  I'embolie  graisseuse.    Strasbourg,  1878. 


32 


INJURIES  OF  BONES. 


a  iergo^  generally  found  in  a  copious  extravasation  of  blood.  Drs.  Sainidby 
and  Barling,  in  a  recent  article,^  quote  papers  by  Boettcher  and  D.  J.  Hamil- 
ton, in  1877,  Dejerine,  in  1878-9,  Buret,  Sinclair,  and  Jolly,  in  1879,  and 
Mansell-Moullin,  in  1881.  Bejerine  is  said  to  have  seen  ten  cases,  and  to 
have  produced  fat-embolism  experimentally  upon  animals  by  means  of 
sponge-tents  or  laminaria-tents  introduced  into  the  bones.  Sinclair  is  quoted 
as  authority  for  the  statement  that  fatty  embola  ^vere  found  in  10  per  cent, 
of  the  bodies  examined  at  the  Pathological  Institute  at  Strasbourg ;  but  it 
should  be  remembered  that  post-mortem  clots  containing  fat-globules  may 
readily  be  mistaken  for  true  fatty  embola.  The  former  have  been  repeatedly 
met  with  in  autopsies  upon  diabetics  with  "  milky  blood." 

Symptoms  of  Fat-embolism. — From  the  accounts  given  by  Scriba  and  others, 
who  have  had  opportunities  of  studying  this  subject  clinically,  it  would  seem 
that  fat-embolism  comes  on  as  a  sort  of  secondary  shock,  within  two  or  three 
days  of  the  receipt  of  the  fracture,  and  therefore  earlier  than  venous  throm- 
bosis usually  appears.  Bs  onset  is  marked  by  transient  attacks  of  dyspnoea, 
with  irregular  action  of  the  heart,  slight  haemoptysis,  and  at  first  shallow 
respiration,  at  times  interrupted  by  deep  sighing  inspirations ;  subsequently  the 
peculiar  form  of  breathing  known  as  "  Cheyne- Stokes"  respiration,^  manifests 
itself.  Collapse,  with  marked  pallor  of  the  skin  and  mucous  membranes,  soon 
ensues ;  spasms  of  various  kinds,  or  paralyses,  generally  bilateral,  and  dimi- 
nution of  reflex  irritability,  have  been  noted.  The  chest  is  free  from  dulness 
or  rales.  Fat  has  been  detected  occasionally  in  the  urine.  As  to  the  tem- 
perature in  this  disorder,  the  accounts  of  observers  vary.  According  to 
Scriba,  it  is  low^ered ;  but  Skirving^  records  a  case  in  which  it  was  a-t  first 
noted  at  100°,  but  increased  to  104°,  and  after  death  reached  105°.  In  another 
case  seen  by  Saundby  and  Barling,  in  1881,  the  temperature  w^as  101.8°. 

Secondary  abscesses  do  not  form  in  fat-embolism. 

Czerny  thinks  that  this  condition  is  a  constant  attendant  uj)on  cases  of 
fracture,  but  mostly  in  very  slight  degree,  and  Avithout  inducing  any  distinct 
symptoms.  Minich*  says  that  it  occurs  in  all  cases  of  fracture  except  in  chil- 
dren, who  are  exempt  from  it  by  reason  of  the  small  amount  of  fat  contained 
in  their  skeletons.  Scriba  is  of  opinion  that  it  may  go  through  several  cycles, 
and  that  its  injurious  efi:ect  is  due  solely  to  the  blocking  of  the  vessels  of  the 
brain,  since  this  w^as  observed  in  all  the  fatal  cases.  Minich  shares  this  view^ 
as  to  the  cause  of  death  ;  but  it  seems  as  if  the  interference  with  the  function 
of  the  lungs  must  be  at  least  contributory,  if  it  has  not  a  large  share,  in 
inducing  the  fatal  result. 

The  diagnosis  of  this  pathological  condition  can  hardly  be  very  obscure  in 
any  case  in  wdiich  the  symptoms  as  described  are  well  pronounced  ;  and  the 
prognosis,  under  such  circumstances,  must  obviously  be  extremely  grave. 

As  to  the  treatment  of  this  afi:ection,  the  intra-venous  injection  of  sulphuric 
ether  would  seem  to  be  clearly  indicated ;  and  diff'usible  stimulants  might  be 
given  by  the  mouth.  I  am  not  aware,  however,  that  any  definite  line  of 
medication  has  yet  been  pointed  out. 

Stiffening  of  neighboring  joints  is  a  very  common  sequence  of  fractures, 
and  may  be  attributed  to  various  causes.    In  some  cases,  violence  is  inflicted 

1  Journal  of  Anat.  and  Physiology,  July,  1882. 

2  "  It  consists  in  the  occurrence  of  a  series  of  inspirations  increasing  to  a  maximum,  and  then 
declining  in  force  and  length,  until  a  state  of  apparent  apnoea  is  established.  In  this  condition 
the  patient  may  remain  for  such  a  length  of  time  as  to  make  his  attendants  believe  that  he  is 
dead,  when  a  low  inspiration,  followed  by  one  more  decided,  marks  the  commencement  of  a  new 
ascending  and  then  descending  series  of  inspirations."     (Stokes,  op.  cit.,  p.  324.) 

3  Lancet,  Oct.  7,  1882. 

<  Lo  Sperimentale,  Marzo  ed  Aprile,  1882  (quoted  in  Medical  News,  Nov.  11). 


CONSEQUENCES  OF  FRACTURE. 


33 


upon  the  joints  as  well  as  upon  the  bone  at  the  time  of  the  accident,  and  ar- 
thritis is  set  up,  with  etiusion  into  the  periarticular  tissues.  Or  the  circula- 
tion in  the  limb  or  its  innervation,  may  be  disturbed,  so  that  the  nutrition 
of  all  the  tissues  is  impaired,  and  the  movement  of  the  joints  is  thus  inter- 
fered with.  By  some  authors,  the  long-continued  immobilization  of  the 
joints  required  by  treatment  is  thought  to  render  them  stiff;  but  this  idea  is 
rendered  untenable  by  the  fact  that  experience  in  other  cases  gives  no  such 
result ;  and  it  is  more  likely  that  ill-advised  pressure  by  apparatus,  or  the 
inflammatory  condition  above  alluded  to,  is  at  fault.  As  a  general  rule,  this 
stiffening  is  only  transient,  and  either  gradually  disappears  with  use,  or 
yields  to  proper  local  medication. 

Atrophy  of  a  broken  limb  sometimes  takes  place,  and  may  affect  all  its 
tissues,  or  the  bone  only.  A  very  curious  instance  of  the  latter  kind  is  re- 
corded by  Drs.  Jackson  and  Dwight,i  in  which  a  humerus,  broken  for  the 
second  time,  was  almost  wholly  absorbed ;  and  another  by  Gross,^  in  which 
the  fracture  was  originally  double.  In  both  these  cases  the  arm  retained 
very  considerable  muscular  power. 

"When  all  the  tissues  of  the  limb  are  atrophied,  the  bone  also  may  shrink, 
but  this  is  not  apt  to  be  the  case.  The  muscles  become  small,  stiff,  and 
weak,  and  the  foot  or  hand,  as  the  case  may  be,  contracted  and  twisted,  much 
as  in  cases  of  paralysis  from  lesions  of  the  central  nervous  system.  Pointed 
foot"  is  not  unusually  due  to  atrophic  contraction  of  the  muscles  of  the  calf. 

Prevention,  it  need  hardly  be  said,  is  in  these  cases  far  better,  and  certainly 
far  easier,  than  cure.  Often,  indeed,  the  latter  proves  to  be  impossible. 
The  measures  to  be  adopted  are  very  simple,  and  their  efficiency  depends 
rnuch  upon  the  regularity  and  perseverance  with  which  they  are  applied. 
Frictions,  with  or  without  medicated  liniments,  bathing,  shampooing,  or 
massage,  and  sometimes  faradization,  may  occasionally  restore  the  tone  of  mus- 
cles which  seemed  at  first  hopelessly  damaged.  But  no  discreet  surgeon  will 
venture  in  a  case  of  this  kind  to  hold  out  hopes  which  may  utterly  +ail  to  be 
realized, 

i^ECROSis,  after  simple  fracture,  is  extremely  rare,  if  it  ever  occur  at  all. 
Possibly  in  some  of  the  cases  in  which  blows  or  other  injuries  are  followed 
by  the  death  of  a  portion  of  the  bone,  there  has  really  been  a  separation  of 
the  part  thus  mortified ;  but  I  have  never  seen  an  instance  in  which  this 
could  be  proved. 

After  compound  fractures,  however,  it  is  very  common  to  find  one  or  more 
splinters  loosened  and  dead  ;  their  presence  may  interfere  with  the  process  of 
union,  which  is  apt  to  take  place  promptly  upon  their  removal. 

DeveloPxMent  of  Morbid  Growths.— Among  the  remoter  local  conse- 
quences of  fracture  may  be  mentioned  the  development  of  tumors  at  the  seat 
of  the  old  injury.  Virchow,^  after  stating  that  enchondroma,  more  frequently 
than  any  other  tumor,  is  clearly  to  be  ascribed  to  trauma.tic  causes,  says  :  

"  Among  these,  fractures  seem  to  be  of  great  interest.  Nelaton  (Gaz.  des  Hop.,  1855) 
mentions  a  man  who,  having  broken  his  leg,  was  completely  cured  in  two  months  ;  but 
six  months  afterward  had  severe  attacks  of  pain  in  the  part.  Re-fracture  occurred 
from  slight  violence,  and  union  again  took  place  in  two  months,  but  the  part  remained 
painful.    A  tumor  began  to  develop  itself,  increased  more  and  more,  and  at  length 

i  Boston  Med.  and  Surg.  Journal,  July,  1838,  and  Oct.  10  1872. 
«  Op.  cit.,  vol.  i.  p.  929 

'  Die  krankhaften  Geschwiilste,  Band  1.  S.  482. 
VOL.  IV. — 3 


34 


INJURIES  OF  BONES. 


burst.  The  patient  died  exhausted  five  years  from  the  date  of  the  first  fracture  ;  the 
autopsy  disclosed  an  enchondroma.  Otto  (Seltene  Beobachtungen  zur  Anatomic,  etc.) 
speaks  of  a  woman  who,  two  years  before  her  death,  sustained  a  fracture  of  the  humerus, 
which  united,  but  remained  painful  and  became  greatly  misshapen  ;  there  was  de- 
veloped a  tumor  (clearly  an  osteoid  chondroma)  which  acquired  a  colossal  size.  Ducluzeau 
(Lebert,  Traite  d'Anat.  Pathol.)  removed  from  the  rib  of  a  man  an  enchondroma, 
which  had  taken  its  origin  from  a  fracture  of  the  bone  several  years  previously.  Lan- 
genbeck  (Deutsche  Klinik,  1860)  disarticulated  the  shoulder  of  a  man  aged  23,  on  account 
of  a  tumor  which  I  recognized  as  an  osteoid  chondroma,  and  which  began  a  year  and  a 
half  after  a  fracture  caused  by  a  fall." 

Adams^  has  recorded  the  history  of  a  man  who  twenty-five  years  before 
his  death  broke  his  humerus  ;  nineteen  years  afterward  he  strained  it,  and 
it  remained  weak ;  four  years  after  this  a  swelling  was  perceived,  which 
grew  rapidly,  so  that  amputation  was  thought  of,  but  declined.  The  tumor 
ulcerated  and  discharged  a  glairy  fluid;  at  the  time  of  death  its  circum- 
ference was  equal  to  that  of  the  body.  It  was  composed  of  enchondromatous, 
colloid,  and  compound  cystic  elements. 

It  is  perhaps  scarcely  proper  to  include  among  the  cases  now  under  con- 
sideration those  in  which,  fracture  occurring  in  a  person  already  affected 
with  malignant  tumor,  the  constitutional  disease  manifests  itself  afresh  at  the 
point  of  local  injury.  Here  the  fracture  merely  serves  as  a  nucleus,  as  it 
were,  around  which  deposit  takes  place,  precisely  as  may  be  observed  in 
other  cases  of  hurts.  Sometimes,  indeed,  it  may  be  questioned  whether  the 
bone  may  not  give  way  because  its  texture  is  already  impaired  by  the  de- 
velopment of  disease  ;  as  in  one  instance  recorded  by  Morton,^  in  which  the 
woman  having  already  a  mammary  tumor,  the  left  humerus  gave  way  as  she 
turned  in  bed,  and  "  shortly  afterwards  the  tumor  was  noticed  at  the  seat  of 
fracture death  occurred  within  three  months. 

The  symptoms  and  diagnosis  in  these  cases  need  hardly  be  discussed,. and 
the  prognosis  is  unfortunately  but  too  clear.  As  to  treatment,  it  must  be  based 
upon  general  principles  ;  often  there  is  no  chance  for  anything  but  palliative 
measures.  Amputation  may  sometimes  save  suffering,  and  delay  the  fatal 
issue.^ 


(a-ENERAL  Prognosis  of  Fractures. 

Various  circumstances  must  be  taken  into  the  account  in  forming  a  prog- 
nosis in  any  case  of  fracture.  Among  these  are :  the  character  and  amount 
of  the  injury  to  the  bone,  its  simple  or  compound  character,  its  extent,  the 
presence  or  absence  of  comminution,  the  nearness  of  the  lesion  to  a  joint,  the 
amount  of  damage  done  to  the  soft  parts.  The  age  and  previous  history  of 
the  patient  are  also  to  be  regarded.  From  a  consideration  of  all  these  points, 
some  idea  may  be  formed  as  to  the  chances  of  saving  the  patient's  life,  as  well 
as  of  preserving  a  useful  and  sightly  limb. 

With  regard^to  the  influence  of  the  local  conditions  of  the  injury  on  the 
prognosis  of  fractures,  it  scarcely  needs  to  be  enlarged  upon  here,  as  it  has 
been  already  set  forth  in  the  discussion  of  the  phenomena  and  varieties  of 
those  injuries.  As  to  age,  it  may  be  said  that  the  fractures  of  children  gene- 
rally unite  with  <?reat  readiness,  and  that  the  ultimate  result  is  apt  to  be  the 
complete  restoration  of  the  shape  and  functions  of  the  limb,  although  an  ex- 
Trans,  of  Pathol.  Society  of  London,  vol.  i.  p.  344. 

2  Supplement  to  Catalogue  of  Penna.  Hosp.  Museum,  p.  19. 

8  The  reader  may  consult  with  advantage  :  Tausch,  Zur  Casuistik  der  vom  Callus  geheilten 
Frakturen  sich  eutwickelnden  Geschwiilste.    Halle,  1881. 


REPAIR  OF  FRACTURES. 


35 


ception  must  be  made  in  the  case  of  epiphyseal  disjunctions  and  fractures  near 
the  elbow-joint.  In  adults,  the  chance  of  permanent  deformity  and  of  stitfen- 
ino-  of  the  joints  is  greater,  and  in  old  persons  it  is  very  apt  to  occur.  Some 
of^the  fractures  to  which  old  people  are  liable,  and  especially  those  of  the  cervix 
femoris,  are  almost  sure  to  end  in  non-union  and  lameness,  if  not  total  dis- 
ability, for  the  remainder  of  life. 

Of  fractures  of  certain  bones— the  patella,  and  the  olecranon  and  coronoid 
processes  of  the  ulna— the  result  is,  as  a  rule,  union  by  fibrous  tissue  only,  and 
the  necessity  of  advising  the  patient  of  this  fact  beforehand  must  be  quite 
obvious.  In  all  cases  the  surgeon  should  insist  most  positively  upon  obe- 
dience to  his  directions,  and  should  remember  that  if  he  is  lax  in  this  respect, 
any  damage  resulting  from  the  waywardness  of  the  patient  will  be  laid  at  his 
door. 

It  is  better  always  to  give  a  guarded  prognosis  even  m  smiple  cases,  as  may 
be  inferred  from  what  has  been  said  in  previous  pages  as  to  the  occasional 
occurrence  of  unexpectedly  serious  symptoms.  And  even  in  the  matter  of 
time,  a  prudent  surgeon  will  be  slow  to  make  promises  which  he  may  not  be 
able  to  fulfil.  For  example,  if  a  man  with  a  broken  leg  is  assured  that  he 
will  be  able  to  walk  in  six  weeks,  he  will  be  very  much  dissatisfied  if  a  cure 
is  not  efte€ted  in  less  than  two  months.  And  if  a  man  with  a  fractured  femur 
is  told  that  he  will  be  able  to  walk  as  well  as  ever,  he  will  naturally  be  dis- 
appointed if  he  finds  himself  with  a  shortening  which  involves  a  permanent 
limp  in  his  gait. 


Repair  of  Fractures. 

Although  the  process  of  repair  of  broken  bones  has  been  the  subject  of 
study  and  discussion  by  many  of  the  ablest  surgical  observers  and  writers,  it 
is  not  as  yet  thoroughly  understood,  many  points  remaining  unsettled.  I 
shall  try  to  give  such  a  practical  summary  of  what  is  known  in  regard  to  it 
as  may  accord  with  the  limits  of  the  present  article,  referring  the  reader  who 
desires  further  information  to  the  admirable  description  given  by  Paget,'  and 
to  the  more  recent  works  of  Cornil  and  Ranvier,^  and  of  Billroth.^  In  Todd 
and  Bowman's  Cyclopaedia  of  Anatomy  and  Physiology,*  there  is  an  excellent 
exposition  of  the  opinions  advanced  up  to  the  date  of  its  publication  (1836), 
by  Dr.  W.  H.  Porter ;  and  Virchow^^  has  presented  a  very  interesting  account 
of  the  result  of  his  own  researches. 

This  subject  may  be  studied  in  various  ways.  By  careful  observation  of 
clinical  cases,  the  general  phenomena  are  learned,  and  further  explained  by 
the  opportunities  afforded  of  dissecting  the  parts  in  patients  dying  at  differ- 
ent periods  after  the  receipt  of  these  injuries.  Experimental  fractures  pro- 
duced on  animals  may  be  examined  with  advantage,  allowance  being  made 
for  known  differences  between  them  and  human  beings.  Microscopical  in- 
vestigations have  thrown  much  light  upon  the  modes  of  development  of  the 
reparative  material. 

When  a  bone  is  broken,  some  injury  is  always  inflicted  on  the  periosteum. 
Its  fibres  may  be  merely  stretched,  but  more  frequently  they  are  torn  across  at 

^  Lectures  on  Surgical  Pathology,  Lecture  XI. 

*  A  Manual  of  Pathological  Histology.  By  V.  Cornil  and  L.  Ranvier,.  Translated  from  the 
French  by  Drs.  Shakespeare  and  Simes.    Philadelphia,  1880. 

*  General  Surgical  Pathology  and  Therapeutics.  By  Theodor  Billroth.  Translated  from  the 
German  by  Dr.  Charles  E.  Hackley.    New  York,  1871. 

*  Art.  "Bone,  Pathological  Conditions  of."    Op.  cit.,  vol.  i. 

*  Cellular  Pathology.    Chance's  translation,  1860. 


36 


INJURIES  OF  BONES. 


the  convexity  of  the  angle  formed  by  the  fragments.  At  the  same  time,  on 
the  other  side,  where  they  are  not  ruptured,  they  are  apt  to  be  stripped  up 
for  a  greater  or  less  distance  along  the  bone.  Occasionally,  when  the  frag- 
ments are  violently  forced  apart,  the  periosteum  may  be  completely  severed ; 
but  even  then,  before  it  yields,  it  is  probably  loosened  from  the  surface  of  the 
bone.  Towards  the  broadened  ends  of  the  long  bones,  and  in  the  thick  and 
flat  bones,  this  stripping  up  is  less,  and  the  complete  severance  of  the  perios- 
teum is  not  apt  to  occur. 

By  the  violence  causing  the  fracture,  the  surrounding  soft  parts,  as  well  as 
the  marroic,  are  also  lacerated,  and  an  effusion  of  blood  takes  place  at  the  seat 
of  injury.  This  blood  is  derived  chiefly,  of  course,  from  the  more  vascular 
of  the  tissues,  and  varies  in  amount  in  different  cases.  Immediately  succeed- 
ing the  infliction  of  the  injury  there  is  set  up  an  inflammatory  condition, 
which  gradually  subsides,  and  then  the  work  of  repair  begins,  perhaps  in  the 
majority  of  cases  early  in  the  second  week. 

This  process  of  repair  does  not  differ  in  any  essential  respect  from  that  of 
wounds  of  the  soft  parts,  except  that  the  final  result  is  the  production  of 
new  bone,  and  hence  that  the  lymph  or  plasma  must  undergo  ossification, 
instead  of  conversion  into  ordinary  cicatricial  tissue. 

Of  the  blood  which  was  poured  out  from  the  vessels  of  the  bone  itself,  of 
the  marrow,  and  of  the  surrounding  soft  tissues,  a  portion,  and  perhaps  a 
large  part,  is  undoubtedly  absorbed.  But  a  part  of  it  very  probably  remains 
and  becomes  organized,  contributing  to  form  the  uniting  medium. 

This  uniting  medium,  constituted  by  lymph  or  plasma  derived  from  the 
tissues  around  the  broken  bone,  from  the  bone  itself,  from  the  periosteum,  and 
from  the  marrow,  is  called,  as  it  begins  to  assume  firmness,  callus.  "What- 
ever may  be  the  abundance  of  the  material  formed  around  the  fracture,  it 
becomes  permanent  only  between  the  fragments;  although  there  are  some 
cases,  to  be  hereafter  mentioned,  in  which  masses  of  this  callus,  deposited  all 
about  the  seat  of  fracture  in  an  aimless  and  capricious  manner,  become  ossi- 
fied, and  are  never  gotten  rid  of.  There  may  be  a  large  production  of  lymph 
about  both  fragments  ;  but  the  superfluous  portion  is  as  a  general  rule  wholly 
absorbed,  and  the  form  of  the  bone  as  nearly  as  possible  restored. 

According  to  Paget,  there  may  be  an  immediate  union  of  a  broken  bone,  as 
in  the  healing  of  wounds  of  the  soft  parts  by  "  primary  adhesion,"  without 
any  uniting  medium  ;  the  continuity  of  vessels  and  other  textures  being  sim- 
ply renewed.  But  this  must  be  extremely  rare,  and  I  know  of  no  cases  on 
record  in  proof  of  its  occurrence.  In  some  instances,  which  would  seem  to 
be  specially  likely  to  present  this  immediate  union,  it  certainly  does  not  occur; 
as,  for  example,  "in  fractures  of  the  clavicle  without  displacement,  the  peri- 
osteum seeming  to  remain  intact.  Here  there  is  always,  after  a  few  days,  a 
very  marked  swelling,  which  hardens  and  is  gradually  absorbed,  just  as  callus 
does  in  the  majority  of  cases. 

By  some  of  the  older  authors  it  was  laid  down  as  a  rule  that  the  callus 
was  deposited  around  the  fragments,  so  as  to  form  a  wide,  flat  "  ring"  about 

them  a  sort  of  splint — and  within  them,  so  as  to  make  what  was  called  the 

"  pin."  To  the  former  was  given  also  the  name  "  provisional  callus,"  as  it 
was  supposed  to  be  merely  temporary. 

Paget,  whose  views  have  met  with  general  acceptance,  says : — 

"The  normal  mode  of  repair  in  the  fractures  of  the  human  bones  is  that  which  is 
accomplished  by  '  intermediate  callus.'  The  principal  features  of  difference  between 
it  and  that  just  described  are  :  (1)  that  the  reparative  material  or  callus  is  placed  chiefly 
or  only  between  the  fragments,  not  around  them  ;  (2)  that,  when  ossified,  it  is  not  a 
provisional,  but  a  permanent,  bond  oi'  union  for  them ;  (3)  that  the  part  of  it  which  is 


REPAIR  OF  FRACTURES. 


37 


external  to  the  wall  of  the  bone  is  not  exclusively,  or  even  as  if  with  preference,  placed 
between  the  bone  and  the  periosteum,  but  rather  in  the  tissue  of  the  periosteum,  or 
indifferently  either  in  it,  beneath  it,  or  external  to  it." 

He,  however,  admits  that  in  the  ribs,  and  occasionally  in  the  clavicle  and 
humerus,  an  ensheathing  callus  may  occur,  in  consequence  of  unrestrained 
movement  of  the  fragments,  just  as  it  does,  as  a  rule,  in  animals.  Yet,  even 
in  the  latter,  the  ultimate  result  may  be  a  much  more  complete  restoration  of 
the  normal  form  of  the  bone  than  would  be  expected.  Mr.  Crisp  exhibited 
to  the  Pathological  Society  of  London^  a  specimen  of  oblique  fracture  of  the 
humerus  of  a  gorilla,  united  without  deformity ;  and  stated  that  this  was 
only  one  out  of  many,  in  animals  and  birds,  in  which  union  was  as  perfect 
and  the  limb  as  useful  as  if  splints  had  been  applied. 

"We  occasionally  meet  with  cases,  as  has  been  already  said,  of  voluminous 
formation  of  callus,  much  beyond  the  needs  of  the  mere  reparative  process. 
Such  a  deposit,  about  a  fracture  of  the  shaft  of  the 
femur,  is  represented  in  the  annexed  diagram  (Fig.  ^^S-  §06. 

806).  But  in  by  far  the  largest  number  of  cases, 
upon  the  subsidence  of  the  inflammatory  swelling 
immediately  following  the  fracture,  there  is  left 
merely  enough  new  material  to  bridge  over  the  in- 
terval between  the  fragments  (for  if  they  are  not 
in  exact  apposition  there  will  be  a  triangular  or 
wedge-shaped  gap  of  greater  or  less  size  on  either 
side),  and  thus  restore  as  nearly  as  may  be  the  nor- 
mal shape  of  the  bone. 

When  the  fragments  are  wholly  separated  and 
driven  apart,  and  the  periosteum  torn  entirely  asun- 
der— an  occurrence  which  is  very  rare,  even  when 
the  ends  of  the  fragments  overlap  one  another  in  a 
marked  degree — each  fragment  may,  like  the  end 
of  the  bone  in  a  stump  after  amputation,  become 
closed  in  by  a  rounded  shell  of  compact  bone. 
Such  is  the  case  in  some  instances  of  ununited  frac- 
ture, as  will  be  presently  more  particularly  de- 
scribed. But  often  when  the  fragments  are  sepa- 
rated, there  is  still  a  bond  between  them  in  the 
shape  of  the  bridge  of  periosteum  before  spoken  of ; 
and  in  the  space  defined  by  this  bridge  there  will 
be  developed  a  mass  of  callus  which,  becoming 
ossified,  connects  the  two  fragments  permanently, 
and  may  even  acquire  the  cancellous  structure 
proper  to  the  medullary  cavity,  as  well  as  the  com- 
pact VVall,  of  the  shaft  of  the  normal  bone.  ^  voluminous  caUus  in  fractured 

I  believe  it  may  be  stated,  without  any  exception  femur, 
whatever,  that  the  periosteum  is  thickened  and 

swollen  in  the  neighborhood  of  a  fracture.  By  some  writers,  and  especially 
by  Oilier,^  this  membrane  has  been  described  as  endowed  with  the  power  of 
promoting  the  formation  of  bone  in  adjacent  plasma,  and  even  in  the  soft  tis- 
sues if  transplanted  among  them.  That  it  has  such  a  power,  exercised  in  the 
original  development  of  the  skeleton,  cannot  be  doubted  ;  and  from  the  state- 
ments just  made  as  to  the  usual  condition  of  the  periosteum  in  cases  of  frac- 
ture,'and  as  to  the  relation  of  the  callus  to  the  broken  ends,  the  inference  is 

1  Transactions,  vol.  xxvii.  1876,  p.  340. 

2  Traite  Experimentale  et  Clinique  de  la  Regeneration  des  Os,  etc.    Paris,  1867. 


38 


INJURIES  OF  BONES. 


clear  that  the  uniting  material  is  formed  under  the  osteogenetic  influence  of 
the  periosteal  membrane. 

Marcyi  quotes  the  statement  of  Ercolani  that  neither  the  periosteum  nor 
the  ends  of  the  fractured  bone  are  concerned  in  the  formation  of  osseous  cal- 
lus, but  that  the  periosteum  is  destroyed  at  the  points  where  callus  is  formed. 
He  thinks  that  the  material  for  the  callus  is  furnished  from  the  blood  of  the 
lacerated  vessels  of  the  injured  tissues,  including  those  of  the  medulla  and 
Haversian  canals.  In  healed  fractures,  both  in  man  and  animals,  he  found 
definite  evidence  of  atrophy  of  the  ends  of  the  fragments.  And  from  his  ex- 
periments on  animals,  he  concludes :  that  the  old  periosteum  at  the  point  of 
injury  becomes  destroyed;  and  that  the  exudation  from  the  parts  surround- 
ing the  fracture  is  well  developed  as  early  as  the  sixth  or  eighth  day,  and 
covered  with  a  new  periosteum.  By  the  osteogenetic  action  of  this  new 
membrane  he  thinks  that  the  exuded  cellular  elements  are  transformed  into 
bone.    Hence  Klein^  observes : — 

"From  the  description  of  the  appearances  in  the  microscopical  specimens  as  given  in 
the  paper,  it  appears  that  the  formation  of  the  osseous  callus  takes  place  in  essentially 
the  same  manner  as  that  described  by  Billroth,  that  is  to  say,  the  new  bloodvessels  and 
the  cells  of  the  soft  callus,  as  well  as  the  new  periosteum — or  rather  its  osteogenetic 
layer — it  seems,  are  derived  from  the  medullary  tissue  of  the  Haversian  canals  at  the 
extremities  of  the  fractured  bone." 

As  to  the  mode  in  w^hich  the  uniting  material,  the  blastema,  whencesoever 
derived,  becomes  bone,  authorities  have  diflered.    Paget  says  : — ■ 

"  It  may  become,  before  ossifying,  either  fibrous  or  cartilaginous,  or  may  assume  a 
structure  intermediate  between  these  ;  and  in  either  of  these  cases,  ossification  may 
ensue  when  the  previous  tissue  is  yet  in  a  rudimental  state,  or  may  be  delayed  till  the 
complete  fibrous  or  cartilaginous  structure  is  first  achieved.    .    .  . 

"  The  new  bone,  through  whatever  mode  it  is  formed,  appears  to  acquire  quickly  its 
proper  microscopic  characters.  Its  corpuscles  or  lacunae,  being  first  of  simple  round  or 
oval  shape,  and  then  becoming  jagged  at  their  edges,  subsequently  acquire  their  canals, 
which  appear  to  be  gradually  hollowed  out  in  the  preformed  bone,  as  minute  channels 
communicating  with  one  or  more  of  the  lacunae.  The  laminated  canals  for  bloodvessels 
are  later  formed.  At  first,  all  the  new  bone  forms  a  minutely  cancellous  structure, 
which  is  light,  spongy,  soft,  and  succulent,  with  a  reddish  juice  rather  than  marrow, 
and  is  altogether  like  foetal  bones  in  their  first  construction.  But  this  gradually  assimi- 
lates itself  to  the  structure  of  the  bones  that  it  repairs  ;  its  outer  portions  assuming  a 
compact  laminated  structure,  and  its  inner  or  central  portions  acquiring  wider  cancel- 
lous spaces,  and  a  more  perfect  medulla.  It  acquires,  also,  a  defined  periosteum,  at 
first  firm,  thin,  and  distinctly  lamellar,  and  gradually  assuming  toughness  and  compact- 
ness. But  in  regard  to  many  of  these  later  changes  in  the  bonds  of  union  of  fractures, 
there  are  so  many  varieties  in  adaptation  to  the  peculiarities  of  the  cases,  that  no  gene- 
ral account  of  them  can  be  rendered." 

Yirchow's  description  of  the  formation  of  callus  may  also  be  quoted,  as  it 
gives  in  some  respects  a  fuller  idea  of  the  process,  and  from  a  slightly  different 
stand-point.    He  says : — 

"  The  pre-existence  of  cartilage  is  by  no  means  necessary  for  the  formation  of  bone  ; 
on  the  contrary,  an  osteoid  substance  is  very  frequently  formed  by  a  direct  sclerosis  in 
connective  tissue,  nay,  ossification  is  thus  really  more  easily  effected  than  when  it  takes 
place  in  real  cartilage.  We  see  also  by  the  history  of  the  theories  concerning  callus, 
that  the  endeavor  to  show  that  it  is  always  developed  in  the  same  way  or  out  of  the 
same  substance  (e.  g.,  extravasated  blood,  periosteum,  medullary  tissue,  exuded  fluids, 
etc.),  has  proved  the  greatest  obstacle  to  the  true  perception  of  the  red!  state  of  things, 

'  Trans,  of  Amer.  Med.  Association,  1881,  pp.  907  et  seg. 
«  London  Medical  Record,  Feb.  15,  1882. 


REPAIR  OF  FRACTURES. 


39 


and  that  all  have  really  liad  right  upon  their  side,  inasmuch  as  new  bone  in  fact  buihls 
itself  up  out  of  the  most  different  materials.  Unquestionably,  when  the  case  runs  a 
very  favorable  course,  that  path  is  chosen  in  which  the  new  formation  can  be  most  con- 
veniently effected,  and  it  is  by  far  the  most  convenient  way  when  the  periosteum  pro- 
duces a  very  large  portion  of  the  whole.  This  takes  place  in  the  following  manner  : 
the  periosteum  -rows  dense  toward  the  edges  of  the  fracture,  and  there  gradually  swells 
UP  the  swellino-  being  of  such  a  nature  that  separate  layers  or  strata  can  afterward  be 
pretty  clearly  distinguished  in  it.  These  continually  become  thicker  and  more  numer- 
ous in  consequence  of  the  constant  proliferation  of  the  innermost  parts  of  the  perios- 
teum and  of  the  formation,  by  means  of  a  multiplication  of  their  cellular  elements,  of  new 
layers  which  accumulate  between  the  bone  and  the  relatively  still  normal  parts  of  the 
periosteum.  These  layers  may  become  cartilage,  but  it  is  not  necessary,  nor  yet  the 
rule  For  we  find  that,  in  the  greater  number  of  favorable  cases  of  fracture,  where 
cartilacxe  is  produced,  not  the  whole  mass  of  the  periosteal  callus  is  produced  from  car- 
tilage but  a  greater  or  less  portion  of  it  is  always  formed  out  of  connective  tissue.  1  he 
Hyers'  of  cartilac^e  crenerally  lie  next  to  the  bone,  whilst  the  further  we  proceed  outward, 
the  less  does  the  formation  out  of  cartilage,  and  the  more  a  direct  transformation  of 
connective  tissue,  prevail.  ,  ,    v         r  .v 

The  formation  of  bone  is,  however,  by  no  means  restricted  to  the  hmits  of  the  perios- 
teum—very commonly  it  extends  beyond  them  in  an  outward  direction,  and  often 
penetrates,  in  the  form  of  spicula,  nodules,  and  protuberances,  to  a  very  considerable 
depth  into  the  neighboring  soft  parts.  It  is  self-evident  that  in  these  cases  we  have  by 
no  means  to  deal  with  any  proliferation  of  the  periosteum  in  an  outward  direction,  but 
that  an  ossifiable  tissue  arises  out  of  the  interstitial  connective  tissue  of  the  neighboring 
parts.  Of  this  it  is  very  easy  to  convince  one's  self,  because  osseous  spicula  are  found 
shootincr  up  in  the  interstitial  tissues  of  the  neighboring  muscles.  In  the  preparation 
from  the  fractured  ribs  [previously  shown],  places  are  still  to  be  found  in  the  external 
parts,  where  fVit  has  been  included  in  the  ossification.  It  cannot  be  said,  therefore,^that 
the  formation  of  callus  around  fractured  parts  is  altogether  a  periosteal  formation.' 

Yirchow  then  goes  on  to  speak  of  a  difierent  mode  of  development  of 
callus, that,  namely,  which  takes  place  in  the  midst  of  the  bone  from  the 
medullmy  tissue.'^ 

"  At  the  moment  when  the  bone  in  a  case  of  fracture  is  shivered,  a  number  of  little 
medullary  spaces  are  naturally  opened.  In  the  neighborhood  of  these,  the  still  closed 
medullary  spaces  are  seen  nearly  invariably,  when  matters  take  a  regular  course,  to 
become  filled  with  callus,  new  lamella?  of  bone  attaching  themselves  to  the  internal 
surface  of  the  osseous  trabeculte  which  bound  the  spaces,  just  as  in  the  ordinary  growth 
of  bone  in  thickness,  the  originally  pumice-stone-like  layers  become  compact  by  the 
deposition  of  concentric  lamellie.  In  this  manner  it  happens,  that  after  some  time  a 
larger  or  smaller  new  layer  of  bone  is  found,  filling  up  the  end  of  the  medullary  canal 
of  each  fragment  so  as  to  occasion  its  occlusion.  This  is  a  kind  of  new  forniation  which 
has  nothing  in  common  with  the  former  one,  as  far  as  their  starting-points  are  con- 
cerned, but°has  its  origin  in  quite  another  tissue,  and  is  altogether  different  in  its  pal- 
pable result,  inasmuch  as  it  produces,  within  the  confines  of  the  old  bone,  a  condensation 
of  that  portion  of  the  marrow  which  lies  in  the  immediate  vicinity  of  the  fracture. 
Even  in  cases  where  the  ends  of  the  bones  perfectly  coincide,  an  internal  formation  of 
bone  such  as  I  have  described  takes  place  in  the  medullary  canal  of  each  fragment, 
producing  its  occlusion. 

"  These  two  kinds  are  the  usual  and  normal  ones.  Around  the  two  fractured  ends, 
the  swelling  takes  place  ;  in  the  interior,  the  condensation.  Gradually— in  proportion 
as  the  extravasated  blood  is  absorbed— the  new  masses  of  tissue  which  have  been  de- 
veloped between  the  broken  ends  draw  nearer  to  one  another,  and  round  about  the 
fracture  there  forms  a  bridge-  or  capsule-like  communication  by  means  of  the  ossifica- 
tion of  the  soft  parts.  There  is,  therefore,  but  little  reason  to  ask  whether  the  callus 
proceeds  from  free  exuded  or  extravasated  matter.  No  doubt  an  extravasation  takes 
place  in  the  first  instance  into  the  space  between  the  fractured  ends,  but  the  extrava- 
sated blood  is  generally  pretty  completely  reabsorbed,  and  it  contributes  comparatively 
but  very  little  to  the  real  formation  of  the  subsequent  uniting  media." 


40 


INJURIES  OF  BONES. 


Ranvier  thinks  that  the  new  bone  constituting  callus  is  always,  in  simple 
fractures,  developed  through  a  cartilaginous  stage,  but  this  is  at  variance 
with  the  views  of  other  observers. 

Mr.  J .  Greig  Smith  has  published^  an  interesting  article  on  the  histology  of 
fracture  repair  in  man,  giving  the  results  of  the  examination  of  a  number  of 
specimens  at  various  stages  of  the  process.    He  sums  them  up  as  follows:  

"  A  plastic,  parent  tissue  is  provided  partly  by  the  swollen  and  inflamed  pre-existing 
tissues,  partly  by  organized  inflammatory  neoplasm.  The  ossific  stimulus  lays  hold  of 
this  parent  tissue  and  infects  it  with  the  first  change  toward  ossification,  viz.,  calcifica- 
tion. The  calcifying  process  proceeds  along  numerous  irregularly  disposed  lines  through 
the  parent  tissue,  modifying  it  before  it  finally  completely  invades  it.  This  modifica- 
tion of  matrix  ahead  of  the  line  of  calcification  consists'  chiefly  of  a  swelling  of  the 
intercellular  substance,  bringing  about  an  occasional  resemblance  to  ordinary  hyaline 
cartilage.  When  the  process  is  completed  by  the  formation  of  an  areolar  calcified  tissue 
containing  variously  modified  embryonic  substance  in  its  meshes,  we  have  the  great 
mass  of  so-called  bony  callus.  This  callus  material  soon  begins  to  undergo  the  further 
changes  toward  true  ossification  ;  namely,  absorption  of  the  calcified  substance  and  de- 
velopment on  these  calcified  lines  of  true  lamellar  bone  by  osteoblasts  derived  from  out- 
growing marrow  or  cambium  layer  of  periosteum." 

As  to  the  individual  tissues  concerned,  he  thus  summarizes:  

^'Blood-clot — The  greater  part  of  the  effused  blood  is  absorbed  and  disappears.  Some 
amount  of  blood-clot  usually  remains  in  certain  positions  to  become  organized.  After 
organization,  more  or  less  perfect,  it  may  either  directly  become  a  parent  tissue  for  bony 
growth,  or  undergo  a  further  transformation  toward  this  end.  Blood-clot  organizes  by 
preference  in  the  exposed  medullary  canal  and  over  the  jagged  ends  of  the  broken 
bones.  Where  it  forms  the  chief  nidus  for  ossification,  bony  union  is  longest  delayed. 
^  ^'Periosteum — Periosteum  contributes  to  fracture  repair  rather  by  virtue  of  its  posi- 
tion as  a  fibrous  tissue  than  through  its  ordinary  function  as  a  bone-producer.  Perios- 
teal callus  is  rather  a  calcifying  cellulitis  than  an  ossifying  periostitis.  Periosteum 
does  not  undergo  very  much  change  preparatory  to  calcification.  The  calcified  perios- 
teal trabecule  are  the  least  perfectly  developed  and  the  most  unstable  of  all  the  areolar 
bony  callus  material.  Shreds  of  periosteal  fibre  traversing  embryonic  inflammatory 
tissue  contribute  materially  to  the  rapidity  with  which  calcification  is  carried  out. 

"  Tendon  and  Ligament — Where  present,  these  tissues  play  an  important  part  in  the 
ossifying  process.  Sometimes  undergoing  calcification  without  exhibiting  material 
change  of  structure,  they  frequently,  however,  are  subjected  to  preparatory  modifica- 
tions which  assimilate  them  in  appearance  to  true  cartilage,  and  thereafter  behave  in 
ossification  as  ordinary  cartilage  does.  The  presence  of  an  abundance  of  ligamentous 
tissue  should  warn  us  of  a  possible  overgrowth  of  uniting  bone. 

''Fihro-cartilage — White  fibro-cartilage  may  become  calcified  without  undergoing 
preliminary  structural  changes.  The  calcareous  deposit  is  finely  divided  and  dense  ; 
and  the  advent  of  the  absorptive  process  is  long  delayed.  As  a  temporary  bond  of 
union,  it  Is,  when  once  formed,  the  strongest  of  all. 

New  inflammatory  tissue  contributes  to  bony  growth  after  it  has  been  in  varying  de- 
grees assimilated  to  the  formed  tissues  in  its  neighborhood.  Occasionally  it  assumes  a 
resemblance  in  structure  to  hyaline  cartilage." 

After  the  callus  has  been  deposited  and  ossified,  and  the  bone  has  begun  to 
acquire  strength,  there  still  remains  the  modelling  process  to  be  accomplished; 
in  other  words,  projecting  points,  edges,  or  other  roughnesses  have  to  be  re- 
moved by  absorption,  so  as  to  restore  as  nearly  as  may  be  the  normal  form 
of  the  bone.  This  is  brought  about  in  the  same  way  as  in  the  case  of  a  bone 
sawed  through  squarely  in  an  amputation,  which  bec^omes  in  time  rounded 
off  by  a  shell  of  compact  bone,  usually  thin,  and  backed  up  by  lamellae  nearly 

1  Joum.  of  Anatomy  and  Physiology,  Jan.  1882. 


REPAIR  OF  FRACTURES. 


41 


as  regular  as  those  already  described  as  seen  in  sections  through  the  articular 
extremities.  Sometimes  the  new  wall  is  thick  and  almost  ivory-like  in  den- 
sity and  hardness ;  but  it  is  always  present,  so  that  the  medullary  cavity  is 
invariably  covered  in.  Probably  there  is  in  the  lirst  place  a  formation  of 
new  bone,  which  scarcely  acquires  its  density  and  hardness  before  the  absorp- 
tion of  the  outer  and  irregular  portions  of  the  old  bone  begins.  How  long 
the  modelling  process  lasts,  cannot  well  be  determined  ;  but  it  is  most  likely 
that  it  always  occupies  more  time  than  all  the  rest  of  the  repair  of  the  injury. 
Sometimes  it  is  not  completed  for  many  months  after  the  bone  has  in  great 
measure  resumed  its  function. 

Thus  far  reference  has  been  made  to  the  reparative  process  in  cases  of  frac- 
ture of  the  shafts  of  the  long  bones.  When  the  breakage  extends  into  a 
joint,  so  as  to  involve  the  articular  cartilage,  we  find  that  although  the  joint- 
cavity  may  have  been  seriously  damaged,  |)erhaps  filled  with  blood,  the  ulti- 
mate result  may  be  very  good.  The  blood  becomes  absorbed,  tlie  secretion  of 
synovia  is  restored,  and  the  end  of  the  bone  may  show  no  trace  of  the  solu- 
tion of  its  continuity  beyond  either  a  groove  or  a  depression.  For,  perhaps 
owing  to  the  absence  of  periosteum,  callus  is  not  thrown  out  at  the  portion  of 
the  fracture  corresponding  to  the  joint ;  and  if  the  fragments  can  be  kept  in 
accurate  apposition,  there  will  be  no  such  bulging  of  new  material  as  exists 
around  the  fragments  elsewhere. 

The  same  may  be  said  of  fractures  of  the  patella.  Here,  if  the  broken 
portions  can  be  kept  in  contact,  so  as  to  become  united  by  bone,  this  will  be 
found  on  the  anterior  surface  to  be  marked  by  a  more  or  less  distinct  ridge, 
while  posteriorly,  or  on  the  joint  surface,  there  will  be  rather  a  depression,  as 
if  there  had  been  material  absorbed  instead  of  deposited. 

Like  all  the  other  processes  of  nature,  and  especially  like  all  the  other 
processes  of  repair,  the  healing  of  broken  bones  takes  place  in  obedience  to 
certain  general  laws ;  and  although  in  the  majority  of  cases  the  result  thus 
provided  for  is  good — -is,  indeed,  the  best  attainable  as  far  as  nature  is  con- 
cerned— still  instances  occur  in  which  these  blind  forces  work  harm.  Thus, 
in  the  case  of  fractures  near  the  joints,  the  deposit  of  new  bone  may  be  such 
as  to  hamper  the  movements  of  the  limb  most  seriously.  In  fractures  of  the 
forearm,  the  callus  of  one  bone  may  unite  with  that  from  the  other,  and  the 
resulting  osseous  bridge  may  do  away  altogether  with  the  possibility  of  the 
pronation  and  supination  of  the  hand,  rendering  it  almost,  if  not  wholly,  use- 
less. N^ature  is  wholly  indifferent  to  the  individual ;  and  it  is  for  the  surgeon 
to  watch  and  guide  her  reparative  efiPorts  in  each  instance. 

Fractures  of  cartilage  are  sometimes  met  with,  and  are  repaired  by  means 
of  a  copious  deposit  of  material  analogous  to  the  callus  of  bone.  In  the 
"  Wistar  and  Horner  Museum"  of  the  University  of  Pennsylvania,  there  is  a 
specimen  of  fractures  of  the  sixth,  seventh,  and  eighth  costal  cartilages  of  the 
right  side,  each  surrounded  by  a  somewhat  irregular  bony  ring.  A  very 
similar  specimen  is  in  the  Miitter  Museum  of  the  Philadelphia  College  of 
Physicians.  Paget  thinks  that  this  occurs  only  in  the  costal  and  laryngeal 
cartilages,  which  have  a  tendency  to  ossify  in  advanced  life. 

When  an  articular  cartilage  is  involved  in  a  fracture  of  the  bone  to  which 
it  belongs,  it  does  not  seem  ever  to  be  fully  repaired  ;  a  groove  lined  by  fibrous 
tissue  always  marks  the  line  of  injury. 

The  repair  of  compound  difiters  from  that  of  simple  fractures,  in  the  fact 
that  suppuration  is  almost  inevitable,  and  that  granulations  spring  up  about 
the  injured  and  exposed  bone,  b}'  the  ossification  of  which  union  takes  place. 
In  point  of  actual  damage  to  the  bone,  many  compound  fractures  are  less 


42 


INJURIES  OF  BONES. 


serious  than  many  simple  fractures.  And  as  soon  as,  by  the  process  of  granu- 
lation  or  by  adhesion,  the  soft  parts  have  closed  in  over  the  bone,  repair  goes 
on  as  rapidly  as  if  the  fracture  had  been  simple  throughout,  l^o  law  can  be 
laid  down  as  to  a  definite  difference  between  simple  and  compound  fractures^ 
in  the  length  of  time  required  for  their  repair. 

According  to  Cornil  and  Ranvier,^  in  compound  fractures — 

"  The  changes  occurring  are  identically  the  same  as  in  osteitis  ;  at  all  the  irritated 
points  of  the  surface  of  the  solution  of  continuity,  the  marrow  becomes  embryonic,  and 
undergoes  changes  similar  to  those  of  a  simple  osteitis.  Under  the  periosteum,  the  new 
embryonic  marrow  soon  forms  osseous  trabeculse ;  five  or  six  days  after  the  accident 
they  may  be  found.  The  Haversian  canals  opened  by  the  fracture  are  enlarged  througli 
the  absorption  of  the  osseous  substance  limiting  them  ;  the  vessels  and  marrow  which 
they  contain  contribute  to  the  formation  of  the  granulation  tissue.  The  marrow  in  the 
central  medullary  cavity  undergoes  the  same  modifications,  although  more  slowly.  Thus, 
over  the  whole  surface  of  the  solution  of  continuity,  there  are  formed  granulations  which 
enlarge  and  by  uniting  together  constitute  an  embryonic  or  inflammatory  tissue,  in  the 
midst  of  which  osseous  trabeculse  are  developed,  as  in  the  physiological  method  of  ossi- 
fication. The  needle-like  points  of  the  old  bone  seem  always  to  act  as  a  base  for  the 
new  osseous  formation.  Growing  in  every  direction,  uniting  one  with  the  other  and 
with  the  opposite  fragments,  they  limit  the  spaces  filled  with  the  embryonic  marrow. 
These  spaces  are  gradually  narrowed  by  the  addition  of  new  osseous  layers,  and  con- 
solidation is  brought  about  by  a  firm  adhesion  between  the  two  fragments  of  bone." 

It  is  very  necessary  to  remark,  that,  while  this  distinction  between  the 
mode  of  union  in  simple  and  compound  fractures  is  clearly  to  be  discerned, 
the  two  processes  are  often  combined  in  the  same  case.  Thus,  either  from 
the  very  first  or  from  a  later  period,  the  deeper  portions  of  a  broken  bone 
may  be  entirely  excluded  from  the  air ;  and  hence  in  these  the  repair  goes 
on  by  the  method  described  for  simple  fractures,  by  the  ossification  of 
lymph  or  plasma  passing  through  a  stage  of  more  or  less  complete  develop- 
ment of  fibrous  or  cartilaginoid  structure.  At  the  same  time,  granulations 
are  forming  about  the  exposed  portions  of  the  injured  bone,  and  'here  the 
uniting  medium,  the  callus,  will  be  the  direct  result  of  the  ossification  of 
those  granulations.  Cicatricial  tissue  will  be  developed  for  the  repair  of  all 
the  damage  to  w^hich  the  air  finds  access,  and  will  take  on  the  structure  of 
the  parts  united.  At  first  the  scar  in  the  skin  will  be  closely  adherent  to 
the  new-formed  reparative  bone ;  indeed,  it  sometimes  remains  so  perma- 
nently. But  in  many  cases  there  is  a  gradual  stretching  of  the  intermediate 
layer,  until  a  very  good  imitation  of  normal  areolar  tissue  allows  the  cuta- 
neous cicatrix  to  play  freely  over  the  bone  even  where  the  fracture  existed. 
This,  however,  corresponds  in  time  to  the  later  stages  of  the  modelling 
process. 


Defects  in  the  Process  of  Repair  of  Fractures. 

In  the  vast  majority  of  cases  of  fracture  of  the  long  bones,  osseous  union 
takes  place  in  due  course.  As  the  surgeon  from  time  to  time,  during  the  period 
of  treatment,  handles  the  limb,  he  finds  the  fragments  less  and  -less  movable 
upon  one  another,  until  at  last  they  do  not  yield  at  all,  and  the  patient  himself 
becomes  able  to  exert  some  muscular  power  upon  the  restored  bone.  Clinical 
observation  has  determined  pretty  nearly  the  average  period  at  which,  under 
ordinary  circumstances,  consolidation  ma}^  be  looked  for  in  the  several  por- 
tions of  the  skeleton ;  and  in  general  we  do  so  expect  it.    Eut  cases  are  met 


•  Op.  cit.,  p.  210. 


DEFECTS  IN  THE  PROCESS  OF  REPAIR  OF  FRACTURES. 


with  in  which  the  fragments  remain  movable ;  and  the  conditions  of  this 
failure  to  unite  are  now  to  be  considered.  ^        x-  -.•     i  i 

These  cases  have  been  divided  into  those  of  delayed  union,  ot  dissolved 
union,  of  fibrous  union,  of  complete  separation  of  the  fragments,  and  of  pseud- 
arthrosis  or  false-joint  properly  so  called. 

Delayed  union  is  by  no  means  uncommon.  Scarcely  a  year  passes  that  I 
do  not  see  one  or  more  instances  in  my  hospital  wards,  and  I  have  repeatedly 
been  consulted  about  such  cases  in  the  private  practice  of  others.  It  is  not 
always  easy  to  assign  a  cause  for  the  failure,  which  may  occur  under  the  best 
treatment,  and  in  persons  seemingly  of  good  general  health.  Porter^  speaks  of 
havino-  "seen  two  cases  of  fractured  femur  remain  ununited  at  the  end  of  hve 
and  six  months,  in  the  persons  of  fine  and  healthy  young  men,  although  the 
ends  of  the  bones  were  kept  in  apposition,  and  in  every  other  respect  the 
treatment  was  correct."  I  have  myself  seen  union  delayed  oftener  in  the  leg 
than  elsewhere,  and  in  some  of  the  instances  the  fracture  has  been  extremely 
oblique  ;  the  patients  have  been  for  the  most  part  male  adults  of  the  laboring 
class,  of  middle  age ;  although  one,  in  private  practice,  was  a  very  young 
man  in  excellent  circumstances,  and  rather  remarkably  robust. 

Although  more  frequent  in  men,  delayed  union  is  met  with  in  women  also, 
and  arnonl?  its  constitutional  causes  pregnancy  has  been  assigned  by  some 
writers  a  ""prominent  place ;  but  against  the  cases  adduced  in  proof  of  this 
view  must  be  set  a  great  many  in  which  the  cure  has  been  rapid.  One  such 
occurred  to  me  at  the  Episcopal  Hospital,  in  1871.2  In  like  manner,  the  evi- 
dence is  confiicting  as  to  the  influence  of  syphilis,  of  cancer  (not  afiecting  the 
bone  itself),  of  paralysis,  of  old  age,  and  of  great  losses  of  blood;  as  to  all  these, 
while  there  are  instances  on  record  of  their  apparent  influence  in  retarding  the 
union  of  fractures,  there  are  enough  in  which  they  seemed  to  have  no  such 
elfect,  to  make  the  matter  at  least^doubtful.  The  reader  will  find  these  vari- 
ous cases  detailed  in  the  systematic  works  of  Malgaigne,  Gurlt,  and  others. 
Xorris^  has  discussed  the  subject  at  great  length  and  very  instructively. 

The  influence  of  very  long-continued  loiD  diet,  and  of  the  debility  thus 
induced,  in  hindering  the  consolidation  of  fractures,  is  much  more  clearly 
proved.  In  two  instances,  one  recorded  by  Thierry^  and  the  other  by  Poncet,^ 
the  repair  of  fractures  seemed  to  have  been  delayed  by  indulgence  in  sexual 
intercourse,  and  took  place  promptly  on  the  withdrawal  of  the  opportunity  for 
such  indulgence. 

Among  local  causes  of  delayed  union  there  are  some  which  seem  to  be  un- 
questionable. Wide  separation  of  the  fractured  ends,  by  a  bad  position  of  the 
fragments,  or  by  loss  of  substance,  may  have  this  efiect.  Here  there  is  more 
to  be  done,  and  nature  takes  longer  to  do  it.  The  wonder  is  that  union  is  not 
in  some  of  these  cases  totally  prevented.  ISTorris^  says :  "  In  the  case  of  a  boy 
aged  12,  who  came  under  my  care  in  the  Pennsylvania  Hospital  in  1837,  two 
inches  of  the  tibia  was  removed,  notwithstanding  which  he  was  discharged 
cured  in  eleven  weeks,  with  shortening  of  the  limb  of  but  half  an  inch, 
the  space  occupied  by  the  removed  bone  being  filled  by  a  firm  and  even 
callus."  When  the  fragments  are  widely  separated,  it  is  very  hard  to  prevent 
some  disturbance  of  their  relative  position  ;  and  this  may  be  sufiicient  to  pull 
upon  the  as  yet  fibrous  uniting  medium,  and  interfere  with  its  ossification, 
thoudi  not  enoudi  to  induce  actual  inflammation.   In  like  manner,  an  attempt 

»  Cyclopaedia  of  Anatomy  and  Physiology,  vol.  i.  p.  447. 
«  Philadelphia  Medical  Times,  Feb.  1,  1872. 

8  Contributions  to  Practical  Surgery,  pp.  23  et  seq.    Philadelphia,  1873. 

4  L'Exp^rience,  4  Nov.  1841.        *  Brit.  Med.  Journal,  March  18,  1882.       •  Op.  cit.,  p.  42. 


44 


INJURIES  OF  BONES. 


to  use  a  broken  limb  before  the  callus  has  become  firm,  may  so  disturb  the 
newly  developed  tissue  as  to  postpone  its  ossification  for  a  time. 

At  the  present  day  scarcely  any  surgeon  can  be  found  who  would  make 
use  of  wet  dressings  to  a  fractured  limb  after  the  inflammatory  stage ;  and 
hence  the  prolonged  employment  of  such  applications,  as  a  cause  of  delayed 
union,  need  be  only  mentioned  as  a  matter  of  history. 

Tight  bandaging^  it  is  to  be  feared,  is  sometimes  practised,  especially  by 
surgeons  in  the  country,  who  cannot  frequently  visit  their  patients ;  yet  it  is 
all  the  more  dangerous  under  such  circumstances.  That  it  may  induce  gan- 
grene of  the  limb  is  well  known ;  but  when  not  sufiacient  for  this,  it  may 
very  probably  so  far  interfere  with  the  nutrition  and  innervation  of  the  part 
as  to  delay  the  process  of  repair. 

Occasionally  the  interposition  betiveen  the  fragments  of  a  portion  of  muscle, 
of  a  separated  splinter,  or  of  a  foreign  body,  may  cause  a  long  delay  in  union, 
or,  unless  either  removed  or  absorbed,  ma}^  wdiolly  prevent  it.  A  curious 
case  is  quoted  bj' I^orris,^  "  in  which  the  fragments  of  a  clavicle,  separated  to 
the  extent  of  an  inch  by  the  subclavius  muscle,  were  united  together  very 
solidly  by  two  bridges  of  newly-formed  bone,  in  the  centre  of  which  the 
muscle,  itself  ossified,  was  imprisoned." 

Necrosis  or  other  disease  of  one  or  both  fragments  may  hinder  consolidation, 
until  by  appropriate  measures  the  disease  has  been  set  aside  or  the  necrosed 
portions  removed. 

The  ligation  of  the  main  artery  of  the  limb,  sometimes  rendered  necessary 
by  a  wound,  has  occasionally  been  thought  to  interfere  with  the  union  of  a 
fracture  by  cutting  ofi:'  the  vascular  supply.  But,  in  other  instances,  as  in  a 
case  recorded  by  Mr.  Bransby  Cooper^,  the  process  of  repair  seems  to  take 
place  quite  as  readily  as  under  other  circumstances. 

As  to  the  efifect  of  nerve  injuries  upon  the  repair  of  fractures,  there  is  a 
decided  conflict  of  evidence.    Thus  Travers^  gives  the  following  case : — 

A  man  had  his  fourth  and  fifth  lumbar  vertebrae  fractured  and  dislocated  by  the  falling 
of  a  load  of  gravel  upon  his  loins  as  he  was  working  in  a  pit.  At  the  same  time  the 
bones  of  his  right  leg  and  his  left  upper  arm  were  fractured.  These  were  adjusted  and 
set ;  the  lower  limbs,  bladder,  and  rectum  were  paralyzed  immediately,  but  the  loss 
of  sensation  was  gradual,  and  both  sensation  and  motion  were  partially  restored  before 
his  death.  He  lived  eight  weeks,  notwithstanding  two  attacks  of  peritonitis.  At  the 
end  of  five  weeks  the  fractured  arm  was  perfectly  united ;  the  bones  of  the  leg  were 
unchanged,  and  exhibited  not  the  slightest  advance  toward  union ;  but  at  the  time  of 
his  death  some  thickening  of  the  fractured  ends  had  taken  place,  and  the  process  of 
union  seemed  to  be  at  length  commencing. 

On  the  other  hand,  Kusmin^  found  that,  in  animals  experimented  on  by 
him,  the  callus  w^as  larger  and  harder  on  the  side  on  which  the  nerves  had 
been  divided.  This  was  still  the  case  after  four  or  five  months.  The  process 
of  ossification  was  more  rapid,  and  the  result  was  true  bone.  The  bony 
formation  in  the  cartilaginous  callus  occurred  in  the  earlier  stages  as  a  meta- 
plastic process.  The  first  signs  of  ossification  began  in  the  coaptated  frag- 
ments in  the  neighborhood  of  the  outer  periphery  of  the  old  bone,  and  under 
the  periosteum,  markedly  earlier  and  to  a  greater  extent  when  the  nerves 
had  been  divided. 

The  amount  of  mobility  at  the  seat  of  fracture,  when  the  consolidation  is 
hindered  by  any  of  the  circumstances  now  mentioned,  varies  somewhat ;  but 

1  Op.  cit.,  p.  48.  2  Lancet,  Dec.  5,  1840.  «  Further  Inquiry,  etc.,  p.  436. 

4  Ueber  den  Einfluss  der  Nerven-durchschneidung  auf  die  Callus-bildung  bei  Fracturen.  Allg, 
Wiener  Med.  Zeitung,  Nos.  33,  34,  und  35,  1882. 


DEFECTS  IN  THE  PROCESS  OF  REPAIR  OF  FRACTURES. 


45 


it  is  apt  to  be  only  slight,  and  its  development  by  the  surgeon's  hands  is 
attended  with  pain,  which  may  be  quite  severe.  The  bone  remains  useless 
as  a  lever  or  as  a  means  of  support.  A  certain  degree  of  oedema  of  the  limb 
is  often  present ;  the  skin  is  apt  to  be  harsh,  and  the  muscles  of  the  part  are 

^It^fs  probable  that  the  callus  is  in  all  these  cases  formed  as  far  as  the  fibrous 
or  fibro-cartilaginous  stage,  and  that  the  delay  is  simply  in  its  ossification  ; 
but  I  know  of  no  instance  on  record  in  which  an  opportunity  has  been  aftbrdcd 
of  determining  the  state  of  the  parts  by  dissection. 

Under  appropriate  treatment,  to  be  hereafter  detailed,  the  full  development 
of  the  uniting  medium  is  generally  brought  about,  and  a  good  result  at  length 
obtained. 

Dissolved  union  is  much  more  rare  than  the  foregoing  condition.  Under 
this  head  are  embraced  cases  in  which,  callus  having  formed,  and  the  frag- 
ments having  become  solidly  united,  the  reparative  material  softens  again 
and  disappears,  and  the  mobility  recurs.  While  there  are  not  many  such 
instances  on  record,  there  are  enough  to  establish  the  possibility  of  the  phe- 
nomenon. 

The  most  frequent  cause  of  this  breaking  down  of  formed  callus  is  the 
occurrence  of  some  systemic  disorder.  Thus,  in  Chaplain  Walter's  account 
of  Lord  Anson's  voyages,^  the  case  of  a  sailor  is  mentioned  who  was  attacked 
with  scurvy,  and  the  callus  of  a  broken  bone,  which  had  been  completely 
formed  for  a  long  time,  w^as  found  to  be  hereby  dissolved,  and  the  fracture 
seemed  as  if  it  had  never  been  consolidated." 

N'orris,^  speaking  of  the  influence  of  erysipelas,  says  that  he^  has  "  seen  a 
rapid  absorption  of  a  large  callus,  which  had  produced  firm  union  of  a  frac- 
ture of  the  lower  third  of  the  leg,  occur,  without  any  apparent  cause,  to  such 
an  extent  as  to  render  the  fragments  very  movable,  and  necessitate  a  renewal 
of  the  treatment." 

Fevers  have  been  known  to  have  a  like  efiect,  as  in  a  case  reported  by 
Schilling.^  An  artilleryman  had  a  fracture  of  the  left  femur,  September  1, 
which,  by  the  middle  of  November,  was  so  firmly  united  that  he  could  bear 
some  weight  on  the  foot.  He  was  then  attacked  with  typhus  abdominalis 
(typhoid  fever),  and  ten  days  afterward  callus  could  no  longer  be  felt,  the 
bones  moving  as  freely  upon  one  another  as  just  after  the  injury.  In  six  days 
more  the  patient  died.  The  examination  exhibited  no  trace  of  callus ;  the 
broken  surfaces  were  bloody,  like  those  in  a  recent  fracture,  and  were  sur- 
rounded by  a  sac-like  membrane,  which  contained  some  bloody  fluid.  Similar 
cases  have  been  recorded  by  Mantell*  and  others.'^  A  very  curious  case  is 
reported  by  Clarke,^  of  a  fast-growing  boy,  who  had  a  fracture  of  the  arm, 
which  united ;  he  returned  to  school,  overworked  himself  in  trying  to  obtain 
a  prize,  and  broke  down  in  health,  when  the  fragments  were  found  to  have 
become  disjoined. 

Occasionally  the  retrogression  does  not  stop  here,  but  the  fragments  them- 
selves become  absorbed,  as  in  the  very  remarkable  case  recorded  by  Jackson 
and  D wight, ^  in  which  almost  the  entire  humerus  disappeared  after  the  oc- 
currence of  a  second  fracture.    A  case  in  many  respects  analogous  to  this  is 

1  A  Voyage  Round  the  World,  etc.,  vol.  i.  p.  120.  «  Op.  cit.  p.  52. 

3  Med.  Zeitung,  Sept.  16,  1840;  Am.  Journal  of  the  Med.  Sciences,  April,  1841. 

4  Lancet,  Oct.  9,  1841. 

s  Morgagni,  De  Sedibus  et  Causis  Morborum,  Alexander's  translation,  vol.  iii.  p.  308 ;  Gage, 
Trans,  of  New  Hampshire  Med.  Society,  1875,  p.  93  ;  Hammick,  op.  cit.,  p.  176. 
6  Med.  Times  and  Gazette,  Nov.  16,  1867. 

1  Boston  Med.  and  Surg.  Journal,  July,  1838,  and  Oct.  10,  1872. 


46 


INJURIES  OF  BONES. 


described  by  Grross.^  In  neither  of  these  instances  was  there  any  apparent 
cause  for  the  destruction  of  the  bone. 

As  far  as  can  be  judged  from  the  observations  published,  the  removal  of 
the  constitutional  disorder,  when  it  can  be  effected,  is  followed  by  a  renewal 
of  the  process  of  repair  of  the  fracture,  which  ultimately  becomes  thoroughly 
united. 

Fibrous  Union  of  Fractured  Bones.— The  cases  of  fibrous  union  differ  from 
those  already  described,  in  that  the  fragments  become  closed  in  at  their  ends 
by  a  rounded  shell  of  bone,  sometimes" very  thin,  but  more  generally  thick, 
hard,  and  dense  ;  while  between  them  and  connecting  them  there  exist  fibrous 
bands  resembling  interosseous  ligaments.  These  bands  may  attach  the  frag- 
ments end  to  end,  in  which  case  there  has  probably  been  absorption  of  some 
portion  of  bone,  perhaps  separated  as  a  splinter  at  the  time  of  injury;  or, 
when  there  is  overlapping  of  the  fragments,  the  fibrous  bands  may  bridge 
over  the  interspace  between  them.  It  seems  highly  probable  that  in  some 
cases  these  bands  may  be  in  reality  remnants  of  interosseous  membrane  or  of 
intermuscular  septa. 

Sometimes  a  condition  of  this  kind  is  not  easy  to  distinguish  clinically 
from  that  of  false-joint,  properly  so  called,  to  be  presently  described.  But 
there  is  generally,  from  the  length  of  the  bands  and  the  comparative  free- 
dom of  the  fragments,  an  even  greater  degree  of  mobility  ;  the  limb  hangs 
like  a  flail,  and  is  useless  except  for  such  actions  as  involve  merely  a  straight 
pull  on  the  part  of  the  muscles. 

Most  of  the  systematic  winters  are  at  pains  to  assure  us  that  results  such 
as  these  have  never  ensued  in  cases  treated  by  them  ;  and  in  the  majority  of  the 
instances  on  record,  the  patients  have  been  sailors,  who  met  with  their  frac- 
tures while  at  sea,  and  who  were  thus  unavoidably  deprived  of  the  benefits  of 
treatment  until  a  long  while— weeks  or  even  months — had  elapsed.  From 
this  fact,  as  well  as  from  the  general  tenor  of  the  other  evidence  in  re2:ardto 
the  matter,  it  seems  to  me  as  if  fibrous  union  were  due  much  more  generally 
to  local  causes  than  to  any  constitutional  disorder.  This  view^,  which  w^as 
maintained  by  Stanley,  Callender,  and  others,  has  been  opposed  by  some  re- 
spectable authorities,  but  I  think  partly  because  the  just  distinction  has  not 
been  drawn  between  these  cases  and  those  of  mere  delayed  union. 

Fibrous  union  is  very  often  the  only  form  attainable  in  certain  bones^ — the 
patella  and  the  olecranon,  for  example ;  and  here,  if  it  is  close  enough,  the 
functions  of  the  limb  may  in  time  be  almost  completely  resumed.  "But  it 
may  also  occur  in  any  of  the  long  bones,  especially  in  fractures  of  both  bones 
of  the  forearm,  and  in  those  of  the  cervix  femoris. 

The  amenability  of  these  cases  to  treatment  is  generally  in  inverse  ratio  to 
the  time  of  their  existence  ;  if  seen  and  recognized  early,  they  may  be  dealt 
with  far  more  readily,  and  the  chance  of  success  from  mild  measures  is  much 
greater,  than  if  the  condition  above  described  has  become  thoroughly  estab- 
lished. In  the  latter  state  of  things,  there  is  very  little  hope  of  amendment 
except  from  operative  procedures,  often  difiicult,  and  by  no  means  free  from 
danger.^  Sometimes,  by  means  of  prothetic  apparatus,  the  limb  may  be  so 
far  stiffened  as  to  enable  the  patient  to  use  it  to  a  certain  extent.  The  other 
plans  of  treatment  will  be  presently  described. 

Complete  separation  of  the  fragments  is  very  rarely  met  withy  and  is 
probably  always  the  result  of  atrophy  of  one  or  both  portions.  I^'orris^  speaks 
of  these  cases;  and  I  think  that  I  have  seen  such  a  condition  in  the  humerus, 


1  Op.  cit.,  vol.  i.  p.  929. 


2  Op.  cU.,  p.  21. 


DEFECTS  IN  THE  PROCESS  OF  REPAIR  OF  FRACTURES. 


47 


Fig.  807. 


Diagram  of 
false  joint. 


but  I  could  not  be  sure  that  there  was  not  a  connection  by  very  long  and 
loose  fibrous  strips,  between  the  ends  of  the  bone.  No  case  is  known  to  me, 
in  which  complete  separation  has  been  placed  beyond  a  doubt  by  dissection. 

False  Joint  or  Pseudarthrosis.— This  term  is  strictly  applicable  only  to 
cases  in  which  there  is  formed  at  the  seat  of  fracture  an  imitation  of  a  normal 
articulation,  as  in  the  annexed  diagram  (Fig.  807).  The  perios- 
teum, and  perhaps  other  fibrous  tissues  in  the  neighborhood, 
become  thickened  and  developed  into  a  sort  of  capsule.  By  con- 
stant motion  upon  one  another,  the-  fragments  become  rounded, 
one  at  the  centre  of  the  end,  the  other  at  the  margin,  so^  that  one 
is  convex  and  the  other  concave ;  and  between  them,Avithin  the 
newly-formed  capsule,  there  occurs  a  secretion  not  unlike  the 
synovia  of  a  true  joint. 

This  state  of  things  is  more  apt  to  occur,  or,  at  least,  has  been 
oftener  met  with,  in  the  shaft  of  the  humerus  than  elsewhere; 
but  it  is  not  always  easy  to  ascertain  from  the  statements  of  wa^i- 
ters  what  the  exact  condition  of  the  bones  may  have  been  in 
cases  treated  by  them.  And,  indeed,  it  may  be  questioned 
whether  it  would  not  be  well  to  retain  simply  the  two  terms, 
delayed  union  and  false  joint,  the  latter  embracing  all  the  cases 
in  which,  Avhether  with  fibrous  union  loose  enough  to  admit  of 
a  wide  range  of  motion,  or  with  an  imitation  of  a  joint  cavity 
between  the  fragments,  there  is  obviously  a  permanent  condition 
of  mobility  at  the  seat  of  fracture.  With  this  understanding, 
which  seems  to  have  been  already  assumed  by  many  writers,  the  discussion 
would  be  simplified,  without  any  real  sacrifice  of  scientific  accuracy ;  since, 
in  the  case  of  fibrous  union,  we  have  an  imitation  of  a  joint  in  its  great  essen- 
tial, mobility,  and,  in  the  other  case,  we  have  but  an  imitation  of  the  structures 
proper  to  a  normal  articulation.  Clinically,  the  two  conditions  are  the  same 
(except  in  the  treatment  required,  w^hich  is  to  be  referred  to  again  hereafter); 
they  both  difter  from  delayed  union  in  the  important  point  that  the  mobility 
in  them  is  unattended  with  pain. 

Otto^  says  that  pseudarthrosis  is  not  unfrequent  in  animals ;  he  has  seen  it 
in  dogs,  cats,  a  fox,  and  several  birds.  He  quotes  Greve  as  having  met  with 
one  example  in  a  hare,  and  Tenon  with  one  in  a  cat.  These  were  probably 
verified  by  dissection. 

Details  of  the  various  plans  available  for  the  treatment  of  the  defects  in  the 
reparative  process  of  fractures  will  be  given  in  the  section  on  the  general 
ti-eatment  of  these  injuries. 

Union  with  deformity  is  almost  invariably  the  result  either  of  want  of 
treatment,  of  improper  or  negligent  treatment,  or  of  the  restlessness  of  the 
patient.  It  may  be  simply  the  perpetuation  of  the  distortion  impressed  upon 
the  limb  from  the  time  of  the  accident,  or  it  may  be  a  new  displacement 
brought  about  by  causes  acting  on  the  limb  at  a  later  period. 

Permanent  deformity  after  fracture  is  by  no  means  uncommon,  and  in  some 
cases  is  absolutely  unavoidable,  by  reason  of  the  difficulty  of  maintaining  the 
fragments  in  proper  position.  It  may  be  very  slight,  or,  it  may  be  so  great  as 
to  entail  upon  the  patient  the  most  annoying  disfigurement,  and  often  very 
serious  disability.  Like  that  spoken  of  among  the  symptoms  or  phenomena 
of  the  original  injury,  it  may  be  either  angular,  rotary,  or  lateral.  One  of 
the  main  objects  of  treatment  is  to  prevent  it ;  to  keep  the  fragments  of  the 


»  Op.  cit.,  p.  140. 


48 


INJURIES  OF  BONES. 


broken  bone  m  their  normal  relation,  or  as  nearly  so  as  may  be  possible,  until 
by  natural  processes  the  repair  has  been  fully  accomplished. 

Angular  deformity  depends  for  its  importance  largely  upon  the  degree  of  the 
angle  and  the  precise  seat  of  the  injury.  The  most  frequent  and  striking 
mstance  of  it  is  in  the  bowing  outward  of  the  femur  after  fracture  of  its 
shaft.  ]^ear  the  lower  end  of  the  humerus,  an  angle  forward  may  cause  great 
and  annoying  limitation  of  the  flexion  of  the  elbow.  These  and  other  points 
will,  however,  be  discussed  at  greater  length  in  connection  with  the  special 
fractures  concerned. 

Rotary  deformity  is  fortunately  not  very  common.  Its  disastrous  effect 
in  the  lower  extremity,  in  fractures  of  the  thigh  or  leg,  needs  no  demon- 
stration. It  is  not  unfrequently  seen  in  fractures  of  the  neck  of  the  thigh- 
bone, the  foot  remaining  permanently  everted ;  but  here  the  disability  from 
other  causes  is  apt  to  be  so  great  as  to  make  the  mere  rotation  outward  of  the 
foot  a  matter  of  minor  moment. 

When  both  bones  of  the  forearm  are  broken,  it  very  often  happens  that 
the  upper  fragments  are  so  rotated  by  the  action  of  the  muscles  inserted  into 
them,  that  union  takes  place  with  the  axes  of  the  respective  portions  in  a 
changed  relation ;  the  result  is  that  either  pronation  or  supination,  or  both, 
may  be  materially  interfered  with ;  and  if  to  this  be  added  any  degree  of 
angular  deformity,  the  usefulness  of  the  member  may  be  lamentably  im- 
paired. 

In  all  our  consideration  of  the  skeleton,  whether  in  its  normal  condition  or 
as  modified  by  injury,  each  of  its  parts  must  be  regarded,  not  only  by  itself, 
but  as  a  member  of  a  system.  A  deformity  of  the  forearm  affects  the  func- 
tions of  that  portion  of  the  limb  primarily,  and  secondarily  interferes  with 
the  use  of  the  hand.  This  secondary  disability  may  be,  and  generally  is,  of 
vastly  more  consequence  than  the  primary.  It  is  true  that  in  many  cases 
there  is  ultimately  acquired,  by  means  of  compensatory  motions  in  other 
joints,  a  closer  approximation  to  the  original  function  than  might  at  first 
seem  possible ;  but  this  cannot  be  counted  on,  and  is  apt  to  be  neither  satis- 
factory to  the  patient  nor  creditable  to  the  surgeon. 

There  remains  to  be  considered  the  lateral  deformity,  the  chief  effect  of 
which  is  to  shorten  the  bone  ;  and  perhaps  this  will  be  the  most  convenient 
point  at  which  to  speak  of  certain  recent  observations  which  have  altered  the 
views  of  surgeons  both  as  to  the  importance  of  this  matter,  and  as  to  the 
possibility  of  correctly  appreciating  shortening  in  any  given  case. 
^  Shortening  mix^f  be  caused,  in  fractures  of  the  long  bones,  either  by  malposi- 
tion of  the  fragments,  and  especially  by  their  overlapping  each  other ;  or  by 
loss  of  fragments,  as  in  compound  comminuted  fractures,  where  it  may  be 
that  portions  are  so  wholly  separated  as  to  demand  immediate  removal  lest  they 
should  act  as  foreign  bodies,  or  where  portions  may  become  necrosed  and  call 
for  extraction  during  the  later  progress  of  the  case ;  or  lastly,  by  the  absorp- 
tion of  the  bony  substance  of  the  ends  of  the  fragments.  The  latter  occur- 
rence is  probably  rare,  but  there  is  abundant  evidence  of  its  possibility,  and 
it  may  be  that  it  is  sometimes  an  unsuspected  element  in  the  apparently  un- 
accountable loss  of  length  in  fractured  limbs. 

The  question,  whether  or  not  shortening  is  an  unavoidable  consequence  of 
fractures  of  the  long  bones,  has  been  discussed  with  much  zeal;  some  sur- 
geons claiming  that  under  proper  treatment  it  ought  not  to  occur,  and  others 
insisting  that  no  care  or  skill  can  prevent  it.  It  would  not,  however,  be 
worth  while  to  quote  opinions  on  this  point,  since  recent  researches  have 
clearly  shown  that  absolute  equality  between  the  two  limbs  of  a  pair,  or  be- 
tween corresponding  bones,  is  not  the  uniform  rule. 

From  observations  recorded  by  Hunt,  Cox,  Wight,  Roberts,  Garson,  and 


DEFECTS  IN  THE  PROCESS  OF  REPAIR  OF  FRACTURES. 


49 


Dwio-ht,'  it  would  seem  that  the  difference  is  never  very  great,  but  varies 
within  somewhat  narrow  limits.  Garson  measured  carefully  the  lower  limbs 
of  70  skeletons,  of  various  ages  from  12  years  upwards.  He  found  that  only 
seven,  or  10  per  cent,  of  these,  had  right  and  left  limbs  of  equal  length,  and  in 
two  cases  only  did  the  femur  and  tibia  of  one  side  correspond  respectively  to 
the  femur  and  tibia  of  the  other.  In  the  remaining  live  cases  it  was  by  com- 
pensation that  the  limbs  were  equal ;  the  tibia  being  shorter  where  the  femur 
was  lon2:er,  or  vice  versa,  lie  found  the  tendency  to  variation  greater  in  the 
femur  than  in  the  tibia.  In  25  instances,  or  35.8  per  cent.,  the  right  limb 
was  lono'cr  than  the  left,  the  average  difference  being  3.3  mm.  In  38  in- 
stances, or  54.3  per  cent.,  the  left  was  longer  than  the  right,  the  average  dif- 
ference being  4.8  mm.  The  left  limb,  therefore,  was  not  only  more  frequently 
lono-er  than  the  right,  but  the  difference  between  the  limbs  Avas  greater,  on 
an  average,  when  it  was  the  longer  than  when  the  right  was  the  longer,  the 
greatest  difference  in  the  latter  case  being  8  mm.,  whereas  in  the  foi*mer  it 
was  13  mm.  Over  the  whole  70  cases,  the  left  limb  was  1.5  mm.  longer  than 
the  right.    On  farther  analyzing  the  differences  : — 

"We  find  tliat  in  41  cases  the  left  femur  is  longer  than  the  right,  and  in  these  its  aver- 
age preponderance  is  3.8  mm. ;  in  20  cases  the  right  is  longer  than  the  left,  the 
average  preponderance  being  2.9  mm. ;  and  in  9  cases  the  bones  are  equal.  Again,  in 
*  24  cases  the  left  tibia  is  longer  than  the  right,  the  average  preponderance  being  3.0 
mm. ;  in  29  cases  the  right  is  longer  than  the  left,  the  average  preponderance  being 
2.6  mm. ;  and  in  7  instances  the  bones  are  equal." 

Garson  hints  at  a  very  important  matter,  which  will  probably  have  already 
occurred  to  the  reader — that  there  may  be  inequalities  between  the  ossa  in- 
nominata  of  the  right  and  left  side,  which  may  be  either  compensatory  or 
otherwise  as  regards  the  unequal  lengths  of  the  corresponding  limbs.  This 
point,  which  has  not  yet  been  at  all  satisfactorily  investigated,  would  ob- 
viously affect  the  bearing  of  the  results  above  quoted  upon  the  surgical  meas- 
urements of  limbs  as  ordinarily  made,  from  the  anterior  superior  spines  of  the 
ilia  to  the  inner  malleoli. 

Dwight  says,  in  regard  to  the  clavicle,  that  he  found  only  six  pairs  equal 
out  of  22  cases  examined  by  him.  The  greatest  difference  noted  was  .39  of 
an  inch.  In  all  but  two  of  the  cases  of  inequality,  the  left  clavicle  was  the 
longer. 

It  must  not,  however,  be  inferred  that  the  correction  of  shortening  likely 
to  result  from  fractures  of  the  long  bones  is  a  matter  of  small  importance,  or 
that  the  surgeon  will  be  justified  in  neglecting  it  when  called  upon  to  treat 
such  injuries.  On  the  contrary,  careful  attention  should  always  be  paid  to 
it;  measurements  should  be  made  from  time  to  time,  especially  during  the 
earlier  period  of  each  case,  and  suitable  means  adopted  for  overcoming  any 
tendency  to  overlapping  of  the  fragments. 

When  shortening  occurs  from  loss  or  absorption  of  portions  of  bone,  it  is  of 
course  wholly  unavoidable.  In  the  former  case,  the  fact  of  the  loss  will  be 
known,  and  in  the  latter  it  may  be  inferred  from  the  absence  of  overriding; 
the  fragments  will  be  in  proper  relation,  and' even  if  at  first  there  is  some  ex- 
uberance of  callus,  the  bone  will  eventually  be  almost  normal  in  shape. 

Shortening  is,  indeed,  under  any  circumstances,  of  much  less  moment  than 
angular  or  rotary  displacement,  either  of  which  nmst  very  gravely  affect  the 

1  Hunt,  Phila.  Medical  Times,  Jan.  16,  1875,  and  Am.  Journ.  of  the  Med.  Sciences,  .Jan.  1879  ; 
Cox,  Am.  Journ.  of  the  Med.  Sciences,  April,  1875  ;  Wight,  Arch,  of  Clin.  Surgery,  Feb.  1877,' 
and  Proc.  of  the  Med.  Soc.  of  the  County  of  Kings,  1878  ;  Roberts,  Phila.  Med.  Times,  Aug.  3, 
1878  ;  Garson,  Journal  of  Anat.  and  Physiology,  July,  1879  ;  Dwight,  Identification  of  the 
Human  Skeleton,  Boston,  1878. 
VOL.  IV. — 4 


50 


INJURIES  OF  BONES. 


usefulness  of  either  the  upper  or  lower  extremity.  The  effects  of  such  de- 
formities, as  well  as  the  means  of  detecting  and  overcoming  them,  will  be 
pointed  out  in  connection  with  special  fractures. 


General  Treatment  of  Fractures. 

The  broad  principles  of  the  treatment  of  fractures  are  very  easily  laid  down : 
to  restore  the  normal  relation  of  the  fragments  as  early  and  completely  as 
possible,  and  to  adopt  the  best  means  of  keeping  them  so  until  their  union 
shall  have  been  accomplished.  But  in  the  application  of  these  principles  a 
vast  number  of  details  must  be  taken  into  account,  and  the  circumstances 
may  vary  so  widely  as  to  make  what  would  be  good  practice  in  one  case 
w^holly  improper  in  another.  Without  attempting  to  enumerate  all  these 
details,  or  all  the  dilFerent  conditions  arising  to  modify  treatment,  I  shall 
mention  briefly  such  leading  matters  as  concern  the  surgeon  in  dealing  with 
this  class  of  cases ;  in  regard  to  those  of  minor  importance,  experience  and 
common  sense  will  be  his  best  guides. 

First  Attentions  to  the  Patient.— Occasionally,  when  it  is  one  of  the 
bones  of  the  upper  extremity  that  is  broken,  the  patient  comes  to  the  sur- 
geon's ofiice.  More  frequently,  the  latter  is  sent  for  after  the  suiferer  has 
been  taken  home,,  or  to  the  place  where  he  is  to  be  treated  ;  and  sometimes, 
especially  if  the  injury  is  severe,  or  if  it  affects  a  lower  extremity,  the  surgeon's 
first  services  are  rendered  at  the  scene  of  the  accident,  or  in  some  neighboring 
house. 

Circumstances  must  determine  w^hether  the  exact  character  of  the  injury 
shall  be  ascertained  at  once,  or  after  the  patient  has  been  removed  to  his 
room,  perhaps  to  his  bed.  If  there  be  much  suffering,  or  shock,  it  may  be 
better  to  adopt  temporary  measures  for  the  relief  of  these  conditions,  espe- 
cially if  the  distance  to  be  gone  over  is  considerable.  By  a  careful  and  gentle 
handling  of  the  limb  complained  of,  over  the  clothing,  a  general  idea  may  be 
acquired  of  the  seat  and  character  of  the  injury ;  but  if  there  be  a  compound 
fracture  a  more  thorough  examination  should  be  instituted,  lest  bleeding  or 
some  other  complication  demanding  relief  should  be  present.  Perhaps  it  is 
unnecessary  to  say  that  the  surgeon's  manner  should  be  firm,  calm,  and  reas- 
suring, and  his  manipulations  carried  on  with  a  steady  and  gentle  hand. 
Shock  may  be  combated  by  stimulants  sparingly  but  frequently  given ;  pain 
generally  subsides  upon  the  application  of  proper  temporary  dressings.  These 
may  be  made  out  of  simple  or  even  rude  materials ;  an  old  blanket  and  two 
or  three  shingles  or  barrel-staves,  or  even  a  mere  truss  of  straw,  may  be  so 
bound  around  a  broken  leg  or  thigh  as  to  give  it  support  and  comfort  until 
more  suitable  appliances  can  be  had. 

The  transportation  should  be  arranged  for  by  the  surgeon,  and,  in  bad  cases^ 
effected  under  his  eye.  If  it  is  to  be  done  by  hand,  it  is  best  to  have  the  bearers 
of  about  equal  height,  if  possible,  and,  in  lifting  the  patient  on  to  the  stretcher 
or  other  means  of  conveyance,  the  surgeon  should  himself  take  charge  of  the 
broken  limb.  The  bearers  should  not  keep  step,  as  this  results  in  a  regular 
swaying  motion,  which  sometimes  gives  great  pain  at  the  seat  of  fracture ; 
they  should,  however,  walk  as  evenly  and  steadily  together  as  possible. 

The  best  form  of  wheeled  vehicle,  for  fractures  of  the  lower  extremity,  is 
a  wagon,  into  which  the  stretcher  can  be  lifted  with  the  patient  upon  it.  For 
(;ases  affecting  the  arm,  a  carriage  does  as  well ;  the  injured  limb  should  be 
carefnlly  placed  in  a  sling,  and  steadied  with  the  patient's  other  hand. 

Arrived  at  the  place  of  destination,  the  surgeon  should  see  the  room  in 


GENERAL  TREATMENT  OF  FRACTURES. 


51 


Avhich  the  patient  is  to  lie,  and  the  approaches  to  it,  and  should  so  direct  the 
bearers  that  there  shall  be  no  awkward  changes  or  turnings  to  be  made  in 
reach ino-  it.  The  best  kind  of  bed  is  a  narrow  one,  with  a  firm  mattress  on 
top  ;  it  makes  very  little  difference  whether  there  are  feathers,  straw,  or  springs 
below,  provided  that  they  give  a  good  and  equable  support.  The  surgeon 
still  taking  charge  of  the  injured  limb,  the  patient  should  now  be  lifted  firmly, 
promptly,  and  gently,  aiid  laid  on  the  bed  in  such  a  position  that  the  fracture 
can  be  gotten  at  with  facility  for  the  purposes  of  examination  and  dressing. 
It  will  readily  be  perceived  that  all  these  manoeuvres  will  be  much  easier  in 
the  case  of  a  child,  a  light  person,  oi'  one  who  can  help  himself  somewhat, 
than  under  opposite  circumstances ;  they  may  present  extreme  difficulty  if 
the  patient  is  very  heavy,  or  otherwise  infirm  and  helpless. 

Sometimes,  as  already  said,  all  this  has  been  done  before  the  arrival  of  the 
surgeon ;  or  the  accident  may  have  taken  place  in  or  close  by  the  patient's 
hoifse.  In  either  case,  the  next  step  is  to  remove  the  clothing,  and  examine 
the  injury.  Often  it  is  better  simply  to  rip  or  tear  the  clothing  away ;  but 
to  poor  people  this  may  be  a  serious  affair,  and  one  to  be  avoided  if  possible. 
Under  such  circumstances  everything  should  be  loosened,  and  tlie  sound  arm 
or  leg  first  stripped,  when  the  rest  is  an  easy  matter.  Too  often  the  patient 
is  needlessly  exposed,  and  may  take  cold ;  he  should  be  at  once  covered  up 
with  blankets  or  any  other  convenient  wraps. 

The  surgeon  should  next  carefully  examine  into  the  nature  and  extent  of 
the  injury,  if  he  has  not  already  done  so.  If  his  previous  investigation  has 
satisfied  him  on  these  points,  he  may  keep  the  temporary  dressings  in  place 
until  he  has  prepared  those  which  he  intends  to  apply.  Xot  unfrequently 
anesthesia  is  required  to  facilitate  this  inquiry,  as  well  as  the  correction  of 
displacement — the  setting  or  reduction  of  the  fracture.  Much  pain  may  be 
thus  saved  to  the  patient,  and  the  surgeon's  task  is  rendered  easier  by  the 
abolition  of  muscular  resistance. 

Reduction. — It  is  now  an  established  rule  in  surgery,  that  the  reduction 
of  a  fracture  should  be  effected  at  the  earliest  available  moment.  Otherwise 
the  muscles  become  shortened,  and  not  only  the  difficulty  of  the  procedure 
itself,  but  the  risk  of  inflammation  and  of  other  unpleasant  symptoms,  from 
the  pressure  of  the  fragments  upon  vessels  or  nerves,  may  be  rendered  much 
greater. 

The  process  of  setting  or  reduction  consists  simply  in  the  overcoming  of 
whatever  displacement  of  the  fragments  may  be  present,  and  restoring  the 
normal  shape  of  the  bone  as  accurately  as  possible.  Very  generally  tlie  de- 
formity, as  mentioned  in  a  preceding  page,  is  somewhat  complicated  ;  so  that 
the  broken  ends  may  have  overlapped,  or  may  be  engaged  together  by  their 
irregularities,  and  at  the  same  time  not  only  placed  at  an  angle,  but  rotated 
in  reference  to  one  another.  When  there  are  two  bones,  as  in  the  forearm  or 
leg,  and  both  are  fractured,  it  will  readily  be  seen  that  the  different  frag- 
ments may  become  so  entangled,  either  with  one  another  or  w^ith  the  inter- 
osseous membrane,  as  to  present  a  condition  equally  difficult  to  recognize 
and  to  correct. 

In  some  cases  a  broken  bone  may  be  set  with  scarcely  any  trouble  to  the 
surgeon,  or  pain  to  the  patient ;  but  occasionally — rarely,  it  is  true — the 
displacement  cannot  be  corrected  by  any  available  means.  Between  these 
two  extremes  there  are  innumerable  gradations.  The  amount  of  difficulty 
encountered  is  by  no  means  proportioned  directly  to  that  of  displacement ;  on 
the  contrary,  a  very  slight  change  in  the  relation  of  the  broken  ends  may  be 
so  maintained  by  the  interlocking  of  their  serrations  as  to  baffle  every  effort 

uSnvoFiumois 


52 


INJURIES  OF  BONES. 


of  the  surgeon  to  disengage  them.  Especially  is  this  apt  to  be  the  case  when 
the  fracture  is  situated  close  to  a  joint,  so  that  one  of  the  fragments  is  too 
small  to  afford  much  purchase.  Sometimes  the  difficulty  may  be  due  to  the 
entanglement  of  one  fragment  in  a  tendon,  looped,  as  it  were,  around  it. 

On  the  other  hand,  if  the  deformity  is  easily  reduced,  it  is  apt  to  recur 
with  equal  readiness.  Very  oblique  fractures  of  the  shafts  of  the  long  bones 
can  generally  be  drawn  into  place  without  much  trouble ;  but  the  causes  of 
displacement  have  like  facility  of  action,  and  a  certain  amount  of  shortening 
is  almost  sure  to  result.  Fractures  of  the  radius  near  the  wrist,  those  of  the 
femur  near  the  knee,  and  those  of  the  leg  near  the  ankle  (not  in  either  case 
entering  the  joints),  are  very  difficult  to  reduce,  the  first  named  especially  \ 
and  they  are  often,  no  doubt,  only  partially  brought  into  place ;  yet,  when 
this  is  once  accomplished,  very  simple  retentive  means  will  suffice  to  obviate 
the  recurrence  of  the  displacement. 

Under  all  circumstances  it  should  be  borne  in  mind  that  the  fragments  can 
only  be  restored  by  reversing  the  process  of  their  displacement ;  they  must 
go  back  by  the  same  w^ay  by  which  they  came  into  their  false  position.  And 
it  is  of  the  utmost  importance  that  the  surgeon  should  know  that  the  reduc- 
tion is  complete ;  it  is  not  enough  that  the  outward  form  of  the  limb  is 
restored,  for  this  is  sometimes  deceptive.  The  soft  parts  may  be  pulled  and 
stretched,  and  the  swelling  may  mask  the  deformity,  w^hile  the  false  relation 
of  the  fragments  remains  unchanged.  Hence  the  most  rigid  examination 
should  be  made  during  and  after  the  efforts  at  replacement,  and  the  exact 
condition  of  things  should  be  determined.  If  restoration  be  found  to  be 
impossible,  the  fact  ought  materially  to  influence  the  prognosis  given  to  the 
patient  and  his  friends. 

An  essential  part  of  the  process  of  reduction,  in  most  cases,  is  the  making 
extension  and  counter-extension.  In  children,  or  with  the  smaller  bones  of 
adults,  the  surgeon  may  often  accomplish  this  with  his  own  hands,  grasping 
the  limb  above  and  below  the  seat  of  the  injury  ;  at  the  same  time  with  his 
thumbs  he  can  push  the  fragments  into  position.  But  in  larger  limbs,  and  in 
all  the  more  difficult  cases,  it  is  better  to  have  one  or  two  assistants  to  apply 
this  extension,  while  the  surgeon  has  both  hands  free  to  mould  and  knead 
the  fragments.  Rotary  and  augular  displacements  are  to  be  corrected  at  the 
same  time  that  extension  is  made,  the  sound  limb  being  taken  as  a  guide 
for  the  normal  shape,  and  certain  lines  and  landmarks,  to  be  hereafter  men- 
tioned, being  kept  in  view^  as  tests  of  the  accuracy  of  the  restoration. 

Some  differences  of  opinion  have  existed  as  to  the  best  way  of  making 
extension,  whether  the  force  should  be  applied  as  far  from  the  fracture  as 
possible,  or  close  to  it.  The  true  rule  w^ould  seem  to  be  that  in  each  case  the 
surgeon  should  be  guided  by  circumstances.  In  very  muscular  and  closely 
knit  limbs,  as,  for  instance,  in  a  fracture  of  the  thigh  in  a  powerful  adult,  it 
may  be  found  necessary,  in  order  to  make  extension,  for  one  assistant  to  put 
the  bend  of  the  left  elbow  under  the  patient's  knee,  and  with  his  right  hand 
grasp  the  patient's  ankle,  flexing  the  leg;  while,  for  counter-extension, 
another  assistant  may  either  have  a  towel  or  sheet  folded  and  applied  to  the 
perineum,  the  ends  being  tied  around  a  stout  stick  for  him  to  grasp,  or  he 
may,  if  very  strong,  clasp  his  own  hands  together  over  the  perineum.  In 
loose-jointed  patients,  traction  at  a  distance  from  the  fractured  bone  may 
simply  put  the  ligamentous  structures  on  the  stretch ;  but  in  such  persons 
there  is  apt  to  be  less  muscular  resistance  to  reduction. 

With  regard  to  the  process  of  measurement,  and  the  points  from  and  to 
which  measurement  is  to  be  made,  details  will  be  given  in  connection  with, 
the  fractures  of  special  bones. 


GENERAL  TREATxMENT  OF  FRACTURES. 


53 


Dressing  the 'Fracture. — Reduction  having  been  effected,  with  the  aid  of 
an  aniesthetic  if  necessary,  the  next  thing  is  to  secure  the  fracture,  so  that 
the  healing  jjrocess  shall  go  on  undisturbed,  with  the  broken  ends  in  their 
restored  relation.  Countless  contrivances  have  been  brought  forward  for  this 
purpose,  some  costly  and  complicated,  some  cheap  and  simple.  I  have  no 
hesitation  in  advising  against  the  use  of  the  former.  The  best  results  can  be 
obtained  with  the  simplest  means,  applied  with  such  dexterity  as  every  sur- 
geon ought  to  have,  with  a  clear  idea  of  the  object  in  view,  and  watched  with 
conscientious  care.  Without  such  intelligent  skill  and  care,  the  most  elabo- 
rate and  expensive  apparatus  may  fail  to  answer  the  purpose. 

Splints  and  bandages  are  very  extensively  used  in  the  treatment  of  frac- 
tures. Various  materials  are  used  for  the  former:  wood,  binders' board, 
leather,  felt,  tin,  sheet-zinc,  wire-netting,  and  wire  frames.  Of  these,  wood 
has  been  most  extensively  employed,  generally  thin  strips  of  white  pine  or 
deal,  which  should  be  shaped  to  lit  the  limb  in  every  case.  Scarcely  any  of 
the  carved  splints  sold  in  the  shops  are  suitable  for  use,  as  they  are  not  made 
with  a  proper  knowledge  of  anatomy,  and  must  be  altered  by  the  surgeon. 
Dr.  Jacob,  of  Dublin,^  "recommended  strips  of  the  bark  of  trees,  cut  when 
the  sap  was  rising,  for  splints  for  fractures  (in  children  especially);  and  Dr. 
Grant,2  of  Ottawa,  Can.,  speaks  highly  of  spruce  shavings  as  a  material  for 
the  same  purpose.  Binders'  board,  cut  in  the  requisite  shape,  and  softened 
in  hot  water,  may  be  moulded  so  as  to  fit  well,  and  becomes  very  hard  on 
drying ;  and  the  same  may  be  said  of  gutta  percha,  of  thick  leather,  and  of 
felt.  "Tin  is  much  less  manageable,  but  can  be  adapted  to  some  cases,  if  the 
surgeon  can  succeed  in  giving  the  proper  measurements  to  the  tin-smith. 
Sheet-zinc  has  no  special  advantage  over  tin,  although  M.  Raoul  Deslong- 
champs  has  extolled  its  virtues  in  a  volume  of  several  hundred  pages.^  Wire 
netting  is  sold  in  sheets,  and  can  be  cut  with  suitable  pliers ;  but  it  is  gene- 
rally prepared  for  use  by  the  addition  of  a  thick  wire  frame  around  the 
edges.  Wire  splints  can  be  better  described  in  connection  with  the  special 
fractures  for  which  they  have  been  most  extensively  employed.  Splints,  of 
whatever  material,  should  always  be  of  exactly  the  proper  size  and  shape. 
If  too  small,  the  edges  may  cut  into  the  skin ;  if  too  wide,  and  especially  if 
loosely  put  on,  they^Avill  not  give  due  support  to  the  limb,  nor  prevent  the 
displacement  of  the  fragments.  When  wood,  binders'  board,  or  gutta  percha 
is  used,  it  is  a  good  plan  to  bevel  the  edges  all  around,  at  the  expense  of  the 
inner  face,  lest  they  should  come  in  contact  with  the  skin  and  irritate  it,  in 
spite  of  the  most  careful  padding. 

Bandages  are  best  made  of  unbleached  muslin,  of  medium  weight,  not  too 
closely  w'oven.  They  may  be  from  two  to  three  inches  wide,  and  about  six 
yards  in  length.  They  are  rolled  up  for  use,  as  described  in  the  article  on 
Minor  Surgery.^ 

In  former  times,  a  custom  prevailed  of  applying  what  was  known  as  an 
immediate"  bandage  to  a  fractured  limb,  in  order,  as  was  supposed,  to  pre- 
vent muscular  contraction.  This  custom  has  now  been  generally  abandoned, 
although  it  is  still  followed  by  some  practitioners ;  it  never  can  do  any  good, 
and  may  do  much  harm. 

For  the  purpose  of  protecting  the  skin,  and  better  adapting  the  pressure  of  the 
splints  to  the  irregularities  of  the  surface,  padding  is  always  employed.  Raw 
cotton  is  the  material  generally  chosen  ;  it  should  be  clean,  fresh,  evenly  torn, 
and  in  sufficient  quantity.  Carded  wool  answers  quite  as  well,  and  even  better 
if  it  cannot  be  frequently  changed,  as  it  does  not  become  lumpy  and  sodden 

1  Am.  Journ.  of  Mea.  Sciencess,  Jan.  1847  ;  from  Dublin  Med.  Press. 

2  British  Med.  Journal,  Jan.  14,  1682.  3  See  Vol.  I.  p.  480. 


54 


INJURIES  OF  BONES. 


with  perspiration,  as  cotton  does.  An  excellent  substitute,  almost  always  at 
hand,  when  neither  cotton  nor  wool  can  be  had,  is  found  in  flannel ;  three  or 
four  thicknesses  of  old  blanket  make  a  very  eflacient  and  agreeable  lining  for 
any  kind  of  splint.  Some  surgeons  use  the  article  known  as  "  canton  flannel" 
in  the  same  way  ;  the  soft  or  flocky  side  should  always  be  placed  in  contact 
with  the  skin. 

By  Tufnell,^  the  use  of  long  bags  of  straw,  as  combined  splint  and  padding, 
has  been  recommended ;  the  straws  are  carefully  arranged  lengthwise,  and 
the  sacks  are  not  so  tightly  stuflTed  but  that  they  can  be  shaped  by  pressure 
to  fit  the  limb.  This  plan,  which  certainly  has  merit,  has  never  come  into 
general  use. 

Allied  to  these,  but  of  less  valu^  because  less  adaptable,  are  various  forms 
of  cushion  and  of  padded  apparatus,  which  do  not  seem  to  me  to  need  de- 
scription. For  merely  temporary  support  and  protection,  an  ordinary  pillow 
may  sometimes  be  applied  with  advantage.  Sand-bags  are  often  of  great 
use,  and  will  be  further  referred  to  hereafter. 

Water-cushions  have  been  proposed  by  Jeaflreson^  and  by  Thompson^  as 
substitutes  for  padding,  but  have  never  been  generally  employed,  and  are  cer- 
tainly open  to  very  decided  theoretical  objections,  apart  from  their  costliness. 
The  same  may  be  said  of  the  air-pads  of  caoutchouc,  devised  by  Gariel.^ 

Solidifying  Dressings. — The  employment  of  bandages  imbued  with  mate- 
rials which  harden  on  drying  (such  as  gum  shellac  or  other  gummy  or  resin- 
ous substances),  is  of  very  ancient  date.  But  it  had  almost  entirely  gone  out  of 
fashion  until  Larrey,  about  1825,  revived  the  idea,  using  the  bandage  of  Scul- 
tetus,  and  cushions  or  compresses  soaked  in  a  mixture  of  spirit  of  camphor, 
acetate  of  lead,  and  the  whites  of  eggs.  The  apparatus  thus  made  was  allowed 
to  remain  until  consolidation  had  taken  place.^  Some  ten  years  later,  Seutin 
proposed  the  substitution  of  starch  for  the  composition  above  mentioned,  as 
well  as  for  plaster  moulds,  which  had  been  used  by  Dieffenbach,  and  proba- 
bly long  before  his  time.  Seutin,  however,  modified  the  plan  by  suggesting 
the  division  of  the  splint  with  pliers,  after  the  lapse  of  a  few  days,  not  only 
in  order  to  examine  the  state  of  the  limb,  but  to  refit  the  apparatus  and 
insure  its  efiectiveness.  By  so  doing  he  made  this  method  what  it  has  been 
ever  since,  although  the  materials  used  for  stiffening  have  been  variouslj 
modified  by  different  surgeons.  Glue,  paraffine,  gum  arabic  and  whiting, 
flour  and  white  of  egg,  plaster  of  Paris,  silicate  of  potassium  or  sodium,  in 
different  combinations  or  alone,  have  been  thus  used.  Of  all  these,  the  best 
are  probably  the  two  last  named,  as  they  are  cleanly,  and  the  solidification 
takes  place  so  quickly  as  to  make  them  much  more  secure  than  those  which 
"set"  only  after  a  length  of  time.  Tripolith,  a  material  recently  employed 
in  Germany  as  a  substitute  for  plaster  of  Paris,  is  said^  to  be  lighter  than  that 
substance,  to  harden  more  quickly,  tp  be  non-absorbent  when  once  dried,  and 
to  be  a  trifle  cheaper.  Its  exact  composition  is  unknown,  and  I  am  not  aware 
of  its  ever  having  been  brought  to  this  country. 

The  silicate  of  potassium  may  be  bought  in  saturated  solution  of  any 
wholesale  druggist ;  it  is  applied  with  a  clean  bristle-brush,  such  as  house- 
painters  use,  to  successive  layers  of  bandage  after  they  are  put  upon  the 
injured  limb,  the  skin  being  carefully  protected  by  a  smooth  and  even  layer 
of  raw  cotton.    I  have  thought  it  well  to  lay  two  or  more  strips  of  thick 

^  Am.  Jourii.  of  the  Med.  Sciences,  Jan.  1847  ;  from  Dublin  Med.  Press. 

2  Lancet,  Nov.  9,  1867.  ^  British  Med.  Journal,  April  10,  1880. 

4  Jamain,  Petite  Chirurgie,  p.  210.    Paris,  1860. 

5  Journal  de  Progres,  etc.,  tome  iv.  1827. 
•  Med.  Times  and  Gazette,  Nov.  27,  1880. 


GENERAL  TREATMENT  OF  FRACTURES. 


55 


muslin  alono-  the  sides  of  the  limh,  one  over  each  layer  of  bandage,  to  act  as 
side-splints.^  During  the  application  the  limb  should  be  kept  in  proper  posi- 
tion by  assistants  graspino;  it  above  and  below.  Generally  ni  about  ten 
minutes  the  silicate  beconies  so  firm  that  the  limb  may  be  safely  laid  on  a 

Plaster  of  Paris  may  be  employed  in  the  same  way,  the  dry  plaster  being 
sifted  into  a  basin  of  hot  (or  cold)  water,  and  applied  with  the  hands  ot  an 
assistant  as  the  surgeon  puts  on  the  bandage.  The  latter  should  be  loose- 
meshed  (what  is  sold  in  the  shops  as  cheese  or  dairy  muslin  answers  very 
well).  The  mixture  is  ready  for  use  as  soon  as  it  begins  to  assume  the  con- 
sistence of  thin  cream ;  it  takes  rather  longer  to  set  than  the  silicate  does. 
Whichever  material  is  used,  a  narrow  space  may  be  left  along  the  back 
(under  surface)  of  the  limb,  along  which  in  a  few  days  the  bandage  may  be 
split  up  with  a  pair  of  strong  scissors,  for  the  purpose  of  examination ;  and 
thereafter  we  have  a  moulded  splint,  which  may  be  simply  reapplied  and 
kept  in  place  by  a  fresh  roller  of  bandage-muslin. 

Another  way  of  applying  plaster  of  Paris  is  by  means  of  loose-meshed  ban- 
dao:es,  filled  with  dry  plaster,  loosely  rolled,  and  dipped  into  water  just  before 
they  are  used.  In  hospitals,  or  where  these  are  extensively  employed,  it  is 
worth  while  to  have  an  apparatus^  for  imbuing  the  bandages  with  the  plaster; 
and  they  should  be  kept  in  close  tin  boxes,  or  wrapped  in  waxed  paper.  To 
divide  a  plaster  bandage  put  on  in  this  way,  the  saw  or  pliers  must  be  used.^ 

Still  another  method  is  known,  in  its  best  form,  as  the  Bavarian.  It  con- 
sists in  cutting  two  pieces  of  stufl"  (shrunk  flannel  is  the  best)  a  little  rnore 
than  wide  enough  to  encircle  the  limb.  Two  rows  of  stitches,  about  an  inch 
apart,  are  now  carried  along  on  either  side  of  the  middle  line,  so  as  to  fiisten 
the  pieces  together.  The  cloth  now  being  laid  under  the  limb,  the  two  upper 
flaps  are  brought  together  above  and  stitched,  thus  encasing  the  limb.  Next 
the  other  flaps  are  evenly  spread  with  the  mixed  plaster,  of  about  the  con- 
sistency of  thick  cream  ;  and  these  l)eing  brought  up  into  place  are  also  sewed 
too-ether,  and  the  spare  stuft*  is  cut  otf.  The  limb  is  thus  encased  withm  two 
do'^ible  layers  of  flannel,  which,  by  the  setting  of  the  plaster  between  them, 
will  form  a  very  firm  support  on  each  side.^  A  roller  over  all  will  serve  to 
reinforce  the  stitching,  and  keep  the  whole  in  place. 

A  somewhat  similar  arrangement  has  been  proposed  ^  by  Mr.  Jordan  under 
the  name  of  "laminated  plaster  splints."  He  uses  six  or  seven  layers  of 
muslin,  with  plaster  of  Paris  spread  evenly  between  them  with  a  spatula; 
they  are  then  dipped  in  water  and  applied.  A  flannel  bandage,  or  layer  of 
cotton  wadding,  is  put  next  the  skin. 

Some  surgeons  advocate  the  insertion  of  strips  of  tin  between  the  layers  of 
the  plaster  bandao-e,  in  order  to  give  it  strength  ;  and  in  the  case  of  very  large 
and  heavy  limbs"  this  might  be  desirable,  as  it  would  largely  increase  the 
firmness  of  the  apparatus"  without  adding  materially  to  its  weight.  Ordin- 
arily, however,  it  would  be  needless. 

Paper  splints,  the  material  being  saturated  with  starch,  and  applied  in 
layers  until  the  requisite  thickness  is  obtained  to  give  firm  support  when  dry, 
were  first  suggested  by  Laugier.^  The  idea  has  since  been  repeatedly  brought 
forward  anew  by  others. 

When  the  fracture  is  compound,  the  wound  must  of  course  be  left  uncovered 
for  the  purpose  of  applying  suitable  dressings.  This  may  be  done  either  by 
cuttino'  the  bandage  as  it" is  put  on,  when  the  proper  point  is  reached,  and 
bea;iuning  afresh  at  the  other  side  of  the  ga^D ;  or  by  cutting  a  hole  in  the 
apparatus  after  it  is  finished.    The  former  is  the  preferable  plan;  the  plaster 


1  See  Vol.  1.  p.  504. 

»  British  Medical  Journal,  July  15,  1882. 


2  Ibid.,  p.  499. 

4  L'Experience,  1  Aout,  1844. 


56 


INJURIES  OF  BONES. 


holds  the  cut  ends  of  the  bandage  securely.  The  other  method  may  involve 
some  pain  to  the  patient.  In  order  to  prevent  soiling  of  the  plaster-dressing 
by  discharges,  etc.,  it  may  be  well  coated,  when  dry,  with  copal  or  other 
varnish. 

Some  surgical  writers  recommend  the  insertion  of  hooks  or  staples  in  the 
plaster  apparatus  for  the  purpose  of  suspension  of  the  limb;  but  a  better 
and  more  secure  arrangement  for  this  purpose  can  be  made  by  means  of  sup- 
plementary wire  frames,  in  a  manner  to  be  described  hereafter. 

After-treatment  of  Fractures.  —  ^sTo  apparatus  which  will  exercise 
rigid  pressure  should  ever  be  applied  to  a  recently  broken  limb,  if  there  is 
much  contusion,  swelling,  or  ecchymosis.  Mischief  may  thus  arise  in  a  very 
few  hours,  which  may  even  cost  the  patient  his  limb  and  the  surgeon  his 
reputation.  Fractures  should  always  be  carefully  watched  for  the  first  few 
days,  and  should  never  be  neglected  at  any  stage  of  the  treatment.  And  here 
I  must  enter  a  protest  against  what  seems  to  me  a  most  dan2:erous  maxim, 
though  it  has  received  the  sanction  of  some  high  authorities,  namely,  that 
"  comfort  is  the  sign  that  a  fracture  has  been  properly  dressed."  It  is  true 
that,  as  a  general  rule,  a  fracture  properly  dressed  ceases  to  be  painful ;  but  it 
is  also  true  that  a  fracture  may  cease  to  be  painful  although  none  of  the  indi- 
cations for  its  proper  treatment  have  been  fulfilled.  The  fra2:ments  may  be 
in  very  bad  position,  the  deformity  wholly  uncorrected,  and  yet  the  patient 
be  free  from  suffering.  I  have  seen  a  man  with  a  fracture  at  the  middle  of 
the  leg,  in  the  third  week,  lying  at  his  ease  in  bed,  with  the  foot  completely 
everted,  so  that  the  toes  pointed  almost  directly  outward ;  and  could  cite 
many  other  cases,  although,  perhaps,  not  so  marked.  Actual  inspection  care- 
fully made,  at  sufficiently  frequent  intervals,  can  alone  guard  against  bad 
results ;  the  whole  limb  should  be  examined,  and  nothhig  be  left  to  the 
chance  of  all  being  right. 

Fractures  of  the  lower  extremity,  as  a  general  rule,  involve  a  long  confine- 
ment to  bed— those  of  the  thigh  always,  and,  in  hospitals,  those  of  the  legs 
also.^  In  private  cases,  I  have  for  some  years  been  accustomed  to  use  such 
appliances  for  swinging  broken  legs  as  to  enable  the  patient  to  sit  up  almost 
from  the  very  first. 

One  of  the  annoyances  of  such  confinement  consists  in  the  difficulty  expe- 
rienced in  having  the  bowels  moved  without  disturbing  the  fracture  ;  and  to 
obviate  this  much  ingenuity  has  been  expended  in  the  devising  of  different 
forms  of  "  fracture-bed."  The  one  in  common  use  in  our  hospitals  is  merely 
a  mattress  perforated  in  the  centre  with  a  round  hole,  filled  up  with  a  pad, 
except  when  the  bowels  are  to  be  moved,  when  the  pad  is  taken  aw^ay  and  a 
chamber-pot  put  below  the  opening.  The  lower  sheet  must,  of  course,  be  per- 
forated in  the  same  way.  Others  have  various  arrangements  of  sections 
sliding  in  and  out ;  and  still  others  are  made  so  that  the  patient  lies  on  a 
perforated  sheet  of  canvas,  stretched  on  a  frame,  which  can  be '  raised  by  a 
mechanical  contrivance,  so  as  to  allow  of  the  vessel  being  pushed  in  under 
the^  nates.^  The  best-known  apparatus  on  this  principle  is  that  of  Jenks,  in 
which  strips  of  canvas  are  substituted  for  the  perforated  sheet.  In  hospitals, 
where  the  services  of  assistants  can  alw^ays  be  had,  the  frame  can  be  lifted  by 
handles,  like  a  stretcher.  Except,  however,  in  the  case  of  fracture  of  both  , 
femora,  these  contrivances  possess  hardly  any  advantage  over  the  common 
bed-pan,  if  the  latter  be  carefully  and  skilfully  used.  I  will  therefore  merely 
mention  the  fracture-beds  of  Earle,i  Daniels,^  Burge,^  Crosby,*  Pancoast,^ 


1  Practical  Observations  in  Surgery,  p.  135.    London,  1823. 

2  Hamilton,  op.  cit.,  p.  474.  3  New  York  Journal  of  Medicine,  May  1,  1857. 
4  Hamilton,  op.  cit.,  p.  475.  6  Gross,  op.  cit.,  vol.  i.  p.  1029. 


GENERAL  TREATMENT  OF  FRACTURES. 


57 


Gariel,^  Rabiot,^  and  Pouillieii.^  By  reference  to  the  work  of  Richter/  it  will 
be  seen  that  the  ingenuity  of  German  surgeons  had  been  early  exercised  in 
the  same  direction,  and  with  very  analogous  results. 

Two  objections  hold  against  every  form  of  perforated  mattress.  One  is  the 
tendency  to  flattening  down  of  the  stuffing  toward  the  central  hole,  so  that 
the  hips  of  the  patient  come  at  length  to  rest  in  a  hollow ;  this  being,  of 
course,  especially  likely  to  happen  where  the  same  mattress  is  used  over  and 
over  again,  as  in  hospitals.  The  other  is  the  difficulty  of  avoiding  the  soil- 
ing of  the  edges  of  the  opening,  which  requires  careful  attention  whenever 
there  is  an  evacuation  either  from  the  bowels  or  from  the  bladder.  Yet  these 
objections  are  not  fatal,  as  they  can  be  set  aside  by  care  in  making  and  using 
the  mattresses,  as  well  as  in  their  proper  renovation  from  time  to  time. 

Patients  who  are  obliged  to  lie  in  bed,  are  often  greatly  relieved  by  even  a 
very  slight  change  of  posture,  from  the  shifting  of  the  bearing-points  of  the 
body.  A  very  old  contrivance,  mentioned  by  Turner,^  may  be  used  w^ith 
advantage  to  facilitate  this ;  it  consists  in  a  strong  cord  attached  to  any  con- 
venient point  above  (a  frame  connected  w^ith  the  bed,  or  one  of  the  joists  of 
the  room),  and  having  its  lower  end  hanging  free,  with  a  stick  fastened  trans- 
versely across  it  so  as  to  serve  as  a  handle  by  which  the  patient  can  raise, 
turn,  and  shift  his  body. 

Many  other  forms  of  apparatus  are  employed  in  the  treatment  of  fractures 

 such  as  fracture-boxes,  inclined  planes,  means  of  making  extension  and 

counter-extension,  and  appliances  for  suspension — which  may  be  more  con- 
veniently described  in  connection  with  the  special  cases  for  which  they  are 
designed. 

The  general  rale  may  be  laid  down,  that  in  fracture  near  a  joint  the  dress- 
ing should  be  arranged  so  as  to  immobilize  that  joint ;  and  that  in  fractures 
of  the  shaft  of  a  bone  the  joints  above  and  below  the  seat  of  injury  must  be 
secured.  And  for  the  first  week  at  least — in  many  cases  for  a  much  longer 
period — the  whole  limb  should  be  kept  at  entire  rest.  Large,  long,  and 
heavy  limbs,  in  which  there  is  a  good  deal  of  leverage  on  the  fragments, 
require  more  protracted  confinement  than  small  and  light  ones.  Sometimes, 
as  in  fractures  about  the  wrist,  and  in  those  of  the  lesser  bones  generally,  the 
patient  can  be  safely  allowed,  after  the  first  few  days,  any  degree  of  freedom 
of  motion  wdiich  does  not  involve  pain. 

Passive  motion  may,  in  my  opinion,  be  resorted  to  much  earlier  than  is  the 
usual  practice,  and  with  great  advantage;  as  soon,  indeed,  as  all  inflammatory 
symptoms  have  altogether  subsided.  In  the  case  of  the  upper  extremity,  no 
assistant  is  needed ;  the  surgeon  may,  at  each  removal  of  the  apparatus,  grasp 
the  fractured  portion  very  firmly  and  gently  with  one  hand,  while  with  the 
other  he  very  cautiously  flexes  and  extends  each  joint  in  turn.  When  the 
fracture  is  in  the  lower  limb,  the  surgeon  may  use  both  hands  to  control  the 
broken  bone,  while  a  trustworthy  assistant  impresses  motion  on  the  joints. 
Gradually,  as  time  goes  on,  this  process  may  be  more  and  more  freely  carried 
out.  Properly  managed,  it  is  productive  of  no  pain,  and  goes  far  toward 
preventing  the  stifi'ening  wdiich  is  sometimes  a  very  troublesome  sequence  of 
these  injuries,  ^o  force  should  be  used  at  any  time.  There  are  cases  in 
which  the  fact  of  difficulty  in  manoeuvres  of  this  kind  is  important  as  an 
indication  that  the  fragments  are  not  in  proper  position. 

During  the  later  stages  of  the  treatment,  after  consolidation  has  begun  to 
be  perceptible,  it  is  well  to  add  to  this  passive  motion  sponging  of  the  limb 

1  Jamain,  op.  cit.,  p.  319.  2  i^id.,  p.  320.  3  Ibid.,  p.  322. 

*  Theoretisch-praktisclies  Handbuch  der  Lehre  von  der  Briichen  und  Verrenkungen  der  Knochen. 
(Text  und  Atlas).    Berlin,  1828. 
5  The  Art  of  Surgery,  2d  ed.,  vol.  ii.  p.  161.    London,  1725. 


58 


INJURIES  OF  BONES. 


with  .soap  and  hot  water,  to  which,  for  persons  of  relaxed  fibre  especially, 
some  whiskey  or  spirit  of  camphor  may  be  added.  This  is  not  only  agree- 
able to  the  patient,  but,  I  believe,  is  positively  beneficial. 

As  the  union  of  the  bone  becomes  more  and  more  firm,  the  muscles  of  the 
limb  may  be  stimulated  by  gentle  friction  and  pinching,  in  order  to  prepare 
them  for  the  renewal  of  their  functions. 

Fractures  of  the  lower  extremity  must  be  allowed  to  become  perfectly  con- 
solidated before  the  apparatus  is  left  off,  and  then  the  limb  must  be  accus- 
tomed by  degrees  to  the  dependent  position  before  any  attempt  is  made  to 
bear  weight  upon  it.  A  patient  will  sometimes  use  crutches  for  a  few  days, 
and  feel  his  way,  as  it  were,  until  he  finds  that  he  can  support  himself  upon 
the  repaired  member.  In  the  case  of  the  upper  extremity,  as  the  bone 
becomes  more  and  more  firmly  united,  the  splint  may  sometimes  be  cut  off 
piece  by  piece  at  either  end,  so  as  give  the  limb  gratiually  increasing  liberty; 
and  in  this  way  the  use  of  the  hand  may  be  almost  imperceptibly  regained. 
Care  and  judgment  are  as  necessary  in  these  latter  stages  as  in  the  very  first 
attentions  to  the  case. 

In  fact,  each  portion  of  the  treatment  of  a  case  of  fracture  has  its  own  duties 
for  the  surgeon,  and  its  own  risks  for  the  patient.  At  first,  the  reduction 
and  the  dressings  must  be  carefully,  thoroughly,  and  skilfully  executed;  while 
the  process  of  union  is  going  on,  attention  must  be  given  to  keeping  up  the 
proper  relations  of  the  fragments  ;  and  towards  the  end,  the  safe  and  complete 
restoration  of  function  must  be  provided  for.  At  any  of  these  stages,  neglect 
may  be  disastrous. 

As  to  the  treatment  of  the  complications  which  may  arise  in  a  case  of  frac- 
ture, very  little  need  be  said.  These  intercurrent  disorders  should  in  general 
be  dealt  with  as  under  other  circumstances ;  they  may  assume  such  import- 
ance {e.  g.,  tetanus  or  pyaemia)  as  to  overshadow  entirely  the  local  injury. 
The  management  of  compound  fractures  may  be  best  described  in  connection 
with  the  fractures  of  the  several  bones,  as  it  differs  in  different  regions  of  the 
body. 

Treatment  of  Delayed  Union  and  False  Joint. — When  the  surgeon  finds 
that  the  fragments  are  still  movable  upon  one  another  at  the  end  of  the  time 
when  union  might  reasonably  be  expected,  he  should  consider  whether  any 
constitutional  defect  or  disorder  exists,  or  any  local  condition,  to  which  the 
failure  can  be  attributed;  and  if  such  hindrance  can  be  discovered,  appropriate 
treatment  must  be  instituted.  Should  the  patient  be  a  pregnant  woman, 
otherwise  healthy,  she  may  be  encouraged  to  hope  that  the  bone  will  knit 
after  her  confinement  shall  have  taken  place. 

As  a  general  rule,  the  use  of  a  solidifying  dressing  is  most  distinctly  indi- 
cated in  these  cases;  and  my  own  choice  is  always  either  the  plaster-of-Paris  or 
the  silicate-of-potassium  bandage.  It  should  be  applied  with  the  utmost  care 
and  accuracy,  so  as  to  keep  the  fragments  absolutely  in  place,  the  whole  limb 
being  encased  in  it ;  and  it  may  be  left  undisturbed  for  a  much  longer  time  than 
would  be  safe  at  an  earlier  period.  On  its  removal,  after  the  lapse  of  three 
or  four  weeks,  if  no  change  can  be  detected,  the  two  portions  of  the  limb 
should  be  firmly  grasped,  and  the  fragments  rubbed  together  with  some  force, 
until  some  pain  and  soreness  are  induced.  The  apparatus  should  now  be  re- 
applied, as  carefully  as  before,  and  kept  on  for  perhaps  two  weeks,  when  the 
parts  may  be  examined,  and  the  rubbing  repeated  if  necessary.  Should  there 
be  absolutely  no  increase  of  firmness,  the  friction  may  be  employed  daily, 
with  shampooing  or  massage  of  the  whole  limb,  for  three  or  four  days ;  or 
the  skin  may  be  stimulated  by  a  blister,  or  by  painting  it  with  tincture  of 


GENERAL  TREATMENT  OF  FRACTURES. 


59 


iodine.    After  this  the  immovable  apparatus  may  be  again  put  on  for  three 

or  four  weeks.  .        ^     n  ,  .  i  i 

Durino-  all  this  time  the  strength  of  the  patient  should  be  supported  and 
improved  by  nutritious  diet,  with  tonics  if  need  be.  Certain  remedies  have 
lono-  been  supposed  to  have  a  direct  effect  in  promoting  the  formation  of  cal- 
lus.^ Thus  the  phosphate  of  lime  and  the  carbonate  and  phosphate  of  mag- 
nesium, have  been  credited  with  hastening  union  in  some  cases.  Probably  the 
"  osteo-colla,"  or  ossifrage,"  recommended  by  Hildanus,  and  spoken  of  by 
Turner^  as  used  both  internally  and  externally — a  stone  found  near  Darmstadt 
in  Germany— was  composed  mainly  of  these  salts.  Milne-Edwards^  found  by 
experiments  on  dogs  that  the  phosphate  and  carbonate  of  lime  given  inter- 
nally promoted  the  healing  of  their  fractures ;  and  quotes  the  favorable  ex- 
perience of  Gosselin  with  the  same  drugs,  in  man,  given  in  the  dose  of  half  a 
gramme  (about  8  grains)  th  rice  daily.  Fletcher^  gives  six  cases  of  remarkably 
early  union,  in  persons  to  whom  lime-water  and  chalk-mixture  had  been  ad- 
ministered. Gurlt  quotes  from  Saucerotte  a  case  in  which  a  tisane  of  madder 
is  said  to  have  produced,  in  two  months,  union  of  a  fracture  of  the  leg  which 
had  been  three  months  unhealed.  Hammick*  says,  that  "  mercury  will  fre- 
quently be  required  by  patients  who  never  had  any  syphilitic  ^  taint,  not 
only  to  act  as  an  alterative,  but  even  it  will  be  necessary  to  push  it  to  a  con- 
siderable extent  before  union  of  a  fractured  bone  will  take  place."  He 


Fig.  808.  Fig. 


Smith's  apparatus  for  nnunited  fracture  Smith's  apparatus  for  ununited  fracture 

of  the  leg.  of  the  thigh. 

quotes  a  case  in  point,  and  says  that  "  this  so  commonly  occurs,  that  it  will 
not  be  necessary  to  trouble  you  with  the  detail  of  any  more  cases  in  con- 
firmation of  it.*''  As  my  own  experience  in  regard  to  the  medication  of 
cases  of  delayed  union  has  never  gone  beyond  the  use  of  tonics,  and  of  anti- 


i  Op.  cit.,  vol.  ii.  p.  153. 
3  Lancet,  1846. 


2  Am.  Journal  of  the  Med.  Sciences,  Oct.  1856. 
4  Op.  cit.,  p.  118. 


60 


INJURIES  OF  BONES. 


syphilitic  remedies  in  some  cases  where  there  was  suspicion  of  a  venereal 
taint,  I  quote  the  foregoing  statements,  without  comment. 

In  the  great  majority  of  cases  of  delayed  union,  perseverance  in  the  line  of 
treatment  now  laid  down  will  be  rewarded  by  success.  When  three  months 
have  elapsed,  if  there  is  not  an  encouraging  increase  in  the  firmness  of  the 
union,  the  patient  may  be  allowed  some  use  of  the  limb,  with  the  safeguard 
either  of  the  plaster  bandage  or  of  a  pro thetic  apparatus,  such  as  that  devised 
by  Dr.  H.  H.  Smith^  (Figs.  808,  809).  This  consists  essentially  of  a  jointed 
splint  composed  of  steel  bars,  with  padded  straps  to  confine  it  to  the  limb. 
Success  has  also  been  reported^  to  have  been  obtained  by  the  use  of  tourniquets 
applied  so  as  to  exert  slight  pressure  over  the  seat  of  fracture.  Percussion  by 
means  of  the  fist  or  a  hammer,  the  limb  being  protected  by  a  padded  leather 
splint,  was  proposed  several  years  ago  by  Thomas,  of  Liverpool,  and  has 
lately  been  reported  on  favorably.^  Electricity^  and  galvanism^  have  been 
occasionally  employed  with  apparent  benefit. 

Grurlt^  speaks  with  commendation  of  the  forcible  tearing  asunder  of  the 
"uniting  medium,  the  patient  being  of  course  placed  under  an  anaesthetic,  and 
the  operation  so  performed  as  to  involve  nothing  but  the  fibrous  bands  hold- 
ing the  fragments  together. 

The  modes  of  procedure  thus  far  mentioned  have  been  such  as  involve  no 
wounding  of  the  skin,  which  for  obvious  reasons  it  is  better  to  avoid  if  possi- 
ble. Sometimes,  however,  it  is  expedient  to  use  means  which  shall  directly 
affect  the  ends  of  the  fragments,  or  the  intermediate  tissue.  Thus  stimulativg 
ivjections  were  used  in  1833,  by  Hulse,^  with  success.  Another  case  was  re- 
ported by  Bourguet  f  but  here  a  silicated  apparatus  was  also  applied,  and 
phosphate  of  lime  was  given  internally. 

Subcutaneous  puncture^  first  recommended  by  Miller,^  has  been  successful  in 
my  hands,  in  a  case  of  false  joint  in  the  thumb,  in  a  child  it  is  particularly 
adapted  to  this  condition,  but  I  have  seen  no  other  cases  reported  except  two 
referred  to  by  Hamilton."  It  consists  ^  simply  in  passing  a  narrow-bladed 
knife  between  the  fragments,  and  scoring  their  ends  with  its  edge,  so  as  to 
freshen  them  up ;  in  my  case,  I  used  a  cataract  needle.  Medro-pancture  is 
said  by  Azam^^  to  have  yielded  a  good  ultimate  result,  although  at  the  ex- 
pense of  extensive  and  long-continued  suppuration,  indicating  an  amount  of 
risk  to  wdiich  most  surgeons  w^ould  hesitate  to  subject  patients,  in  order  to 
obviate  a  mere  inconvenience. 

The  seton  w^as  first  employed  by  Physick  in  1802,  in  a  case  of  ununited 
fracture  of  the  humerus,'^  and  for  many  years  was  by  far  the  most  efiicient 
means  of  obtaining  union ;  the  list  of  reported  cases  in  which  it  has  been 
used  would  be  too  long  to  cite.  It  w^as  kept  in  place  for  varying  periods, 
from  a  few  days  to  many  months.    Somme,  of  Antwerp,  wishing  to  aftect  a 

1  Am.  Journal  of  the  Med.  Sciences,  Jan.  1848.  The  idea  was  not  new,  having  been  success- 
fully carried  out  by  White  in  1768. 

2  Ibid.,  Nov.  18-34. 

3  Jones,  Medical  News,  Nov.  18,  1882 ;  from  Lancet,  Oct.  28. 
*  Lente,  New  York  Med.  Journal,  Nov.  1850. 

5  Burman,  Am.  .Tourn.  of  the  Med.  Sciences,  April,  1848,  fi'om  Provincial  Med.  and  Surg. 
Journal,  December  1,  1847. 

6  Op.  cit.,  Bd.  i.  S.  652. 

7  Am.  Journ.  of  the  Med.  Sciences,  Feb.  1834. 

8  Ibid.,  April,  1874,  from  L'Union  Medicale,  10  Fev. 

9  Principles  of  Surgery,  Am.  ed.  1845,  p.  503. 

10  Am.  Journ.  of  the  Med.  Sciences,  July,  1875. 

"  Op  cit.,  p.  81  ;  Trans,  of  Am.  Med.  Association,  1850. 

'2  Mem.  et  Bull,  de  la  Soc.  Med.-Chir.,  etc.  de  Bordeaux  ;  review  in  Am.  Journ.  of  the  Med. 
Sciences,  Jan.  1868,  p.  180. 
"  Medical  Repository,  New  York,  1804 ;  Am.  Journ.  of  the  Med.  Sciences,  Nov.  1830. 


GENERAL  TREATMENT  OF  FRACTURES. 


61 


lar«:er  surface,  passed  a  wire  loop  between  the  fragments.^  At  present  the 
seton  has  been  abandoned  in  favor  of  more  certain  methods ;  it  was  not  free 
from  danger,  and  I  have  myself  witnessed  a  death  from  its  use. 

Drilling  of  the  fragments  has  been  practised  by  many  surgeons,  with  a  large 
measure  of  success;  it  may  be  done  with  an  ordinary  gimlet,  although 
various  forms  of  more  surgical-looking  instruments  have  been  devised  for  the 
purpose.    Fig.  810  represents  that  employed  by  the  late  Prof.  J.  Pancoast ; 


Fig.  810. 


Pancoast's  screw  for  ununited  fracture. 


and  Fig.  811  a  more  complex,  but  very  convenient  instrument,  invented  by 
Mr.  T.  Gemrig.  Dieffenbach's  plan  of  introducing  ivory  jpegs  into  the  holes 
thus  made  in  the  bone,  enjoyed  for  a  time  a  high  place  in  surgical  esteem,  and 


Fig.  811. 


Improved  drill  for  ununited  fracture. 


has  not  yet  been  w^holly  given  up.  Bickersteth^  is  said  to  have  described,  in 
1854,  a  modification  of  Dieffenbach's  process,  which  proved  very  efficient ;  it 
consisted  in  drilling  the  broken  ends,  and  nailing  them  together  with  ivory 
pegs.  Anderson^  reports  a  case  in  which  the  pegs  were  not  removed  for  four 
months,  and  quotes  from  Trendelenburg  one  in  which  they  w^ere  allowed  to 
remain  for  a  year  and  a  half.  From  an  observation  reported  by  Riedinger 
to  the  tenth  German  Surgical  Congress,^  it  would  appear  that  ivory  pegs 
buried  in  a  human  bone  need  not  undergo  absorption,  but  may  remain  for  years 
without  exciting  reaction  ;  any  portion,  however,  which  may  project  outside 
of  the  periosteum,  does  become  absorbed  at  that  level,  and  drops  off. 

M.  Schede,  of  Hamburg,  recently  exhibited  to  the  Congress  of  the  German 
Society  of  Surgery,^  some  gilt  steel  needles^  three  and  a  half  centimetres  in 
length,  and  two  millimetres  in  thickness,  used  with  advantage  by  him  in 
cases  of  pseudarthrosis.  Ten  or  twelve  of  these  needles  are  inserted  into  the 
softened  part  of  the  bone,  without  any  complaint  of  pain  on  the  part  of  the 
patient;  an  antiseptic  dressing  is  then  applied.  The  needles  are  kept  in 
place  about  fifteen  days.  So  far,  M.  Schede  says,  this  simple  and  convenient 
procedure  has  succeeded  in  all  the  cases  in  which  it  has  been  employed. 

1  Med.-Cliirurgical  Transactions,  vol.  xvi.  1830. 

2  Note  signed  "  W.  T.  C,"  Lancet,  Dec.  16,  1882. 
'  Trans,  of  Pathological  Society  of  London,  1881. 

<  Verhandlungen,  1881,  S.  167.  ^  o^z.  Med.  de  Paris,  Aug.  12,  1882. 


62 


INJITRIES  OF  BONES. 


Remedial  measures  such  as  those  now  described  are  suited  for  cases  of  de- 
layed union,  and  for  those  in  which  the  fragments,  although  movable  upon 
one  another,  are  yet  in  relation  by  somewhat  wide  surfaces.  But  they  would 
have  failed  in  the  instance,  for  example,  reported  by  Borland,^  in  which  a 
portion  of  muscle  was  caught  between  the  fragments.  Stanley ^  mentions  a 
like  case.  They  would  be  equally  useless  where  the  fragments  were  rounded 
off,  walled  in  at  the  ends,  and  connected  by  well-defined  ligamentous  bands. 
Here  nothing  short  of  the  exposure  of  the  bone,  the  renovating  of  the  broken 
ends,  and  the  securing  of  their  apposition,  could  be  of  any  avail. 

Perhaps  the  indications  for  such  grave  interference  with  the  parts  may  be 
stated  to  be,  in  general  terms,  the  obstinate  persistence  of  mobility,  with  pain 
and  other  evidence  of  some  unusual  obstacle  to  union ;  or  the  very  great 
degree  of  mobility,  with  subsidence  of  all  swelling,  and  entire  absence  of  pain 
or  tenderness.  In  one  or  two  instances  I  have  been  able  to  make  out  the 
rounded  and  atrophied  condition  of  the  fragments. 

Of  the  old  plans  of  refreshing  the  broken  ends  by  means  of  the  actual  or 
jpotential  cautery^  nothing  need  be  said,  except  that  while  the  probability  of 
their  doing  good  is  very  small,  the  possibility  of  their  doing  harm  by  setting 
up  osteo-myelitis  is  too  real  to  be  overlooked.  They  should  be  accorded  a 
merely  historical  importance. 

Resection  for  ununited  fracture  dates  back  to  1760,  and  the  credit  of  it  is 
due  to  White ,^  of  Manchester,  w^ho  practised  it  with  brilliant  success  in  a 
number  of  instances.  It  involves  the  complete  exposure  of  the  fractured 
ends,  w^hich  are  then  freshened  by  scraping,  or  by  cutting  them  off  on  either 
side  with  a  saw  or  with  bone-nippers.    The  bone-director  (Fig.  812)  is  very 

Fig.  812. 


Blandin's  bone-director. 


useful  in  turning  out  the  ends  to  be  sawed  off".  The  incision  should  always 
be  made  where  the  bone  is  most  accessible,  and  where  there  is  least  risk  of 
injury  to  important  structures.  Any  large  vessels  or  nerves  which  are  ex- 
posed, should  be  carefully  held  aside  with  blunt  hooks,  and  the  chain-saw  will 
be  found  more  convenient  in  every  way  than  any  other.  Listerian  precau- 
tions may  be  adopted  by  those  who  think  that  they  diminish  the  danger  of 
such  procedures  ;  if  they  do  no  good,  they  will  do  no  harm.  As  a  rule,  both 
fragments  should  be  attacked,  although  success  has  sometimes  been  achieved 
by  section  of  one  only,  the  other  having  been  beyond  reach  except  by  greatly 
increasing  the  magnitude  and  difficulty  of  the  operation,  as  well  as  the  risk 
to  the  patient. 

The  earlier  operators  in  this  direction  were  content  to  employ,  after  the 
cutting  of  the  bones,  a  carefully  adapted  apparatus  for  retaining  them  in 
place.  An  improvement  was  introduced  by  Horeau,  in  1805,  in  the  tying 
together  of  the  obliquely  divided  fragments  by  a  metallic  wire  carried  around 
them  ;  and  a  still  further  advance  was  made  in  1838,  by  Dr.  Eodgers,  of  i^ew 

'  Canada  Med.  and  Surg.  Journal,  1881. 

2  Dublin  Med.  Press,  Aug.  2.  1854;  Am.  Journ.  of  the  Med.  Sciences,  Oct.  1854. 

3  Cases  in  Surgery :  London,  1770,  pp.  69  et  seq. 


GENERAL  TREATMENT  OF  FRACTURES. 


68 


Y'ork,^  in  passing  the  wire  through  holes  drilled  in  the  walls  of  the  frag- 
ments, so  as  to  keep  them  in  apposition.  Many  cases  of  union  brought  about 
in  this  way  are  upon  record  ;  it  is  especially  applicable  where  there  are  two 
bones,  and  those  very  movable,  as  in  the  forearm.  Dr.  H.  J.  Bigelow^  at- 
taches importance  to  stripping  up  the  periosteum  from  the  fragments,  for  a 
short  distance,  before  dividing  the  bony  structure.  Other  American  surgeons 
who  have  operated  in  this  way  with  success  are  Brainard,^  Byrd,*  Jones,^ 
Sanborn,^  Ashhurst,  and  myself.^  Cases  are  also  reported  by  Annandale,^ 
and  Renton.^  A  somewhat  more  complicated  device  was  employed  by  Le 
Moyne,^°  in  the  shape  of  a  steel  clamp^  drilling  and  ivory  pegs  having  been 
previously  used  without  success.  Next  day  the  clamp  was  found  to  have 
started  from  the  upper  fragment ;  the  wound  was  therefore  reopened,  and 
silver  wires  placed  around  clamp  and  fragments,  so  as  to  hold  the  former 
firmly  in  place.  Two  months  after  the  operation  union  seemed  to  be  perfect, 
but  the  wire  and  clamp  w^ere  so  firmly  held  that  it  was  determined  to  leave 
them,  and  the  wires  were  cut  ofi:'  as  closely  as  possible.  At  the  last  report, 
some  months  afterward,  the  wound  w^as  almost  entirely  closed. 

Hamilton'^  speaks  of  having  on  one  occasion  engaged  the  end  of  one  frag- 
ment in  the  medullary  canal  of  the  other,  but  does  not  state  with  what  suc- 
cess. Roux^^  did  the  same,  but,  although  no  bad  symptoms  ensued,  a  fall  at 
the  end  of  two  months  caused  such  fresh  injury  that  the  arm  was  amputated, 
[t  would  be  interesting  to  know  what  w^as  the  state  of  the  bone  which  had 
been  so  treated. 

]N"ussbaum  is  reported have  operated  by  transplcmtation  in  a  case  of  frac- 
ture of  the  ulna  with  loss  of  substance.  He  cut  a  portion  two  inches  long, 
comprising  about  half  the  thickness  of  the  bone,  from  the  upper  fragment, 
and,  without  severing  its  fibrous  attachments  entirely,  he  shifted  it  dow^n- 
wards  so  as  to  fill  up  the  gap.  The  result  is  said  to  have  been  entirely  satis- 
factory. Such  a  procedure  could  scarcely  be  undertaken  except  by  a  surgeon 
with  shoulders  broad  enough  to  take  the  consequences  of  possible  failure. 

Having  now  passed  in  review  the  various  plans  which  have  from  time .  to 
time  been  employed  for  the  cure  of  pseudarthrosis,  the  subject  may  be  dis- 
missed with  a  few  general  remarks. 

In  the  first  place,  the  milder  measures  should  be  first  adopted,  where  they 
ofter  any  chance  of  success.  In  cases  of  long  standing,  where  the  broken 
ends  have  obviously  become  rounded  off,  and  are  completely  separated,  there 
may  be  no  reason  for  delay  ;  and  here  resection  and  wiring  seems  to  me  to  be 
the  safest  and  most  certain  of  the  methods.  But  in  more  hopeful  cases,  after 
rest  and  accurate  adaptation  have  been  tried,  with  rubbing  of  the  fragments 
upon  one  another,  drilling  may  be  resorted  to,  with  or  w^itliout  the  insertion 
of  ivory  pegs.    Failing  all  these,  an  operation  may  be  determined  upon. 

As  to  the  gravity  of  resection,  it  has  been  by  some  surgeons  over-estimated, 
and  by  others,  perhaps,  not  sufiiciently  appreciated.  The  condition  brought 
about  is  not  precisely  that  of  compound  fracture,  since  there  is  fiir  less  injury 
inflicted  on  the  soft  parts,  and  the  previous  pathological  processes  have  estab- 

^  Heard,  New  York  Journal  of  Medicine,  Oct.  1839. 

2  Ununited  Fractures  successfully  treated,  with  Remarks  on  the  Operation.  By  Henry  J. 
Bigelow,  M.D.,  etc.    Boston,  1867. 

'  Northwestern  Med.  and  Surg.  Journal,  Aug.  1848. 

<  Richmond  and  Louisville  Med.  Journal,  Oct.  1874,  and  N.  Y.  Med.  Jonmal,  May,  1876. 
*  Am.  Journal  of  the  Med.  Sciences,  July,  1866.  ^  Ibid.,  July,  1859,  and  April,  1860. 

^  Ibid.,  July,  1875.  »  British  Med.  Journal,  Jan.  9,  1875. 

^  Lancet,  July  22,  1882. 

10  Am.  Journal  of  the  Med.  Sciences,  April,  1879.        "  Op.  cit.,  p.  82. 
'2  Malgaigne,  op.  cit.,  t.  i.  p.  315.    Translation,  p.  255. 
Med.  Times  and  Gazette,  April  24,  1875. 


64 


INJURIES  OF  BOXES. 


lished  a  certain  tolerance  in  the  tissues  which  does  not  exist  in  a  healthy  limb 
suddenly  subjected  to  violence.  Moreover,  the  surgeon  should  be  on  his  guara 
against  all  the  avoidable  sources  of  trouble,  and  may,  before  operating,  assure 
himself  that  the  patient  is  in  such  a  state  as  to  reduce  the  chances  of  failure 
to  a  minimum.  On  the  other  hand,  however,  there  are  risks  which  must  be 
run  ;  and  the  question  is  always  to  be  carefully  considered,  whether  the  object 
to  be  o'ained  is  sufficient  to  justify  taking  them. 

For  the  condition  of  some  limbs  aflected  with  pseudarthrosis  is  by  no 
means  intolerable.  ^lany  a  man  is  able  to  earn  his  living  in  spite  of 
such  a  drawback,  especially  if  it  is  the  upper  extremity  which  is  affected. 
Even  without  any  prothetic  apparatus,  such  a  thing  may  be.  Thus  Dr.  Sut- 
ton^ reported  the  case  of  a  man  who  was  shot  in  the  arm,  the  ball  passing  through 
the  humerus  just  above  the  condyles.  It  would  appear  that  no  very  strict 
treatment  was  pursued.  After  some  weeks,  he  regularly  bent  his  arm  every 
day.  This  arm  got  well  with  the  elbow  stiff,  and  a  false  joint  at  the  place  of 
fracture.  The  artificial  joint  supplied  the  place  both  of  the  elbow-joint  and 
of  the  rotary  motion  of  the  forearm,  in  a  very  perfect  manner ;  and  the  man 
was  able  to  do  a  good  day's  work  at  any  kind  of  labor.  Xorris^  quotes  a 
number  of  analogous  cases. 

It  must  further  be  remarked  that  the  surgeon  must  be  cautious  in  his 
promises  to  the  patient  as  to  the  amount  of  benefit  to  be  derived  from  opera- 
tion. Althouoli,  as  a  general  rule,  the  union  of  the  broken  bone  may  be 
expected,  there  may  be  a  failure ;  and  even  if  the  main  object  be  accom- 
plished, there  may  be  drawbacks  to  the  ultimate  result,  which  will  cause 
much  disappointment  to  the  patient  if  his  hopes  have  been  raised  too  high. 
In  illustration  of  this  I  may  mention  a  case  which  came  under  my  notice 
some  years  ago : — 

R.  G.,  aged  36,  sustained  a  fracture  of  the  right  femur  in  December,  1865,  in  Nevada, 
and  was  kept  in  bed,  six  weeks,  with  a  screw  extension  apparatus.  No  union  taking 
place,  a  seton  was  passed  June  10,  1866;  this  failing,  a  steel  screw  was  introduced 
November  3,  and  kept  in  for  seven  weeks.  Abscesses  formed  on  either  side  of  the 
patella  during  that  time,  but  the  bone  became  firm.  When  I  saw  him  several  years 
afterwards,  he  had  three  inches  shortening,  the  lower  fragment  being  behind  the  upper. 
Only  shght  flexion  of  the  knee  was  possible.  He  could  walk  very  well,  and  all  day, 
but  not  fast. 

Had  this  patient  been  assured,  after  the  manner  of  some  over-sanguine  sur- 
geons, that  he  would  be  able  to  walk  as  well  as  ever,  he  would  have  had 
just  cause  of  complaint,  although  the  ultimate  result  was  perhaps  the  best  that 
could  have  been  obtained. 

Amputation  has  been  resorted  to  in  some  cases  of  pseudarthrosis.  It  is  of 
course  only  justifiable  when  the  limb,  after  a  thorough  trial  of  all  reasonable 
means,  not  only  fails  to  unite,  but  remains  in  such  a  condition  as  to  be  a 
burden  to  the  patient.  Thus  when  the  bone  affected  is  in  the  lower  extre- 
mity, and  the  fragments  very  loosely  connected,  the  usefulness  of  the  limb 
as  a  means  of  support  and  progression  is  lost,  and  .  the  patient  may  be  disa- 
bled from  obtaining  a  livelihood.  Or  if  there  be  extensive  necrosis,  or  ab- 
sorption of  a  very  large  portion  of  the  bone,  so  that  the  member  hangs 
dangling  like  a  flail,  it  may  be  a  mere  incumbrance. 

Persons  in  good  pecuniary  circumstances  may  often  be  enabled  by  means 
of  prothetic  apparatus  to  obtain  a  fair  degree  of  use  of  a  limb  which  would 
otherwise  be  only  in  the  way  ;  and  even  among  the  poor  this  should  be  sug- 
gested as  a  possibility.  For  example,  if  the  humerus  be  the  bone  concerned, 
an  appliance  for  its  external  su[)port  ma}' ,  even  if  rude  and  homely,  give  the 


1  Western  Journal  of  Med.  and  Surgery,  Oct.  1842. 


*  Op.  cit.,  p.  56. 


GENERAL  TREATMENT  OF  FRACTURES. 


65 


patient  such  use  of  the  forearm  and  hand  as  would  be  far  better  than  any 
artificial  substitute. 

In  any  case  it  is  a  good  rule  for  the  surgeon  to  wait  until  the  patient  asks 
for  the  removal  of  the  limb ;  and  to  satisfy  himself,  before  consenting  to  a 
resort  to  this  extreme  measure,  that  there  is  no  available  method  of  restoring 
some  degree  at  least  of  the  usefulness  of  the  part. 

Treatment  of  Union  with  Deformity. — If  from  restlessness  or  insubor- 
dination on  the  part  of  the  patient,  a  fracture  is  found  to  be  uniting  in  bad 
position,  no  time  should  be  lost  in  correcting  the  deformity,  and  in  so  modi- 
fying the  dressings  as  to  make  a  more  efiicient  retention  of  the  fragments. 

he  means  of  doing  this  must  vary  with  the  part  concerned,  and  with  the 
circumstances  under  which  the  treatment  is  conducted.  Occasionally,  the  end 
may  be  gained  by  gradual  pressure  with  properly  padded  splints ;  but,  gene- 
rally speaking,  it  is  the  better  plan  to  bring  the  bone  into  good  sha})e  at 
once,  the  patient  being  etherized  if  necessary ;  and  this  may  often  be  done 
with  the  surgeon's  hands  applied  at  either  end  of  the  bone,  while  his  knee 
is  used  as  a  fulcrum.  Should  the  union  be  already  too  firm  for  such  force  to 
be  efiective,  the  bone  may  be  straightened  over  the  padded  edge  of  a  table, 
with  the  aid  of  assistants.  Or  an  osteoclast,'' such  as  that  represented  in 
Fig.  813,  devised  by  Dr.  C.  F.  Taylor,  of  'New  York,  may  be  employed.  In 


Fig.  813. 


Taylor's  osteoclast. 

whatever  way  the  thing  be  done,  care  should  be  taken  to  exert  the  force  ex- 
actly on  the  spot  desired,  and  to  get  as  much  leverage  on  the  bone  as  possi- 
ble; otherwise  greater  pressure  will  be  necessary,  or  a  second  fracture  may 
be  produced  at  some  other  portion  of  the  bone.  The  soft  parts  should  always 
be  well  protected,  and  pressure  upon  large  vessels  or  nerves  should  be  studiously 
avoided. 

For  retaining  the  fragments  in  their  improved  position,  a  very  rigid  splint, 
VOL.  IV. — 5 


66 


INJURIES  OF  BONES. 


properly  shaped  and  padded,  may  be  put  along  either  side  of  the  limb,  and 
accurately  bandaged.  Firm  compresses  may  be  put  under  the  padding,  be- 
tween it  and  the  splint,  at  any  points  where  special  pressure  is  desired ;  and 
if  extension  seem  to  be  needed,  it  may  be  made  by  an  adaptation  of  methods 
to  be  hereafter  described. 

When  cousolidation  has  actually  taken  place,  and  the  bone  is  permanently 
fixed  in  its  distorted  condition,  there  are  several  courses  open  to  the  suro:eon. 
Brainarcli  advised  weakening  the  bony  texture  at  the  seat  of  fracture,  by 
drilling  it  subcutaneously,  and  then  breaking  it  up  in  the  manner  already 
described.  It  must,  however,  be  borne  in  mind  that  re-fracture  is  bv  no  means 
a  trifling  aftair.  Union  may  fail  to  occur  after  it,  whether  it  be  accidental  or 
produced  intentionally  by  the  surgeon ;  and  symptoms  of  great  gravity  may 
ensue,  as  in  a  case  reported  by  Hunt,^  in  which  the  patient,  though  he  ulti- 
mately recovered  with  a  useful  limb,  was  placed  in  imminent  danger  of  his 
life  by  the  operation. 

Besedion  of  a  w^edge-shaped  piece  of  bone  from  the  projecting  angle  has 
been  done  in  a  large  number  of  cases.^  It  dates  back  as  far  as  the  sixteenth 
century,  and  from  the  published  reports  would  seem  to  have  been  very 
generally  successful.  Yet  there  are  not  wanting  accounts  of  its  failure,  and  I 
have  myself  seen  several  instances  in  which  it  has  proved  fatal. 

Subcutaneous  osteotomy/,  either  with  the  saw  after  the  method  of  Adams,  or 
with  the  chisel  of  Linhart  and  Maunder,  is  certainly  a  safer  procedure ;  but 
for  obvious  reasons  it  would  sometimes  afford  much  less  advantage  in  the 
correction  of  the  deformity. 

The  deformities  which  are  most  frequently  met  with  after  fracture,  are  such 
as  admit  of  no  treatment.  They  are  apt  to  be  very  close  indeed  to  joints  ;  I 
have  seen  them  in  the  neighborhood  of  the  elbow  and  ankle  more  often  than 
elsewhere.  They  are  mainly  due  to  the  extreme  smallness"  of  one  fragment, 
which  gives  no  purchase  for  any  form  of  retentive  appai'atus ;  moreover,  in 
these  cases  there  is  commonly  very  great  swelling  in  the  early,  and  even  in 
the  later  stages,  so  that  the  precise  condition  of  affairs  cannot  be  determined 
until  all  chance  of  correcting  it  is  past.  Hence  the  surgeon,  when  called 
upon  to  attend  fractures  in  these  regions,  should  be  careful  to  2:uard  the 
patient  or  his  friends  from  disappointment,  and  himself  from  blame,  by  stat- 
ing from  the  outset  the  probability  of  more  or  less  deformity  and  loss  of 
movement  resulting. 

The  foregoing  remarks  apply  especially  to  the  treatment  of  cases  of  angular 
deformity,  which,  indeed,  is  the  one  most  generally  brought  ic  the  notfce  of 
the  surgeon,  and  the  one  which  affords  most  chance  of  relief  by  operative 
measures.  Mere  shortening,  after  union  has  taken  place,  can  scarcelv  be 
remedied,  as  it  is  due  either  to  tbe  loss  of  bone-substance  or  to  overlappino;  of 
the  fragments  ;  and  the  section  of  a  bone  so  united,  in  order  to  splice  it  anew, 
would  be  a  procedure  so  grave  in  its  risks  as  to  prevent  any  prudent  surgeon 
from  attempting  it.  As  to  rotary  displacement,  disabling  and  disfiguring  as 
it  is,  in  the  very  rare  cases  in  which  it  occurs,  the  prospect  of  improvement 
from  an  operation  must  be  acknowledged  to  be  too  small  to  warrant  its  em- 
ployment. 

The  subject  is  in  practice  still  further  narrowed  by  the  fact  that  the  cases 
which  have  been  hitherto  reported  as  dealt  with  by  operation  have  nearly  ali, 
if  not  all,  concerned  either  the  leg  or  the  thigh.  Here  angular  deformity 
involves  shortening  of  the  whole  limb,  as  well  as  a  most  awkward  and  incoii- 

*  Chicago  Med.  .Journal,  Jan.  1859. 

2  Philadelphia  Medical  Times,  Oct.  26,  1872;  Surgery  in  the  Pennsylvania  Hospital,  p.  151. 
»  Norris,  op.  cit.,  pp.  124  et  seq.  > 


FRACTURES  OF  THE  BONES  OF  THE  FACE. 


67 


venient  hamperino:  of  its  laovenients,  not  remediable,  as  mere  shortening  is,  by 
the  weariiio'  of  a^boot  with  a  thick  cork  sole,  or  with  a  metallic  stirrup  to 
nnke  up  the  want  of  leui^tb  ;  and  for  such  a  condition  the  surgeon  is  justihed 
in'  ad()i)ting  severer  measures,  and  running  greater  risks,  than  tor  one  less 

^^^OnTorTvvo  instances  are  upon  record  in  which  surgeons  have  shortened  a 
sound  limb  in  order  to  obviate  the  limp  due  to  a  badly  healed  fracture  m 
the  other.  I  mention  the  fact  only  to  enter  a  protest  against  any  such  pro- 
cedure, which,  in  my  opinion,  could  never  be  otherwise  than  rash  and  un- 
suro-ical,  and  the  result  of  which  could  not  be  satisfactory. 

Reference  will  be  again  made  to  the  subject  of  union  with  detormity  in 
connection  with  certain  special  fractures. 


FRACTURES  OF  SPECIAL  BOJSTES. 


Fractures  of  the  Bones  of  the  Face. 

From  the  size,  shape,  and  arrangement  of  the  bones  constituting  the  skele- 
ton of  the  face,  they  are,  with  the  exception  of  the  lower  jaw,  unapt  to  be 
broken  sino-ly.  By  crushing  forces,  such  as  a  fall  from  a  height  on  the  tace, 
the  kick  of  a  horse,  or  the  passage  of  a  wheel,  very  extensive  injury  may  be 
inflicted.    These  fractures  are  generally  compound,  and  often  comminuted. 

Cottinc^  has  reported^  the  case  of  a  man  ran  over  by  a  cart,  who  had  "  a  fracture  of 
the  lower  jaw  on  one  side,  and  a  dislocation  on  the  other ;  and  a  separation  ot  the 
whole  face  from  the  base  of  the  skull.    The  patient  recovered  without  much  deformity. 

A  man  was  brought  to  the  Pennsylvania  Hospital  in  1855,  who  had  had  his  head 
caught  between  the  platform  of  a  steam  hoisting-machine  and  a  floor.  The  face  was 
sepitrated— bones,  soft  parts  and  all— from  the  cranium,  as  far  back  as  the  sphenoid  ;  a 
crhastly  <rash  across  the  face,  with  a  curious  falling  away  of  all  the  features  from  the 
forehead'^  had  been  produced,  and  the  shock  was  so  great  that  death  ensued  m  a  few 
hours. 

A  very  remarkable  case  of  smashing  of  the  facial  bones,  not  fatal,  may  be  found 
recorded  by  Heath.^ 

Such  very  severe  injuries  are  rarely  met  with  ;  and  the  cases  vary  so  much 
that  they  can  only  be  discussed  in  the  most  general  terms.  Although  at  first 
sio;ht  they  may  be  frightful,  and  it  may  seem  as  if  recovery,  if  possible  at  all, 
would  be  necessarily  attended  with  hideous  deformity,  the  surgeon  should 
not  despair.  He  should  endeavor  to  ascertain  the  exact  extent  and  character 
of  the  fractures,  and  to  replace  the  broken  portions  of  all  the  bones  involved.^ 
It  may  tax  his  ingenuity  to  keep  them  in  place,  but  by  careful  adaptation  of 
the  means  to  be  presently  described,  a  great  deal  may  be  done.  Union  takes 
place  very  rapidly,  and  the  disfigurement  ultimately  resulting  is  often  far  less 
than  might  at  first  be  expected. 

One  rule  is  recognized  by  all  the  authorities  in  regard  to  compound  com- 
minuted fractures  of  the  facial  bones ;  it  is,  that  splinters  of  bone  should  not 
be  removed  until  they  are  actually  necrosed  and  thrown  off.  Loss  of  sub- 
stance produces  the  worst  deformity ;  and  it  often  happens  that  small  frag- 


>  American  Journal  of  the  Medical  Sciences,  Jan.  1850. 
2  Diseases  and  Injuries  of  the  Jaws,  p.  55.    London,  1868. 


68 


INJURIES  OF  BONES. 


ments  which  seem  hopelessly  detached  will  adhere  and  live,  perhaps  helping 

materially  to  preserve  the  contour  of  the  face. 

Generally  the  attention  of  the  surgeon  is  confined  to  the  prevention  of  de- 
formity after  these  injuries ;  but  sometimes  other  bad  consequences  may 
ensue.  Thus,  Martin  reports^  a  case  in  Avhich  amaurosis  followed  a  fracture 
of  the  nasal  portion  of  the  superior  maxilla,  as  well  as  of  the  palate  bone,  and 
most  probably  of  the  lachrymal;  the  patient,  a  man  aged  sixty,  had  been 
struck  with  a  stone.    Sight  was  ultimately  restored. 

A  numl)er  of  instances  are  on  record  in  which  foreign  bodies  have  been 
forcibly  thrust  into  the  orbit,  producing  fracture  of  its  bony  walls,  and  in- 
juring the  eye,  or  even  the  brain  itself;  but  these  will  be  more  appropriately 
discussed  elsewhere. 

The  treatment  of  fractures  of  the  facial  bones  must  be  directed  to  the  re- 
placement, as  already  said,  of  the  fragments.  This  may  often  be  done  (after 
the  careful  removal  of  all  foreign  bodies,  if  the  fracture  be  compound)  by 
simply  moulding  with  the  fingers.  Compresses  should  then  be  applied,  ex- 
actly adapted  to  the  size  of  the  part  over  which  pressure  is  to  be  made,  and 
fastened  in  place  by  means  of  strips  of  fine  isinglass  plaster,  or  of  rubber 
adhesive  plaster.  Of  course  the  eyebrows,  moustache,  or  any  hair  that  may 
interfere  with  the  dressing,  should  be  carefully  shaved.  A  light  ice-bag,  not 
filled  so  full  as  to  prevent  its  taking  the  shape  of  the  part,  should  be  lard  on, 
to  keep  down  inflammation ;  the  patient  should  be  placed  in  bed ;  and  liquid 
diet  only  should  be  allowed.  If  the  efitbrt  of  swallowing  even  this  be  pro- 
ductive of  pain,  or  disturb  the  fracture,  nutritive  enemata  may  be  employed. 

It  is  rarely  necessary  to  confine  the  lower  jaw ;  but  this  may  readily  be  done 
in  case  of  need  by  means  of  a  broad  strip  of  rubber  plaster  applied  under  the 
shaven  chin,  and  brought  up  with  the  ends  crossed  above  the  forehead. 

^^hen  the  fracture  involves  the  alveolar  margin  of  the  upper  maxilla,  it  may 
become  necessary  to  have  a  cast  taken  of  the  teeth,  and  on  this  a  vulcanized 
rubber  mould,  to  serve  as  a  splint.  (In  large  cities  it  is  generally  easier  to 
have  this  done  by  a  dentist,  to  whom  the  process  is  thoroughl}-*^  familiar.) 
Having  put  the  splint  in  place,  the  surgeon  brings  up  the  lower  jaw  against 
it,  and  applies  the  broad  strip  of  plaster  above  mentioned.  A  roller  may  be 
employed,  in  the  form  known  as  "Barton's  bandage,"' ^  if  there  be  any  objec- 
tion to  shaving  the  chin,  or,  in  the  case  of  females,  to  shaving  the   front  hair." 

Fractures  of  the  Zygoma. — Fractures  of  the  zygomatic  arch  are  very  rare, 
and  can  only  be  caused  by  great  violence.  Malgaigne  quotes  from  Duvemey 
an  account  of  "  a  young  child,  who,  having  in  his^  mouth  the  end  of  a  lace- 
bobbin,  fell  headforemost,  so  that  the  end  of  the  bobbin,  piercing  the  soft 
parts,  broke  the  zygomatic  apophysis  from  within  outwards  ;''  and  another, 
in  which  Duverney  says  that  he  detected  the  fracture  by  passing  his  finger 
through  the  patient's  mouth.  But  since,  as  Malgaigne "^justly  remarks,  the 
zygomatic  arch  cannot  be  reached  in  this  way,  there  is  good  reason  to  doubt 
both  these  stories. 

I  have  seen  one  case  of  fracture  of  the  zygomatic  arch,  firmly  united  with 
deformity  outward.  It  had  occurred  sevei^al  months  previously,  by  the  fall- 
ing of  some  chains  on  the  head  and  left  shoulder  of  the  maii,  who  was  a 
sailor. 

When  the  deformity  is  outward,  which  may  perhaps  result  from  the  jam- 
ming backward  of  the  malar  bone,  simple  pressure  inward  may,  in  a  recent 
case,  overcome  it.   When  it  is  inward,  resort  may  be  had  to  incision,  and  the 

^  Medical  Press  and  Circular,  Sept.  23,  1874. 
2  See  Vol.  I.  p.  499. 


FRACTURES  OF  THE  BONES  OF  THE  FACE. 


69 


introduction  of  an  instrument  to  i>ry  the  fragnients  up.  Malgaigne  quotes  a 
case  thus  operated  upon  by  Ferrier,  with  a  good  result. 

Muhlenberg'  has  recorded  a  case  of  fracture  of  the  zygomatic  process  by 
the  kick  of  a'horse,  followed  by  very  troublesome  false  anchylosis  of  the  tem- 
poro-maxillary  joint. 

Malar  Bone. — Fractures  of  the  malar  bone  are  exceedingly  rare,  as  might 
be  expected  from  its  great  strength,  and  from  its  attachments.  A  few 
instances  are  on  record  in  which  it  has  been  separated  from  the  adjoining 
bones,  by  very  great  force.  In  one,  recorded  by  Malgaigne,  there  was  depres- 
sion, especially  marked  posteriorly,  where  the  malar  bone  had  been  driven 
inward  away  from  the  zygomatic  process  of  the  temporal,  and  injury  was 
done  to  the  infra-orbital  nerve,  paralyzing  the  area  sup[)lied  by  it. 

Replacement  may  be  difficult,  or  even  impossible  ;  but  the  resulting  defor- 
mitv  is  not  very  great,  unless  from  some  such  lesion  of  nerves  as  that  just 
mentioned.  There  would  be  no  valid  objection  to  making  a  slight  incision 
so  as  to  introduce  an  elevator  for  the  purpose  of  prying  the  bone  up,  as  in 
Ferrier's  case  of  depression  of  the  zygomatic  arch.  In  any  such  case,  by 
making  the  section  of  the  skin  obliquely,  the  resulting  scar  would  be  materially 
lessened. 

Upper  Jaw. — Fracture  of  one  upper  maxillary  bone  is  very  rare,  except  in 
the  alveolar  portion.  This  is  sometimes  broken  off  by  blows  or  falls;  thus 
I  have  seen  a  semicircular  piece  detached  in  front,  carrying  with  it  the  incisor 
teeth,  in  a  man,  who,  having  fallen  from  a  wagon  on  his  face,  had  a  heavy 
box  come  down  on  his  head  as  he  lay ;  his  lower  jaw  was  also  broken  in  two 
places.  I  have  seen  a  much  smaller  piece  knocked  loose  in  a  boy  of  six,  by 
a  fall  against  a  step  ;  he  bled  profusely  for  a  time,  but  a  good  result  ensued. 

Occasionally  the  wall  of  the  antrum  is  pierced  by  a  thrust  \vith  a  stick  or 
sharp  instrument ;  and  in  such  a  case  the  bone  may  be  more  or  less  splintered 
in  various  directions. 

In  most  cases,  the  force  fracturing  the  upper  jaw-bone  is  exerted  at  the 
same  time  upon  adjacent  bones,  and  a  more  complex  injury  is  produced.  Thus 
the  kick  of  a  horse  may  crush  and  drive  back  both  upper  maxillae,  with  the 
palate  bones  and  vomer ;  or  the  same  effect  may  be  produced  by  a  fall  on  the 
face  from  a  height. 

Wiseman"^  relates  a  curious  instance,  in  which,  a  boy,  aged  8,  liaving  had  a  kick 
from  a  horse,  which  drove  the  bones  backward,  he  "  caused  an  instrument  to  be  made, 
whereby  the  great  fractured  body  was  more  easily  brought  into  its  natural  place,  and 
also  kept  there  by  the  hand  of  the  cliild,  liis  mother  and  my  servants  helping  him  some 
while."  The  result  is  said  to  have  been  "  better  than  could  have  been  hoped  for  from 
such  a  distortion  in  that  place." 

Hayes'  reports  the  case  of  a  man,  who,  being  thrown  from  a  carriage  and  striking 
upon  the  end  of  a  fence-rail,  sustained  com})Ound  comminuted  fractures  of  the  right 
upper  maxilla  and  right  malar  bone,  with  simple  fractures  of  the  left  upper  maxilla 
and  the  lower  maxilla  on  tlie  right  side.  There  was  a  good  deal  of  cerebral  commo- 
tion, and  very  severe  hemorrhage  ;  but  the  patient  ultimately  did  well. 

A  man,  aged  40,  was  brought  to  the  Episcopal  Hospital,  in  December,  1876,  having 
been  injured  by  the  caving  in  of  a  culvert.  He  had  a  compound  fracture  of  both  nasal 
bones,  the  greater  part  of  the  left  one  being  crushed  off;  and  a  laceration  of  the  right 
lower  eyelid,  tlie  ball  being  partially  torn  away  and  falling  forward  in  the  orbit.  The 
whole  face  was  enormously  swollen,  and  there  was  continuous  and  free  bleeding  from  the 


1  Phila.  Med.  Times,  May  15,  1871. 
8  South.  Med.  Record,  1882,  p.  281. 


2  Op.  cit.,  vol.  ii.  p.  253. 


70 


INJURIES  OF  BONES. 


nose.  On  the  next  day,  the  swelling  having  subsided,  a  fracture  was  discovered  begin- 
ning near  the  zygomatic  arch  on  the  right  side,  and  extending  across  the  upper  jaw  to 
the  left  side  in  front  of  the  molar  teeth.  The  fractured  portion  was  very  freely  movable. 
Plugging  of  the  posterior  nares  was  resorted  to,  but  the  patient  persisted  in  pulling  the 
tampons  away,  and  the  hemorrhage  was  finally  arrested  by  means  of  astringent  injec- 
tions. About  the  fourteenth  day  an  abscess  formed  below  the  right  eye,  although  the 
swelling  and  ecchymosis  had  almost  wholly  disappeared  ;  this  continued  to  discharge 
for  some  weeks,  but  no  dead  bone  could  at  any  time  be  felt.  Union  of  the  fracture  took 
place  readily,  and  on  January  1,  when  I  gave  up  the  wards  to  Dr.  John  Ashhurst,  Jr., 
there  only  remained  a  condition  of  ptosis  due  to  tearing  of  the  muscles  above  the  right 
eyeball.  This  was  remedied  by  Dr.  Ashhurst  by  operation,  January  11,  and  on  tlie 
20th  the  man  went  out  cured. 

Occasionally  these  injuries  are  productive  of  most  ghastly  deformity.  Thus 
Malgaigne  mentions  a  case  seen  by  him  a  long  time  after  the  injury,  which 
the  patient  had  sustained,  when  a  child,  by  the  kick  of  a  horse,  comminuting 
the  nasal,  upper  maxillary,  and  palate  bones,  and  tearing  and  bruising  the 
soft  parts. 

The  nasal  bones  were  destroyed  ;  the  anterior  portion  of  the  alveolar  arch,  and  most, 
if  not  all,  of  the  vault  of  the  palate,  had  likewise  disappeared.  He  had  no  nose  nor 
mouth  ;  the  two  lips  being  fastened  together  by  a  thick  and  firm  cicatrix,  the  chin  was 
continued  up  to  an  oval  opening,  formed  between  the  two  ascending  processes  of  the 
maxillary  bones  as  high  as  the  frontal.  By  this  one  opening  the  patient  breathed, 
spoke,  ate  and  drank  ;  when  a  piece  of  bread  was  put  into  it,  the  tongue  was  seen  to 
come  up,  and  to  carry  it  down  to  the  molar  teeth,  which  performed  their  functions  very 
well. 

Concerning  the  symptoms  and  diagnosis  of  these  cases,  there  is  very  little 
to  be  said ;  the  nature  of  the  injury  is  generally  clear  enough. 

As  to  the  treatment^  the  indications  are  to  restore  the  fragments  to  their 
place  as  nearly  as  this  can  be  done,  and  to  keep  them  so  until  union,  which 
generally  takes  place  very  readily,  has  occurred.  In  compound  fractures,  no 
splinters  should  be  removed  by  the  surgeon  ;  they  may  unite,  and  if  they  do 
not,  they  will  be  thrown  off".  By  the  older  surgeons,  very  complex  appliances 
were  devised,  with  head-bands,  curved  steel  bars,  and  plates  to  press  against 
the  fragments.  Bat  the  improved  resources  of  modern  dentistry  render  such 
apparatus,  for  the  most  part,  needless ;  and  in  the  great  majority  of  cases  the 
retention  of  the  fragments  can  be  effected  by  means  of  well-fitted  vulcanite 
splints  made  to  fit  the  dental  arches.  When  these  are  arranged,  a  bandage  is 
put  on  so  as  to  restrain  the  movements  of  the  jaws. 

In  some  cases,  after  the  first  day  or  two,  there  is  no  difiiculty  in  the  admin- 
istration of  liquid  food  by  the  mouth,  the  patient  learning  to  take  it  with- 
out deranging  the  fragments  or  the  apparatus.  But  should  there  be  any 
awkwardness  in  this,  rectal  alimentation  may  be  resorted  to. 

Fractures  of  the  ITasal  Bones. — The  bones  of  the  nose  are  so  thick,  at 
their  upper  part,  and  so  well  supported,  that  they  are  not  often  broken  except 
in  their  lower  portions.  Sometimes  the  septum  sufters  also  ;  perhaps  this  is 
more  generally  the  case  than  is  suspected.  It  is  not  always  easy  to  tell  how 
far  the  injury  consists  also  in  separation  of  the  cartilages  from  the  edges  of 
the  bones ;  but  this  certainly  does  occur  in  some  instances.  The  mucous 
membrane  is  often  ruptured,  and  thus  the  fracture  is  rendered  compound. 

I  have  seen  the  nose  broken  by  a  cricket-ball,  by  a  blow  with  the  fist,  by 
a  blow  received  in  boxing  with  the  gloves,  by  a  fall  from  a  horse ;  the  vio- 
lence is  always  great  and  direct.  Oftentimes  it  falls  a  little  to  one  side  or  the 
other,  so  as  to  drive  the  nose  crooked  ;  and  if  this  deformity  is  not  corrected, 
it  is  very  disfiguring. 


FRACTURES  OF  THE  BONES  OF  THE  FACE. 


71 


Concussion  of  the  bniin  is  sometimes  produced  by  the  severity  of  the  blow, 
but  it  seems  very  unlikclv  that  tlie  force  can  be  transmitted  tlirough  the  nasal 
bones;  it  is  more  prol)abfe  that  it  bears  also  upon  the  neighboring  portions  of 
tlie  walls  of  the  cranium.  .     ,     ,       •      i  •  i 

Hamilton  gives  several  cases  of  injury  of  tlie  nose  in  cliildren,  m  wliieli  tiie 
na^al  ])rocesS?s  of  the  upper  maxillary  bones  were  spread  outwards ;  one  of 
these  was  in  a  child  only  three  weeks  old,  upon  whose  face  a  block  ot  wood 
fell  as  she  lay  asleep.    Such  an  occurrence  could  hardly  take  place  in  an 

'^'^^The  history  of  the  injury,  and  the  deformity,  generally  point  to  the  diag- 
nosis, which  is  nearly  always  rendered  certain  by  the  detection  ot  crepitus. 
Other  symptoms  apt  to  be  present  are :  severe  pain  and  headache,  hemorrhage 
from  one  or  both  nostrils,  and  sometimes  emphysema  in  the  surrounding 
areolar  tissue.  Swelling  takes  place  so  rapidly  as  often  not  only  to  make  the 
exact  seat  and  direction  of  the  fracture  obscure,  but  to  interfere  seriously  with 
attempts  to  correct  the  displacement.  .     ,  ,  i 

In  many  of  these  cases,  especially  if  the  violence  inflicted  has  been  very 
o-reat,  the  bones  are  comminuted  ;  and  this  adds  notably  to  the  dithculty  of 
exact  diao'uosis  as  well  as  of  treatment.  The  mere  detection  is  easier,  as 
well  as  the  reduction,  but  the  latter  is  hard  to  maintain. 

IWatmcnL—Frnctwves  of  the  nasal  bones  usually  unite  very  readily,  and 
this  fact  makes  it  very  desirable  that  the  displacement  should  be  carefully 
corrected  at  the  earliest  possible  moment.  Hence  the  surgeon^  should  at  once 
press  the  frao-ments  into  their  proper  relation  by  means  of  an  inliexible  probe 
or  director  luissed  into  the  nostril,  first  on  the  one  side  and  then  on  the  other, 
mouldino;  them  at  the  same  time  with  the  fingers  of  his  other  hand  applied 
on  the  outside.  Another  good  plan  is  to  use  a  pair  of  forceps.  In  many 
cases  this  will  be  sufiicient ;  the  deformity,  once  reduced,  does  not  recur,  and 
all  that  is  needful  is  to  keep  down  infiammation.  Hemorrhage  may  be 
arrested  by  o-ently  introducing  a  slender  bit  of  ice,  or  by  making  the  patient 
snufi"  up  into  the  nose,  water  as  hot  as  he  can  bear.  Emphysema  will  subside 
of  itself. 

Should  the  fragments  be  so  loose  as  to  foil  out  of  place,  the  attenipt  may 
be  made  to  support  them  from  within  by  means  of  pieces  of  thick  soft-rubber 
catheters,  with  adhesive  plaster  externally;  or  the  plan  suggested  by  Dr.  L.  D, 
Mason^  may  be  adopted.  This  consists  in  pushing  through  the  base  of  the  nose 
a  strong  pin  (gilt  or  nickel-plated),  and  bringing  a  strip  of  rubber  or  adhesive 
plaster  across  from  one  end  to  the  other  so"  as  to  support  and  compress  the 
parts. 

For  the  treatment  of  deflections  of  the  septnm  it  is  impossible  to  give  any 
rules  which  shall  apply  to  the  more  diflicult  cases,  since  they  may  require 
judicious  modifications  of  operative  procedures.  Usually,  in  the  simpler 
cases,  properly  applied  pressure  will  sufiice  to  overcome  them. 

Sometimes,  when  the  nasal  process  of  the  upper  maxillary  bone  is  involved, 
there  may  be  violence  infiicted  on  the  lachrymal  duct.  From  this  may  arise 
stoppage  of  the  duct  and  flstula.  lachrymalis  ;  it  is  obvious  that  such  a  case 
would  present  unusual  diflficulties. 

Malgaigne  quotes  from  Duverney  a  case  in  which  the  ultimate  result  of  an 
injury  of  this  kind  was  a  cancer,  which  destroyed  the  patient's  life. 

Fractures  of  the  Lower  Jaw. — The  lower  jaw  presents  the  figure  of  a 
more  or  less  pointed  arch,  bent  upward  neiu'  each  buttress.  Its  bod}^  com- 
prising all  in  front  of  the  angles,  is  thick  and  strong,  and  especially  dense  at 

'  Annals  of  Anatomy  and  Surgery.    Brooklyn,  1880. 


72 


INJURIES  OF  BONES. 


the  symphysis.  The  rami  are  flat  and  comparatively  thin,  widening  out 
transversely  above  and  posteriorly  to  form  the  condyles,  while  above  and  an- 
teriorly they  run  up  into  the  thin  points  known  as  the  coronoid  processes. 
Without  a  careful  study  of  the  anatomy  thus  briefly  sketched,  a  proper  com- 
prehension of  the  fractures  of  this  bone  is  impossible ;  and  such  study  must 
embrace  the  relations  of  the  condyles  to  the  base  of  the  skull,  as  well  as  of 
the  arrangements  of  the  osseous  structure  as  seen  in  sections.  As  to  the 
latter,  it  aftbrds  a  very  striking  illustration  of  the  law  before  stated,  that  the 
lamell8e  always  run  perpendicularly  to  the  planes  of  pressure,  and  as  nearly  as 
possible  parallel  with  the  lines  of  muscular  action.  If  a  line  be  drawn  from 
the  symphysis  to  the  centre  of  either  condyle,  it  will  be  found  to  represent 
the  resultant  of  all  the  normal  forces  to  which  the  corresponding  half  of  the 
bone  is  subjected. 

As  might  be  inferred  from  its  complicated  shape,  the  fractures  of  this  bone 
present  great  varieties.  They  may  result  from  direct  violence  at  almost  any 
point,  or  from  indirect  violence  at  one  or  even  at  a  number  of  points.  A 
force  from  without  may  tend  to  crush  down  the  whole  arch,  in  which  case  it 

may  give  way  at  its  apex,  at  two  or 
Fig-  ^^4.  more  weak  points,  or,  if  the  force  be 

exerted  somewhat  obliquely,  at  some 
point  on  the  opposite  side  of  the  arch. 
Occasionally  there  is  a  distinct  lever- 
age, and  sometimes  a  j)ressure  on  one 
side  of  the  arch,  with  a  counterpressure 
on  the  other. 

The  annexed  diagram  (Fig.  814)  will 
serve  to  show  the  portions  of  the  bone 
at  which  fractures  are  most  apt  to  oc- 
cur. The  body  is  the  part  oftenest 
involved ;  it  may  be  broken  just  at 
the  symphysis  (although  on  the  autho- 

Fractures  of  the  lower  jaw.  rity  of  BoyCr  this  WaS  loug  tllOUght 

to  be  impossible),  or  at  a  variable 
distance  from  it.  Double  fractures,  the  body  being  broken  through  at  two 
points,  are  by  no  means  rare.  The  angle  may  give  way,  probably  ahvays  to 
leverage  across  it.  Occasionally  the  neck  of  the  condyle  has  been  broken, 
and  very  rarely  the  coronoid  process. 

Fractures  of  the  lower  jaw  are  rarely  met  with  in  children,  by  reason  of 
the  small  size  of  the  bone  at  their  age  ;^  and  they  are  infrequent  also  in  women 
and  old  people,  whose  habits  of  life  exempt  them  in  great  measure  from  the 
kind  and  degree  of  violence  by  which  these  injuries  are  produced.  Blows  of 
all  kinds— with  the  fist,  with  weapons,  by  the  kicks  of  horses,  by  flying 
masses  in  mining  accidents — falls  on  the  face,  and  crushing  forces,  such  as  the 
passage  of  a  wagon-wheel,  are  the  chief  causes  of  fractures  of  the  lower  jaw. 
Hamilton  states  that  he  has  seen  the  bone  broken  on  both  sides  by  the  vio- 
lent grasp  of  a  hand.  Gross^  mentions  the  case  of  a  man  of  70,  who  sustained 
a  fracture  of  the  neck  of  the  bone  during  a  violent  paroxysm  of  coughing ; 
this  case  I  believe  to  be  unique. 

The  amount  of  injury  done  to  the  bone  varies  greatly,  l^o  other  single 
bone  is  so  apt  to  be  broken  in  several  places ;  a  fact  which  is  readily  ex- 
plained by  its  complex  shape,  and  its  double  articulation,  giving  two  points 

I  Bouchut  (op.  cit.  p.  759),  says  that  fractures  of  the  lower  jaw  are  sometimes  caused  by  the 
accoucheur  in  aiding  delivery  ;  but  he  cites  no  cases  in  proof  of  the  statement.  Two  are  quoted, 
however,  byClurlt  (op.  cit.,  Bd.  ii.  S.  409). 

«  Op.  cit.,  vol.  i.  p.  940. 


FRACTURES  OF  THE  BONES  OF  THE  FACE. 


73 


of  resistance.  Malgaigne  quotes  from  Ilouzelot  a  case  in  which,  the  patient 
bavin"-  been  killed  by  a  fall  from  a  height,  it  was  found  that  he  had  sustained 
fractures  of  the  symphysis,  of  the  neck  of  each  condyle,  and  of  both  coronoid 
processes.  Sir  W.  Fergusson^  mentions  an  almost  similar  case,  in  which, 
however,*  only  one  coronoid  process  was  broken.  Ileath^  describes  a  speci- 
men in  tiie  Museum  of  King's  College,  in  which  the  body  of  the  bone  is  frac- 
tured on  either  side,  with  the  necks  of  both  condyles.  The  probability  is  that 
in  all  these  cases  the  force  was  received  on  the  symphysis,  and  that  the  frac- 
tures were  produced  sinmltaneously,  the  bone  yielding  at  all  its  weakest 

^^Another  specimen  mentioned  by  Heath  will  serve  to  illustrate  multiple 
fracture,  due,  it  may  be  supposed,  to  lateral  compression  :— 

"  One  fracture  runs  obhquely  forward  in  front  of  the  first  molar  tootli  into  the  men- 
tal foramen.  A  second  fracture  runs  vertically  between  the  right  incisor  teeth.  A 
third  fracture  runs  very  obliquely  from  the  hist  molar  on  the  right  side  down  to  the 
lower  border  of  the  bone  opposite  the  canine  tooth.  This  is  met  by  a  fourth  fracture 
running  obliquely  backward  in  front  of  the  first  molar  tooth  of  tlie  same  side.  The 
lower  border  of  the  bone  in  the  mental  region  is  broken  off  and  comminuted  into  numer- 
ous fragments,  one  of  which  contains  the  mental  foramen  of  the  right  side.  The  left 
condyle  is  also  broken  off  obliquely." 

Still  another  is  described  by  Heath  as  follows : — 

A  fracture  extends  obliquely  backward  between  the  second  and  third  molar  teeth 
of  the  left  side,  the  external  and  internal  plates  of  the  bone  being  equally  involved.  There 
is  also  an  oblique  (downward  and  backward)  fracture  of  the  neck  of  the  right  condyle." 

Fractures  of  the  body  of  the  jaw-bone  are  almost  always  compound,  by  lace- 
ration or  rupture  of  the  mucous  membrane  and  underlying  tissues,  so  that 
the  air  within  the  mouth  gets  access  to  the 

broken  ends.    Hence  there  is  very  apt  to  Fig.  8i5. 

be  suppuration,  and  the  breath  and  secre- 
tions of  the  mouth  are  generally  offensive 
from  the  decomposition  which  ensues. 

The  annexed  sketch  (Fig.  815)  from  a 
specimen  in  the  Mutter  Museum  of  the 
Philadelphia  College  of  Physicians,  shows 
a  comminuted  fracture,  one  portion  of 
which,  extending  backward,  is  a  mere  fis- 
sure. Malgaigne  quotes  from  Gariel  an 
instance  in  which  he  "  proved  by  an  autopsy 
the  existence  of  a  fissure  on  a  level  with  the  dental  canal,  involving  but  part 
of  the  thickness  of  the  bone ;"  the  patient  had  fallen  from  a  height. 

When  there  is  double  fracture  of  the  body  of  the  jaw,  the  two  lines  of 
separation  may  be  on  the  same  side,  or  on  opposite  sides,  of  the  symphysis. 
In  the  former  case  the  intermediate  fragment  will  not  be  as  greatly  displaced, 
or  as  hard  to  control,  as  in  the  latter. 

Peirson^  has  recorded  an  instance  of  double  fracture  of  the  jaw  by  the  passage  of  a 
wagon-wheel,  in  which  the  middle  fragment  of  bone,  with  the  tongue,  "  was  forced 
down  the  throat,  so  as  nearly  to  occasion  suffocation.  Tlie  accident  occurred  in  the 
night,  but  fortunately  near  a  house  whose  inliabitants  were  awake  ;  and  the  patient 
obtained  the  loan  of  an  iron  spoon,  with  whicii  he  contrived  to  drag  the  tongue  for- 
ward, and  prevent  the  impending  suffocation,  till  I  was  enabled  to  secure  tlie  fragments 


Comminuted  and  fissured  fracture  of  lower  jaw. 


>  System  of  Practical  Surgery,  p.  457.  London,  1870. 
3  Remarks  on  Fractures.    Boston,  1840. 


Op.  cit,,  p.  5. 


74 


INJURIES  OF  BONES. 


by  wiring  the  teeth.  Great  swelling  followed,  preventing  deglutition  for  many  days ; 
but  the  patient,  being  supported  through  an  oesophagus  tube,  eventually  recovered." 

Here  it  was  the  unopposed  action  of  the  muscles  of  the  floor  of  the  mouth' 
that  dragged  back  the  fragment.  Indeed,  the  effect  of  muscular  action  in 
causing  or  keeping  up  displacement  is  generally  as  clearly  demonstrable  in  frac- 
tures of  the  lower  jaw  as  in  those  of  any  other  bone.  In  one  case,  in  1877,  I 
was  obliged  to  divide  the  muscles  behind  the  symphysis,  in  a  fracture  close 
to  that  point,  in  order  to  reduce  the  fragment  drawn  back  by  them. 

Occasionally,  however,  the  degree  of  displacement  is  curiously  slight,  per- 
haps because  the  actions  of  different  muscles  counterbalance  one  another,  as 
is  noticed  in  some  other  parts  of  the  skeleton  also. 

The  signs  of  fracture  of  the  body  of  the  lower  jaw  are  seldom  very  obscure, 
and  sometimes  very  plain.  Usually  there  is  rapid  swelling,  which,  when  the 
bone  is  broken  at  one  side,  produces  a  curious  twist  of  the  face.  Of  course 
the  motion  of  the  part  is  limited,  not  only  by  the  mere  loss  of  continuity  in 
the  bone,  but  by  the  pain  caused  by  it ;  and  there  is  apt  besides  to  be  at  least 
a  temporary  paralysis  of  the  lip,  from  the  injury  to  the  inferior  dental  nerve. 
Hence  speech  is  impaired  and  chewing  often  impossible.  Profuse  salivation 
is  an  almost  constant  symptom,  and  is  made  more  apparent  by  the  loss  of 
control  of  the  mouth.  Sometimes,  especially  if  the  fracture  be  compound, 
the  saliva  is  offensive,  even  to  the  patient  himself.  When  the  finger  is 
inserted  into  the  mouth,  and  the  other  hand  applied  outside,  the  line  of  the 
teeth  is  found  to  be  abruptly  irregular,  and  the  fragments  maybe  moved 
upon  one  another,  with  the  production  of  pain,  and  of  more  or  less  distinct 
crepitus.  It  must  be  borne  in  mind  that  very  few  adults  have  perfectly 
regular  teeth  ;  and  that  even  very  marked  irregularities  do  not  indicate  frac- 
ture, unless  there  is  pain  on  pressure,  and  a  corresponding  deviation  at  some 
point  on  the  opposite  margin  of  the  bone.  Abnormal  mobility,  also,  is  very 
rarely  wanting,  though  it  may  be  so  slight  as  to  require  extreme  care  for  its 
detection. 

The  irregularity  in  the  line  of  the  teeth  may  be  either  transverse,  one  frag- 
ment being  drawn  down  below  the  level  of  the  other,  or  lateral,  the  anterior 
fragment  generally  slipping  up  within  the  posterior.  This  latter  displace- 
ment is  due  partly  to  muscular  action,  but  partly  also  to  the  fact  noted  by 
Malgaigne,  that  the  plane  of  the  fracture  is  apt  to  run  inward  and  backward, 
the  posterior  fragment  being  beveled  at  the  expense  of  its  inner  face ;  and 
this  again,  it  seems  to  me,  may  be  accounted  for  by  the  pointed  arch-shape  of 
the  whole  bone. 

Although  it  would  seem  as  if  the  dental  nerve  could  never  escape  being 
torn  or  stretched  in  fractures  of  the  body  of  the  lower  jaw,  the  occurrence  of 
permanent  trouble  from  this  cause  is  very  rare.  Hamilton^  gives  one  case, 
and  refers  to  another  seen  by  Desirabode. 

Fractures  at  the  angle  of  the  jaw  are  generally  oblique,  in  the  direction 
shown  in  the  annexed  cut  (Fig.  816),  representing  a  specimen  without  history 
in  the  Mutter  Museum.  In  this  case  there  had  been  a  false  joint  formed. 
Another  case  occurred  in  my  ward  at  the  Episcopal  Hospital,  in  1882,  in  the 
person  of  an  elderly  man  who  had  fallen  down,  striking  on  a  stone. 

A  much  rarer  form  of  fracture,  partly  involving  the  angle,  is  shown  in  Fig. 
817 ;  it  represents  a  specimen  also  in  the  Miitter  Museum,  and  of  unknown 
history.  Besides  a  very  old  and  firmly  united  fracture,  almost  exactly  at  the 
symphysis,  there  is  a  recent  oblique  one  beginning  at  the  angle  and  running 
downward  and  forward  to  near  the  middle  of  the  lower  margin  of  the  right 
half  of  the  body  of  the  bone. 


•  Op  cit.,  p.  127. 


FRACTURES  OF  THE  BONES  OF  THE  FACE. 


75 


The  coronoid  process  has  very  rarely  been  seen  fractured ;  never  without 
other  lesions.  Besides  the  cases  before  quoted  from  J  [ouzelot  and  Fergusson, 
Gurlt  gives  one  other,  from  Middeldorpf,  andTatum  has  reported  ^  a  fourth. 

Fig.  81(J.  Fig.  817. 


Fracture  of  lower  jaw  at  augle.  Fracture  of  lower  jaw  at  symphysis  and  augle. 


A  number  of  instances  are  on  record  in  which  the  condyloid  process  has  been 
broken,  either  by  itself  or,  as  in  cases  already  referred  to,  along  with  other 
i)()rti()n's  of  the  bone.  I  have  seen  the  former  condition  caused  by  a  stone,  in 
a  man  injured  by  the  premature  explosion  of  a  blast.  WilP  has  reported  one 
observed  by  him  in  a  patient  hurt  by  a  falling  wall.  Watson^  has  recorded 
a  case  of  fracture  of  the  necks  of  both  condyles,  by  a  fall  from  a  yard-arm,  the 
iaw-bone  being  otherwise  uninjured.  Cockburn*  gives  a  curious  case  in  which 
'bv  a  blow  on  the  left  side  of  the  face,  the  neck  of  the  right  condyle  was  broken. 
Other  instances  are  quoted  by  Malgaigne,  who  points  out  that  the  condyle 
itself  remains  in  relation  with  the  glenoid  cavity;  but  the  pterygoid  muscle 
makes  it  execute  a  movement  of  rotation,  carrying  the  fractured  neck  up- 
ward, forward,  and  imvaid,  so  that  the  fractured  surface  of  the  inferior  frag- 
ment'is  in  relation  only  with  the  posterior  surface  of  the  neck  and  of  the 

condvle."  .  i     •  i 

A  "'case  is  reported  ^  in  udiich,  along  with  fracture  about  an  inch  to  the  right 
of  the  symphysis,  there  was  discovered  after  death,  fifty-four  days  from  the 
time  of  the  accident  (a  fall  from  a  horse),  a  fracture  "situated  in  the  left 
condyle,  and  extendhig  obliquely  downward  and  inward."  If  this  fracture 
involved  the  condyle  itself,  it  was,  as  far  as  my  knowledge  goes,  altogether 

unique.  . 

The  symptoms  of  fracture  of  the  neck  of  the  condyle  may  be  readily  in- 
ferred; they  will  be  more  clearly  made  out  if  the  fracture  is  on  one  side  only. 
Besides  crepitus,  pain,  and  inability  to  move  the  jaw,  there  will  be  a  twisting 
of  the  chin  toward  the  injured  side,  which,  according  to  Malgaigne,  is  apt  to 
be  permanent  in  cases  wdiich  do  not  prove  fatal.  This  t\yist  has  an  obvious 
diagnostic  significance,  as  in  unilateral  luxation  the  chin  is  directed  away 
from  the  injured  side. 

Fractures  of  the  jaw  vary  greatly  in  their  degree  of  gravity.  Even  when 
they  are  compound,  healing  often  takes  place  with  readiness,  and  in  cases 
which  look  very  unpromising  a  good  result  may  be  obtained  by  careful  and 
well-directed  treatment.  Yet  it  must  be  remembered  that  injuries  about  the 
face  are  particularly  liable  to  be  followed  by  erysipelas ;  and  the  interference 
with  nutrition  which  necessarily  attends  the  lesion  in  question,  may  be  a 
source  of  serious  debility,  especially  in  persons  previously  broken  down  by 

>  Lancet,  Dec.  1,  I860  ;  see  also  Trans,  of  Path.  Society  of  London  for  1861,  p.  159. 

*  Lancet'  .Jan.  21,  1882.  ^  New  York  .Journal  of  Medicine,  Oct.  1840. 

■*  British  Medical  .Journal.  December  28,  1867. 

6  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Part  III.,  Surgical  Vol.,  p.  649. 


76 


INJURIES  OF  BONES. 


hard  labor  and  bad  habits.  Hemorrhage  very  rarely  ensues  to  a  troublesome 
degree,  unless  in  very  bad  compound  fractures,  in  which  the  facial  artery  is 
wounded.  Stephen  Smith^  reports  a  case  in  which,  on  the  twentieth  day 
after  fracture  of  the  body  and  ramus,  the  patient  lost  a  pint  of  blood,  prob- 
ably from  the  inferior  dental  artery. 

Necrosis  of  detached  fragments,  with  loss  of  teeth,  is  a  common  consequence 
of  severe  fractures  of  the  lower  jaw.  Abscesses  often  form,  and  may  even 
prove  fatal.  Thus  Mr.  Abraham^  exhibited  to  the  Pathological  Section  of 
the  Academy  of  Medicine  in  Ireland,  a  jaw  fractured  on  the  right  side  at  the 
mental  foramen,  on  the  left  side  from  behind  the  last  molar  tooth  to  the 
angle.  The  patient,  a  man  aged  36,  had  been  knocked  down,  and  kicked 
while  on  the  ground.  "  On  the  fourth  day  after  the  receipt  of  the  injury  he 
got  out  of  bed,  walked  from  his  house  a  short  distance,  and  returning  fell 
dead  at  his  own  door.  The  fracture  at  the  angle  was  found  to  be  compound, 
communicating  with  the  mouth ;  and  an  abscess  traced  from  the  parotid 
region  dow^n  along  the  carotid  artery  into  the  pericardium,  had  formed  in 
connection  with  it." 

Eichet,^  in  1865,  called  attention  to  the  occasional  occurrence  of  putrid 
infection  (septiccemia)  as  the  result  of  fractures  of  the  jaw  with  laceration  of 
the  alveolar  periosteum,  and  Chassaignac  stated  that  he  had  seen  and  pub- 
lished similar  cases. 

Salivary  fistula  is  said  to  have  sometimes  occurred  after  compound  fracture. 

Treatment. — This  may  be  a  very  simple  affair,  or  it  may  require  great 
mechanical  skill  and  ingenuity  on  the  part  of  the  surgeon.  Sometimes  reduc- 
tion is  readily  effected,  and  maintained  with  ease  by  bandaging;  sometimes, 
although  the  fragments  can  be  replaced  without  difficulty,  they  resume  their 
faulty  relation  the  moment  they  are  left  to  themselves.  Sometimes  the 
obstacles  to  reduction  are  very  great. 

One  case  is  recorded  by  Lonsdale,*  in  which  a  woman  had  the  jaw  fractured 
by  a  blow  with  a  poker  ;  "  there  was  great  difficulty  in  getting  the  two  por- 
tions to  lie  in  apposition,  and  the  cause  was  not  discovered  till  two  or  three 
days  after  the  receipt  of  the  injury,  when,  on  passing  a  probe  down,  a  tooth 
was  felt  jammed  between  the  fractured  surfaces;  as  soon  as  it  was  withdrawn, 
the  ends  of  the  bone  came  easily  into  contact."  Sometimes  splinters  become 
wedged  cross-wise  between  the  fragments.  I  have  already  mentioned  having 
had  to  divide  the  muscles  just  behind  the  symphysis  in  one  case,  in  order  to 
effect  reduction  ;  and  my  belief  is  that  in  very  many  cases^  even  with  the  best 
apparatus  that  can  be  devised,  muscular  contraction  is  not  wholly  overcome, 
but  a  certain  degree — too  slight  it  may  be  to  produce  obvious  deformity — 
remains. 

The  great  object  to  be  aimed  at  is,  so  to  restore  the  form  of  the  bone  that 
the  teeth  shall  come  into  proper  apposition  with  those  of  the  upper  jaw,  and 
thus  to  insure  to  the  patient  the  ability  to  masticate  food.  It  is  by  no  means 
always  easy  to  judge  of  the  degree  of  accuracy  of  the  reduction,  during  the 
progress  of  the  treatment ;  and  the  surgeon  will  do  well  as  early  as  possible — 
say  about  the  third  week — to  cautiously  test  the  question  by  removing  all 
apparatus,  and,  carefully  supporting  the  broken  bone  below,  bringing  it  up  so 
that  the  line  of  the  teeth,  upper  and  lower,  can  be  compared  by  means  of  the 
finger  inserted  into  the  mouth.  Should  there  be  any  defect  in  the  apposition, 
it  may  be  much  more  readily  corrected  at  this  stage  than  at  any  later  period. 

1  New  York  Journal  of  Medicine  and  Surgery,  January,  1857. 

2  British  Medical  Journal,  December  23,  1882. 

3  (laz.  des  Mopitaux,  1865  ;  Am.  Journal  of  the  Med.  Sciences,  July,  1866. 
'*  Practical  I'reatise  on  Fractures,  p.  229. 


FRACTURES  OF  THE  BONES  OF  THE  FACE. 


77 


In  effecting  reduction,  the  surgeon  should  pass  one  or  two  fingers  of  one 
hand  into  tlfe  patient's  mouth,  applying  them  to  the  teeth,  while  with  the 
thumh  and  lingers  of  the  other  hand  he  endeavors  to  bring  the  bone  itself,  at 
its  lower  border,  into  proper  shai)e.  As  a  general  rule,  the  greater  the  vio- 
lence which  has  caused  the  injury,  the  inova  will  the  bone  be  likely  to  be 
shattered,  and  the  soft  parts  to  be  torn. 

Fractures  at  or  close  to  the  sym[)hysis  are  more  easily  kept  reduced  than 
those  of  the  middle  of  the  body  at  either  side.  And  fractures  at  the  angle 
are  but  little  liable  to  displacement,  partly  because  they  are  at  the  widest 
part  of  the  pointed  arch  before  spoken  of,  partly  because  the  disposition  of 
the  muscles  is  such  that  neither  fragment  is  pulled  upon  more  than  the  other; 
they  are  as  it  were  balanced. 

The  bandage  most  frequently  employed  in  Philadelphia,  in  the  retention  of 
fractures  of  tlie  lower  jaw,  is  that  known  as  Barton's.^  Hamilton  describes 
an  apparatus  made  with  straps  and  buckles,  on  a  very  similar  plan,  which  he 
has  used  with  satisfaction.  Before  applying  either,  it  is  better,  if  the  patient 
be  a  male  adult,  to  have  the  face  shaved^  or,  at  least,  to  have  the  beard  clipped 
very  short ;  the  hair,  if  long,  should  also  be  cut. 

If  the  fracture  is  at  either  side,  it  will  readily  be  seen  that  the  pressure  of 
the  bandage  may  be  so  exerted  as  simply  to  flatten  out  the  broken  bone,  as 
it  were ;  a"n  action  which,  carried  to  excess,  would  produce  between  the  frag- 
ments an  angle  salient  toward  the  mouth.  Hence  it  is  much  better  to  use  a 
8j)ruit  made  of  binder's  board,  felt,  or  gutta-percha,  moulded  to  tit  the  chin, 
and  smoothly  lined  with  a  thin  sheet  of  raw  cotton,  or  with  Caution  flannel. 

Greater  security  may  be  given  to  this  apparatus,  if,  before  applying  the  ban- 
dage, the  outer  splint  be  fastened  in  place  by  a  strip  of  plaster  about  an  inch  and 
a  ludf  in  width,  passing  well  up  on  each  cheek.  What  is  known  as  "  rubber 
adhesive  plaster"  is  the  best,  but  any  well-made  adhesive  plaster,  not  too 
fresh,  will  answer.  If  the  strip  be  made  twice  as  wide,  and  doubled  on  itself 
so  as  to  have  an  adhesive  surface  toward  the  splint  and  another  toward  the 
bandage,  tlie  latter  will  be  still  further  prevented  from  slipping.  Such  a 
precaution  is  by  no  means  needless  in  the  cases  of  some  very  unruly  or 
delirious  patients. 

When  the  surgeon  has  any  doubt  as  to  the  accurate  retention  of  the  frag- 
ments, a  very  siniple  and  easy  expedient  may  be  adopted  to  insure  it,  at  least 
until  a  permanent  apparatus  can  be  made.  A  large  vial-cork  may  be  cut 
down  so  as  to  square  it  on  two  opposite  sides,  leaving  it  of  sufiicient  thickness 
for  spaces  to  be  cut  out  on  these  square  sides,  on  one  side  for  the  upper  and  on 
tlie  other  side  for  the  lower  teeth.  This  shaping  can  be  easily  done  with  a  sharp 
knife,  by  any  one  with  ordinary  dexterity  in" such  matters.  When  finished, 
this  interdental  splint  can  be  fitted  to  the  upper  teeth,  the  lower  jaw  brought 
up  to  it,  and  the  fragments  properly  placed  in  their  groove,  after  which  the 
outside  splint  and  bandage  may  be  put  on. 

Another  very  ancient  device  is  that  of  surrounding  the  adjacent  teeth  on 
the  two  fragments  with  a  wire,  which  thus  includes  them  in  a  loop,  secured 
by  twisting  the  ends  of  the  wire.  Such  a  loop  need  not  be  retained  very 
long,  and,  indeed,  ought  not  to  be,  lest  it  should  injure  the  gums ;  a  week  or 
ten  days  will  generally  be  a  sufficient  time,  as  the  process  of  union  will  then 
have  begun,  and  the  fragments  will  be  apt  to  keep  their  place. 

In  cities,  or  where vei" the  services  of  a  competent  dentist  can  be  had,  the 
best  plan  is  to  have  a  mould  taken  of  the  patient's  jaws,  the  fragments  being 
held  in  place  by  the  surgeon.  From  this  an  accurate  cast  may  be  made,  and 
upon  this  again  a  vulca^iite  plate,  to  fit  above  and  below.    When  skilfully 


^  See  Vol.  I.  p.  500,  Fig.  64. 


78 


INJURIES  OF  BONES. 


done,  this  gives  the  surgeon  as  absolute  control  of  the  fragments  as  it  is  pos- 
sible to  obtain.  By  some,  splints  of  this  kind  have  been  attached  to  steel 
arms  or  branches  coming  out  at  the  corners  of  the  mouth,  and  connected 
with  an  outside  framework,  a  padded  plate  fitting  underneath  the  chin ; 
when  such  an  apparatus  is  employed,  there  is  no  need  of  the  upper  teeth  being 
taken  into  the  account  at  all,  as  the  fragments  are  securely  held  between  the 
mould  above  and  the  padded  plate  below.  The  arms  connecting  the  two  are 
arranged  with  screws  and  nuts,  so  that  they  can  be  tightened  to  the  requisite 
degree. 

Rutenick,  Lonsdale,  Gunning,  Bean,  Kingsley,  and  many  others,  have  exer- 
cised much  ingenuity  in  devising  modifications  of  apparatus  based  upon  this 
idea.  The  appliances  known  by  their  names  may  be  found  described  in 
detail  in  so  many  systematic  works,  that  it  seems  hardly  worth  while  to 
devote  more  space  to  them  here. 

During  the  confinement  of  the  jaw  by  any  of  the  means  now  mentioned,  it 
is  obvious  that  the  patient  is  debarred  from  the  use  of  ordinary  food  ;  and  by 
some  of  the  older  writers  it  was  advised  that  a  front  tooth  should  be  drawn 
in  order  to  allow  of  the  introduction  of  milk,  soups,  etc.  This,  however,  is 
unnecessary ;  scarcely  any  one  has  the  teeth  so  closely  set  together  as  to  pre- 
vent liquids  from  finding  their  way  to  the  back  of  the  mouth.  If  from  swel- 
Ihig  or  other  cause  deglutition  be  very  much  hindered,  nourishment  may  be 
administered  either  by  means  of  a  tube  passed  along  the  floor  of  the  nose, 
and  so  down  into  the  stomach,  or  by  enema.  The  difiiculty  of  swallowing 
rarely  persists  more  than  a  few  days. 

Suturing  of  the  fragments  has  been  practised  with  advantage  in  a  few 
instances  of  very  oblique  fracture,  where  retention  by  ordinary  means  was 
found  impossible.  Kinloch's  case,i  the  first  of  which  I  have  any  knowledge, 
was  one  of  compound  fracture,  and  the  result  was  excellent.  Thomas^  has 
reported  two  cases  attended  with  like  success. 

Fastening  the  fragments  together,  by  means  of  silver  pins,  as  recommended 
by  Wheelhouse,3  appears  to  ofter  no  advantage  over  the  ligature,  while  it 
multiplies  the  chance  of  irritation  of  the  soft  parts. 

Fractures  of  the  lower  jaw  are  sometimes,  but  very  rarely,  complicated 
with  luxation  of  one  condyle.  Probably  the  dislocation  occurs  first,  as  other- 
wise there  would  scarcely  be  purchase  enough  to  force  the  condyle  out  of  its 
socket.  Details  of  the  reported  cases  are  given  by  Heath.^  In  one  case 
only  were  both  condyles  displaced,  and  the  necks  fractured ;  and  in  one,  in 
which  only  one  condyle  was  luxated,  it  was  also  broken  oft'  at  the  neck.^ 
Replacement  of  the  condyle  would,  under  such  circumstances,  be  obviously 
impossible ;  but  when  the  fracture  is  far  enough  from  the  condyle  to  give 
sufticient  purchase,  the  luxation  may  be  reduced  in  the  ordinary  manner,  and 
the  treatment  of  the  fracture  then  proceeded  with. 

Non-union. — While,  as  a  general  rule,  fractures  of  the  lower  jaw  unite 
readily,  there  are  not  a  few  cases  on  record  in  which  they  have  failed  to  do 
so.  Malgaigne  quotes  from  Berard  a  curious  case  of  "  a  child  whose  fracture 
made  no  progress  toward  recovery  until  the  apparatus,  an  ordinary  bandage, 
was  removed."  On  a  previous  page  a  specimen  of  false  joint  formed  at  the 
angle  was  depicted  ;  and  Physick's  case,  in  which  union  was  brought  about 
by  the  employment  of  a  seton,is  among  the  most  widely-known  instances  ot 
success  by  that  mode  of  treatment. 

But  little  need  be  said  as  to  the  course  to  be.  adopted  when  union  takes 

1  American  Journal  of  the  Medical  Sciences,  July,  1859.  2  Lancet,  Aujjnst  17,  1867. 

a  Ibid.       *  'Op.  cit.,  p.  22. 

6  Botli  these  cases  are  quoted  from  Bonn  by  Coote,  in  Holmes's  System  of  Surgery,  2d  ed. 
vol.  ii.  p.  429;  Am.  ed.  vol.  i.  p.  G80. 


FRACTURES  OF  THE  LARYNGEAL  APPARATUS. 


79 


place  slowly,  or  when  a  false  joint  has  formed,  in  fractures  of  the  lower  jaw, 
since  the  general  principles  already  laid  down  are  of  particularly  easy  appli- 
cation here. 

In  cases  of  slow  consolidation,  the  surgeon  should  first  have  made  a  very 
accurately  fitting  interdental  splint,  and,  after  thoroughly  rubbing  the  frag- 
ments together,  he  should  apply  it,  so  as  to  keep  them  at  absolute  i^est  in 
good  relative  position.  Failing  in  this,  he  should  proceed  at  once  to  drill  the 
frao:ments,  and  wire  them  together,  confining  the  jaw  subsequently  with  a 
moulded  outside  splint  and  a  carefully  applied  bandage. 

When  a  false-joint  has  formed,  the  fragments  may  be  at  once  scraped, 
drilled,  and  wired. 

It  will,  perhaps,  seem  as  if  so  prompt  a  resort  to  the  most  heroic  mea- 
sures, without  a  previous  trial  of  milder  means,  were  at  variance  with  the 
accepted  rules  of  surgery.  But  it  must  be  remembered  that  this  bone,  though 
easily  accessible,  is  very  difiicult  of  control ;  and  that  the  interference  with 
nutrition  during  the  period  required  for  such  attempts,  would  be  of  itself  a 
serious  evil. 

Union  with  Deformity. — When  a  fracture  of  the  jaw  has  united  with  the 
fragments  in  bad  relative  position,  it  is  very  seldom  that  any  means  of  cor- 
rection are  available ;  only,  in  fact,  when  the  bone  has  been  broken  some- 
where near  the  symphysis,  as  elsewhere  interference  would  either  endanger 
the  vessel  or  nerve,  or  both,  or  would  be  useless  by  reason  of  the  want  of 
purchase  for  mechanical  treatment.  Yet  it  may  be  that  in  some  few  cases, 
even  as  far  back  as  the  angle,  subcutaneous  osteotomy  might  aftbrd  a  chance 
of  dividing  the  uniting  medium,  as  it  would  indeed  be  the  best  means  of 
doing  it  at  any  point.  Afterward,  drilling,  wiring,  and  a  well  made  inter- 
dental splint,  with  a  bandage  externally,  should  be  employed. 

Fractures  of  the  Laryngeal  Apparatus. 

Fractures  of  the  IIyoid  Bone. — From  its  position  and  connections,  this 
bone  is  greatly  protected,  yet  a  number  of  instances  are  upon  record  in  which 
it  has  been  broken,  either  alone  or  along  with  severe  injuries  of  neighboring 
parts.  It  is  of  the  former  class  of  cases  only  that  I  have  now^  to  speak,  since 
this  lesion  is  in  the  others  a  comparatively  unimportant  complication. 

Strange  as  it  may  seem,  the  hyoid  bone  is  seldom  fractured  in  cases  of 
hanging,  whether  suicidal  or  judicial.  Casper  says^  that  he  has  never  seen 
it  in  any  of  the  numerous  bodies  ofi&cially  examined  by  him.  Mackmurdo, 
for  many  years  surgeon  to  the  IS^ewgate  Prison,  in  London,  is  quoted  by  Gibb^ 
as  stating  that  he  had  only  once  seen  the  body  of  the  bone  broken  in  a  hanged 
man,  and  that  in  three  or  four  only  had  he  seen  one  or  other  cornu  (never 
both)  fractured.  In  suicides,  the  body  of  the  bone  w^as  seen  broken  by  Orfila, 
and  a  cornu  by  Diefienbach  and  Cazauvieilh  (two  cases). 

In  the  body  of  Wirz,  hanged  at  W^ashington,  D.  C,  in  1865,  "  the  hyoid 
bone  had  received  six  injuries  ;  separation  of  the  greater  and  lesser  processes 
on  both  sides  from  the  body  of  the  bone,  and  true  fracture  of  the  outer  third 
of  the  greater  process  on  either  side."^ 

This'bone  has  been  several  times  observed  to  be  broken  by  throttling 
(Auberge,  Diefl:enbach,  Murchison,  Lalesque,  Devergie,  Helwig),  and  by  falls 
in  which  the  front  of  the  neck  is  struck  against  some  resisting  body  (Harley, 

•  Forensic  Medicine,  voL  ii.  p.  174. 

B  On  Diseiises  of  the  Throat  and  Windpipe,  etc.    London,  1864. 

3  Med.  and  Surg,  Hist,  of  the  War  of  the  Rebellion,  Part  I.,  Surg.  Vol.,  p.  400. 


80 


INJURIES  OF  BONES. 


Griinder,  T.  Wood),  and  in  three  cases  the  lesion  was  ascribed  to  muscular 
contraction  (Ollivier  d' Angers,  Obre,^  La  Roe^). 

Ollivier's  case  was  that  of  a  woman,  aged  56,  who  made  a  false  step  and 
fell,  her  head  being  thrown  forcibly  backward.    "At  the  same  moment  she 
heard  a  very  distinct  crack  at  the  upper  part  of  the  left  side  of  the  neck ; 
there  was  a  fracture  of  the  greater  cornu  of  the  hyoid."    La  Roe's  patient . 
sustained  the  injury  in  yawning. 

From  the  few  recorded  cases,  the  symptoms  of  this  fracture  would  seem 
to  be:  sharp,  sticking  pain;  sometimes  spitting  of  blood ;  swelling,  and 
embarrassment  in  speaking  or  swallowing  ;  and,  when  the  fragments  remain 
in  contact,  crepitation.  Upon  examination  with  one  linger  in  the  mouth  and 
one  outside,  the  fragments  can  be  felt,  and  perhaps  pushed  into  place. 

In  Grlinder's  case,  the  only  uncomplicated  one  which  proved  fatal,  the 
broken  cornu  was  found  "jammed  between  the  epiglottis  and  the  rima  glot- 
tidis."  In  all  the  other  instances,  there  was  union  b}^  means  of  callus  ;  and 
this  had  taken  place  in  two  specimens,  one  without  history,^  and  the  other 
taken  from  a  woman  who  several  years  before  her  death  had  received  a  blow 
on  the  neck  by  a  heavy  boot  falling  on  her  as  she  lay  asleep.* 

As  to  the  treatment^  the  first  point  must  of  course  be  to  remedy  any  dis- 
placement of  the  fragments,  by  manipulation  ;  next  to  allay  inflammation, 
by  suitable  local  applications  ;  to  enjoin  upon  the  patient  perfect  quiet,  and 
to  provide  for  his  due  nourishment,  should  swallowing  be  difficult  or  impossi- 
ble, by  means  of  nutrient  enemata.  A  stomach-tube  has  been  used  in  some 
cases,  but  at  some  risk  of  disturbing  the  fracture. 

Fractures  of  the  Laryngeal  Cartilages. — The  laryngeal  cartilages  are 
from  their  situation  exposed  to  the  same  causes  of  fracture  as  the  hyoid 
bone — compression  by  hanging  or  throttling,  falls,  and  blows — but  they  are 
less  under  the  shelter  of  the  lower  jaw,  and  hence  more  frequently  suffer. 

Casper^  says  that  he  has  never  yet  seen  fractures  of  the  larynx  in  cases  of 
hanging ;  but  instances  are  recorded  by  Weiss  and  Cazauvieilh,  and  in  the 
Warren  Anatomical  Museum,  in  Boston,  there  is  a  specimen  of  fracture  of  the 
right  upper  cornu  of  the  thyroid  cartilage  from  a  Sandwich  Islander,  who 
took  his  own  life  in  this  way.  A  case  in  which  the  cricoid  was  broken  by 
hangins:  is  also  recorded  by  Porter.®  (In  the  official  report^  of  the  autopsy  on 
the  assassin  Guiteau,  it  is  stated  that  the  thyro-hyoid  membrane  was  ruptured, 
and  that  the  hyoid  bone  and  thyroid  cartilage  were  widely  separated.)  Mor- 
gagni^  says:  "That  the  larynx  is  sometimes  broken  from  that  cause  [hanging], 
I  have  seen,  together  with  Valsalva."  ..."  A  hanged  man  had  the  sterno- 
thyroidei  and  hyo-thyroidei  muscles  torn,  so  that  only  a  membranous  sub- 
stance remained  in  their  place  about  the  annular  cartilage.  And  this  very 
cartilage  was  also  broken  asunder."  .  .  .  "  The  celebrated  Professor  Weissius 
found,  in  a  soldier  who  had  been  hanged,  the  annular  cartilage  broken  asunder 
into  many  pieces,  and  the  inferior  part  of  the  trachea  entirely  torn  away  from 
the  larynx." 

Malgaigne  quotes  cases  of  fracture  of  the  thyroid  cartilage,  by  the  grasp  of 
a  hand,  from  Ladoz  and  Marjolin.  Fractures  of  the  cricoid  cartilage  alone, 
produced  in  the  samcvway,  have  been  reported  by  Fredet^  and  Pemberton.^" 

•  (xibb,  op.  cit.  2  Medical  Record,  April  15,  1882. 

3  (libb,  Trans,  of  the  Pathol.  Society  of  London,  1862. 

4  Clurlt,  op.  cit.,  Bd.  i.  S.  327.  ^  Op.  cit. 

6  Archives  of  Laryngology,  June  30,  1880.  ^  Medical  News,  July  8,  1882. 

^  De  Sedibus  et  Causis  Morborum,  Lib.  ii.  Epist.  xix. 
9  Brit,  and  For.  Med.-Chir.  Review,  Jan.  1869. 

^0  Lancet,  May  22,  1869.  Mr.  Pemberton  refers  also  to  papers  on  Manual  Strangulation,  by 
Wilson  and  Keiller,  in  tlie  Edinburgli  Med.  Journal  for  1855  and  1856. 


FRACTURES  OF  THE  LARYNGEAL  APPARATUS. 


81 


Wales^  reports  a  case  of  fracture  of  the  thyroid  cartilage  and  lower  jaw  by 
a  fragment  of  a  shell ;  Hamilton  gives  one  case^  of  fracture  of  the  thyroid  and 
cricoid  by  a  kick  from  a  man,  and  another^  by  the  kick  of  a  horse.  I  have 
myself  met  with  a  case''  of  supposed  fracture  of  the  larynx  (probably  of  the 
thyroid  cartilage  only)  by  the  kick  of  a  man. 

Hunt  records^  an  instance  in  which  both  the  thyroid  and  cricoid  were 
broken  by  a  blow  from  a  piece  of  wood  thrown  off  from  a  circular  saw.  Per- 
haps the  most  remarkable  case,  however,  is  that  reported  by  Sawj'ei-,^  in 
which  there  was  double  fracture  of  the  lower  jaw,  with  fracture  of  the  hyoid 
bone,  thyroid  cartilage,  right  radius,  and  left  patella ;  tracheotomy  was  per- 
formed on  the  fifth  day,  having  become  urgently  necessary;  the  patient  ulti- 
mately made  a  good  recovery. 

Instances  have  been  reported  by  Maclean^  and  Roe,^  in  which  the  thyroid 
cartilage  alone  was  broken  by  falls  against  resisting  objects — a  stump  and  the 
edge  of  a  table.  Sometimes  the  hyoid  bone  also  suffers,  as  in  a  case  recorded 
by  Koch,^  and  in  Sawyer's  case  above  referred  to ;  and  sometimes,  again,  the 
cricoid  is  involved,  as  in  the  instance  quoted  by  Malgaigne  from  Plenck. 

Fractures  of  the  cricoid  alone  by  hanging  and  throttling  have  already  been 
spoken  of;  Stokes  records^^  an  instance  in  which  this  lesion  was  the  result  of 
a  kick. 

The  mechanism  of  production  of  these  lesions  is  sufficiently  apparent."  It 
does  not  seem  that  the  rigidity  of  the  cartilages  has  anything  to  do  with 
their  liability  to  fracture :  Gibb^^  mentions  a  number  of  cases  occurring  in 
young  children. 

As  to  the  symptoms^  there  is  always  more  or  less  swelling  of  the  parts, 
often  increased  by  the  occurrence  of  emphysema ;  in  the  case  observed  by 
me,  there  was  a  curious  limitation  of  the  emphysematous  condition  to  the 
cervical  region  both  anteriorly  and  posteriorly.  Pain,  increased  by  efforts  at 
coughing  or  swallowing,  is  generally  present,  and  is  sometimes  marked ; 
there  is  always  tenderness,  and  often  the  handling  of  the  parts  elicits  crepitus. 
The  voice  is  husky,  perhaps  almost  extinct ;  breathing  is  difficult,  and  the 
face  generally  more  or  less  livid,  with  an  anxious  expression.  A  very  con- 
stant symptom  is  the  expectoration  of  bloody,  frothy  mucus,  with  or  without 
cough.  From  the  presence  of  all  or  most  of  these  phenomena,  and  the  his- 
tory of  the  case,  a  diagnosis  may  be  arrived  at  without  much  difficulty. 

The  prognosis  is  a  matter  open  to  more  doubt.  In  Plenck's  case  death  was 
instantaneous,  as  it  was  also  in  a  case  of  throttling  reported  by  Damonetta  ;^^ 
but  more  frequently  the  patient  dies  gradually  by  suffocation,  from  hemor- 
rhage beneath  the  mucous  membrane,  inflammatory  swelling,  or  oedema. 
Roe,  in  the  article  before  quoted,  speaks  of  fracture  of  the  cricoid  as  "  almost 
invariably"  fatal ;  and  from  the  records  it  would  seem  as  if  he  might  have 

*  Am.  Journal  of  the  Med.  Sciences,  Jan.  1867. 
8  Medical  Record,  Jan.  1,  1867. 

8  Fractures  and  Dislocations,  6th  ed.  p;  153. 

*  Reported  in  Archives  of  Laryngology,  March,  1880. 

6  Am.  Journal  of  the  Medical  Sciences,  April,  1866.  The  reader  may  consult  with  advantage 
the  table  of  29  cases  given  at  the  close  of  Dr.  Hunt's  article. 

6  Ibid.,  Jan.  1856.  7  Canada  Med.  Journal,  Sept.  1865. 

^  Trans,  of  Am.  Laryngological  Association,  1880,  p.  99. 

^  Quoted  by  Roe,  loc.  cit. 
Dublin  Quarterly  Journal  of  Medical  Science,  May,  1869. 

"  In  the  Index  Medicus  for  1882  (p.  380),  there  is  given  a  reference  to  a  paper  by  R.  Haume- 
der,  "  Uber  den  Entstehungs-mechanismus  der  Verletzuugen  des  Kehlkopfes  und  des  Zungenbeins 
beim  Erhangen,"  in  the  Wiener  med.  Blatt,  1882,  S.  810.  This  pjobably  embodies  the  latest 
views  on  the  subject. 

'2  Diseases  of  the  Throat  and  Windpipe,  etc.,  p.  436. 

^  Ann.  des  Mai.  de  I'Oreille  et  du  Larynx,  Mai,  1879. 
VOL.  IV. — 6 


82 


INJURIES  OF  BONES. 


omitted  tlie  qualification.  One  case  only  has  been  reported^  in  whicJi  reco- 
very is  claimed  to  have  occurred  after  lesion  of  this  part  of  the  larynx ;  I 
have  seen  a  French  translation^  of  the  account,  which  is  too  vague,  and 
apparently  too  inaccurate,  to  weigh  against  the  mass  of  testimony  on  the 
other  side.  (Possibly  this  gloomy  condition  of  affairs  might  be  changed  by 
the  very  early  performance  of  tracheotomy).  Unfavorable  indications  are, 
in  any  case :  great  interference  with  breathing,  severe  cough,  marked  cya- 
nosis, and  free  spitting  of  blood.  When  recovery  takes  place,  the  voice  is 
apt  to  be  permanently  altered. 

As  to  treatment,  anodyne  fomentations  and  poultices,  the  latter  made  of 
light  materials,  may  be  nsed  locally,  to  allay  irritation.  No  compresses,  or 
other  confining  apparatus,  should  be  employed,  as  they  would  only  still 
further  embarrass  respiration.  Opiates  may  be  given  by  the  mouth  if  swal- 
lowing is  not  verv  difficult.  Absolute  silence  and  rest  in  bed  should  be 
enjoined,  and  a  warm  and  moist  atmosphere  should  be  provided  by  the  usual 
means.    For  a  few  days,  at  least,  the  patient  should  be  ted  by  enemata. 

I  think  that  the  invariable  rule  should  be  to  contemplate  from  the  very  first 
the  probability  that  tracheotomy  may  become  necessary,  and  to  arrange  for  its 
immediate  performance  should  the  breathing  become  increasingly  difiicult. 

case  of  this  kind  can  be  safely  left  unwatched ;  and  unless,  as  in  a  w^ell- 
ordered  hospital,  aid  can  be  instantly  rendered  in  case  of  need,  it  would  be 
the  best  practice  to  open  the  trachea  at  once,  in  anticipation  of  trouble. 

Fractures  of  the  Ribs,  Costal  Cartilages,  and  Sternum. 

For  a  reason  already  stated,  fractures  of  the  vertebrae  are  given  considera- 
tion elsewhere ;  and  the  subject  now  to  be  taken  up  embraces  the  fractures  of 
the  lateral  and  anterior  portions  of  the  Avail  of  the  thorax.  In  order  to  a  full 
understanding  of  these  injuries,  the  anatomy  should  be  carefully  studied,  not 
only  of  the  separate  bones,  but  of  the  framework  as  a  whole,  and  as  covered 
in  great  part  by  muscular  and  other  structures. 

It  will  be  seen  that  the  seven  upper  ribs  are  attached,  not  rigidly,  but 
nearly  so,  both  posteriorly  and  anteriorly ;  the  next  three  have  in  front  a 
greater  degree  of  motion,  by  reason  of  the  length  of  the  cartilaginous  branches 
which  run  up  to  give  them  an  indirect  connection  with  the  sternum  ;  while 
the  eleventh  and  twelfth  are  merely  tipped  with  cartilage.  Each  rib  has  an 
angle,  a  curve,  and  a  twist ;  and  the  mobility  of  the  walls  of  the  chest  is  the 
aggregate  of  that  of  all  the  constituent  ribs.  The  sternum  has  a  mobility 
dependent  chiefly  on  the  elasticity  of  the  ribs  and  their  cartilages. 

Fractures  of  the  Ribs. — The  ribs  may  be  broken  by  direct  or  indirect 
violence,  or  by  muscular  action.  They  are,  in  children,  extremely  elastic, 
and  are  not  often  fractured  in  them  except  by  very  great  crushing  force. 
Holmes 3  quotes  the  opinion  of  Coulon,  that  incomplete  fractures  of  the  ribs 
are  very  common  in  childhood.  One  case  is  mentioned  by  the  latter  author, 
in  which  a  child,  who  died  of  rupture  of  the  lung,  was  found  to  have  sus- 
tained partial  fracture  of  two  or  three  ribs  on  each  side.  It  is  highly  probable 
that  in  many  cases  in  adults,  supposed  to  be  mere  contusions,  one  or  more 
ribs  may  have  given  w^ay  in  a  part  only  of  their  thickness.    Mention  has 

1  In  tlie  Index  Medicus  for  Aug.  1882,  the  reference  is  given  as  foHows  :  "  Masucci  (P.)  Su  di 
'Un  caso  di  frattura  della  cricoide,  seguito  da  guarigione.  Arch.  Ital.  di  LaringoL,  Napoli, 
1881-2." 

2  In  the  Revue  Mcnsuelle  de  Laryngologie,  etc.,  1  Nov.  1882. 
*  Surgery,  its  Principles  and  Practice,  p.  219,  note. 


FRACTURES  OF  THE  RIBS,  COSTAL  CARTILAGES,  AND  STERNUM. 


83 


already  been  made  of  two  cases  of  "  willow  fracture"  of  tlie  ribs  from  gun- 
shot, noticed  during  the  late  war. 

Direct  violence,  ma}^  affect  only  a  limited  area,  and  one  rib  only  may  be 
broken ;  or  it  may  crush  a  large  portion  of  the  chest-wall.  Indirect  violence 
generally  acts  in  the  latter  way.  Blows  with  the  tist  or  with  weapons,  falls 
against  resisting  objects,  etc.,  are  the  chief  direct  causes  of  fracture  in  this 
region.  Of  indirect  causes,  one  of  the  most  frequent  is  the  passage  of  a 
wheel  over  the  chest;  the  caving  in  of  earth,  crushing  under  heavy  falling 
bodies,  and  the  pressure  of  crowds,  have  also  been  noted.  Double  fractures 
are  not  unfrequent. 

An  important  difference  obtains  between  the  effects  of  these  two  forms  of 
violence.  Direct  force  is  apt  to  drive  the  broken  ends  inward,  so  that  the 
inner  wall  of  the  bone  or  bones  gives  way  iirst,  and  is  more  extensively^ 
splintered;  and,  hence,  injury  to  the  pleura  or  lung  is  more  apt  to. ensue, 
either  as  a  primary  or  secondary  effect.  By  indirect  violence,  on  the  other 
hand,  the  arch  of  the  thoracic  wall  is  bowed  outward,  and  the  fragments  are 
caused  to  project. 

For  an  obvious  reason,  when  the  ribs  are  broken  by  direct  force,  the  line 
of  separation  is  apt  to  be  less  oblique  than  when  the  fracture  is  due  to  indirect 
violence. 

Fractures  of  the  ribs  by  forces  acting  from  without,  are  much  more  com- 
mon in  men  than  in  women,  the  habits  and  occupations  of  the  former 
involving  more  exposure  to  such  causes  of  injury. 

Muscular  action  has  been  observed  as  a  cause  of  fracture  of  the  ribs  in  a 
large  number  of  instances.  It  is  not  easy  to  understand  the  mechanism  of 
such  lesions,  unless  we  suppose  that  they  are  the  result  of  a  sudden  pull  by  the 
extra-thoracic  muscles,  as  by  the  serratus  magnus  (its  lower  part),  the  shoulders 
being  lixed.  Coughing  has  been  the  action  to  which  these  accidents  have 
been  most  frequently  due ;  the  portion  of  the  chest  involved  has  been  near  or 
below  the  middle,  and,  whether  from  coincidence  or  not,  almost  always  the 
left  side.  Thus  Despres^  has  recorded  the  case  of  a  woman,  aged  53,  who  broke 
"the  eleventh  left  rib,  four  fingers'  breadths  from  its  junction  with  the  car- 
tilage," in  a  fit  of  coughing.  Doit^  reported  a  fracture  of  the  sixth  left  rib 
in  its  anterior  third,  produced  in  the  same  way,  the  patient  being  a  man, 
aged  59.  Malgaigne  mentions  a  case  observed  at  the  Hopital  Xecker,  in 
which  "  there  took  place  in  less  than  one  month  three  successive  fractures, 
aftecting  first  the  tenth,  then  the  ninth,  and,  lastly,  the  eleventh  rib." 

One  case  is  related  by  Castella,^  in  which  a  fracture  of  the  ninth  rib  on  the 
left  side,  was  caused  by  sneezing.  Gurlt  quotes  from  Groninger  a  case  in 
which  the  seventh  and  eighth  ribs  gave  way  in  a  robust  man  of  45,  as  he 
made  a  great  effort  to  save  himself  from  falling.  J^ancrede''  records  the  case 
of  a  robust  Englishman,  aged  44,  who  sustained  a  fracture  of  the  second  rib 
on  the  right  side,  in  an  effort  to  straighten  a  scythe-blade. 

Fractures  of  the  ribs  are  rarely  eitlier  compound  or  comminuted ;  they  are 
very  generally  complicated  with  pleurisy,  although  this  may  be  of  very 
limited  extent. 

The  chief  symptoms  of  fracture  of  a  rib  are  pain  and  difiiculty  of  breathing, 
which  are  combined  so  as  to  constitute  what  is  known  as  "  a  stitch  in  the 
side."  The  respiration  is  apt  to  be  largely^  abdominal ;  as  a  rule,  the  patient 
can  lie  indifferentl}-  on  either  side.  Cough,  slight  and  suppressed,  but  con- 
stant, and  troublesome  from  the  pain  caused  by  it,  is  very  generally  present; 

'  Gazette  des  Hopitaux,  28  Fev.  1882. 

2  Med.  Times  and  Gazette,  May  6,  1882,  from  L'Union  Medicale,  29  Avril. 
8  Ibid.,  Jan.  25,  1862,  from  Gaz.  des  Hopitaux,  1861. 
4  Philadelphia  Med.  Times,  May  23,  1874. 


84 


INJURIES  OF  BONES. 


it  has  been  suggested  that  it  may  be  reflex,  from  the  irritation  of  the  inter- 
costal nerves,  which  can  scarcely  fail  to  exist.  Crepitus  may  often  be  elicited 
by  merely  placing  the  hand  flat  on  the  seat  of  injury,  or  by  making  alternate 
pressure  on  either  side  of  it ;  or  by  placing  the  ear  over  the  spot,  and  inducing 
the  patient  to  take  as  long  a  breath  as  he  can.  Tenderness  on  pressure  is  a 
constant  symptom. 

When  the  lung  has  been  punctured  by  one  of  the  fragments,  emphysema 
is  very  generally  the  result,  air  escaping  into  the  subcutaneous  areolar  tissue. 
Of  this  Hammick^  gives  a  very  curious  instance : — 

"  A  man  was  brought  in  for  fractured  ribs  from  the  Glory,  then  lying  in  Cawsand  Bay, 
and  when  the  sailors  uncovered  him,  it  being  night  and  very  dark,  they  were  aston- 
ished, for  when  they  quitted  the  ship,  immediately  after  he  had  fallen,  he  was  a  thin 
person,  but*  from  the  escape  of  air  into  the  cellular  membrane,  he  was  blown  up  to  a 
frightful  size — the  scrotum  being  as  large  as  his  head — the  breathing  so  laborious,  and 
the  symptoms  so  urgent  that,  without  waiting  to  put  him  into  bed,  with  a  scalpel  I 
freely  incised  several  parts,  particularly  the  scrotum ;  the  escape  of  air  was  so  great 
that  it  blew  out  a  large  candle  held  before  it.  By  the  next  day  there  was  only  a  little 
crackling  feel  in  the  neighborhood  of  the  fractured  ribs  ;  he  recovered  finally  from  the 
injury,  though  it  was  many  months  before  he  could  be  discharged  from  the  hospital." 

The  slight  pleurisy,  already  mentioned  as  generally  attendant  upon  frac- 
tured rib,  may  spread  and  assume  such  proportions  as  to  endanger  life  ;  and 
pneumonia  may  be  superadded  to  it. 

The  prognosis  is,  of  course,  grave,  if  the  injury  is  very  extensive ;  yet 
Holmes^  says  he  has  seen  a  young  woman  recover  from  fracture  of  every  rib 
in  the  body,  and  comminuted  fracture  of  the  left  clavicle  involving  such 
damage  to  the  brachial  plexus  as  to  cause  permanent  paralysis  of  the  arm. 

Injury  to  the  vessels,  or  to  the  viscera,  adds  very  greatly  to  the  danger. 
Turner  3  has  recorded  an  instance  in  which  a  robust  man,  fencing  with  another 
in  sport,  was  struck  with  a  light  cane  over  the  eighth  rib  on  the  right  side, 
and  died  from  rupture  of  the  intercostal  artery,  five  pints  of  blood  being 
found  in  the  pleura. 

Wounds  of  the  heart  are  not  infrequent.  Lonsdale*  gives  an  account  of  a 
man,  aged  21,  run  over  by  a  wagon-wheel,  in  whom  the  following  condition 
was  found  after  death : — 

"  Eight  ribs  of  the  left  side  w^ere  fractured  at  their  posterior  part,  about  an  inch  from 
their  tubercles ;  and  the  four  middle  ones  were  broken  at  the  anterior  part  as  well, 
causing  a  double  fracture.  The  pericardium  was  filled  with  blood,  and  a  large  quantity 
had  escaped  into  the  chest  as  well.  The  left  auricle  was  found  to  be  torn  by  the  frac- 
tured ends  of  the  ribs  having  been  thrust  against  it.'* 

Eve^  quotes  from  Lees  a  very  singular  case : — 

"  A  brewer's  man  had  fallen  under  a  dray,  when  it  was  heavily  laden,  which  passed 
over  his  chest ;  he  was  lifted  up  and  complained  of  pain  and  weakness,  but  was  able  to 
continue  sitting  on  the  side  of  the  dray,  driving  the  horse  for  nearly  an  hour,  when 
being  in  the  vicinity  of  the  hospital  he  thought  he  might  as  well  get  himself  examined  ; 
he  w^alked  in  and  lay  on  a  bed,  but  on  turning  on  his  side  he  suddenly  expired.  On 
dissection  it  was  found  that  the  fifth  rib  was  fractured,  and  that  the  extremity  of  one 
portion  had  penetrated  the  pericardium,  but  had  freed  itself  from  the  heart ;  and  this, 
as  Mr.  Wilkin  observes,  accounts  for  the  sudden  death  of  the  man.  For  it  is  probable 
that  the  portion  of  rib  had  filled  up  the  wound  of  the  heart,  and  thus  prevented  any 
hemorrhage  until  his  arrival  at  the^hospital,  when,  on  its  coming  out,  the  sudden  effusion 
of  blood  into  the  pericardium  caused  death." 


1  Op.  cit.,  p.  163. 

8  Med.  Times  and  Gazette,  Dec.  22,  1860. 
6  Remarkable  Cases  in  Surgery,  p.  221. 


2  Op.  cit.,  p.  218. 
4  Op.  cit.,  p.  258. 


FRACTURES  OF  THE  RIBS,  COSTAL  CARTILAGES,  AND  STERNUM. 


85 


Hammick^  mentions  a  case  in  Avhicli  a  man  was  struck  on  the  side  by  the 
end  of  a  flying  rope,  and  died  immediately  : — 

The  post-mortem  showed  that  "  one  rib  only  had  been  broken,  both  ends  of  which 
bad  been  driven  inward,  piercing  the  very  apex  of  the  heart,  penetrated  both  ventricles, 
and  then  had  returned  to  their  situation  by  their  own  elasticity ;  the  pericardium  was 
full  of  blood,  but  none  had  escaped  into  the  chest." 

Hammick  suggests  that  death  was  due  here  to  the  shock  to  the  diaphragm 
or  to  the  heart ;  but  it  seems  as  if  the  escape  of  blood  into  the  pericardium 
might  amply  account  for  it. 

Still  another  case  may  be  cited,  reported  by  West:^ — 

A  young  man  fell  into  a  coal-pit,  and  was  taken  out  dead.  There  was  no  wound  on 
the  surface  ;  but  the  sternum  was  broken  into  two  fragments,  and  the  third,  fourth, 
fifth,  sixtli,  and  seventh  ribs  on  the  left  side  were  fractured  also.  The  pericardium  and 
pleura  were  full  of  black  fluid  blood,  and  both  right  and  left  ventricles  of  the  heart 
extensively  lacerated. 

Fractures  of  the  ribs  generally  unite  without  difficulty,  in  the  simpler  cases; 
but  from  the  unavoidable  mobility  of  the  parts  there  is  apt  to  be  some  excess 
of  callus.  When  several  ribs  are  involved  this  condition  is  more  marked, 
and  sometimes — as  in  a  specimen  in  the  Wistar  and  Horner  Museun*  of  the 
University  of  Pennsylvania — there  are  curious  stalactitic  prolongations  from 
each  bone  at  the  fractured  part,  as  if  the  plasma  had  been  pulled  upon  and 
drawn  out  when  soft. 

]^on-union  is  sometimes  met  with : — 

Boardman^  found  in  a  colored  girl,  aged  22,  a  fracture  of  the  eighth  right  rib,  of  three  or 
four  months'  standing,  ununited,  and  the  fragments  carious ;  a  fistulous  opening  led  into 
tlie  pleura,  which  was  coated  with  lymph  and  contained  about  two  pints  of  pus.  On 
the  left  side,  the  eighth  rib  was  also  broken,  and  there  was  an  abscess  between  the  in- 
tercostal muscle  and  the  pleura,  pointing  within,  and  apparently  ready  to  burst.  This 
latter  lesion  was  only  discovered  after  death  ;  the  other  was  attributed  to  a  kick. 

The  treatment  of  fractured  ribs,  when  uncomplicated  with  lesions  of  the 
internal  structures,  consists  simply  in  immobilizing  the  parts ;  and  this  is 
best  done  by  means  of  adhesive  strips,  as  first  recommended  by  Hannay.^  It 
had  been  previously  effected  by  the  application  of  bandages,  either  ordinary 
wide  rollers,  or  broad  strips  of  flannel  or  muslin  pinned  about  the  chest.  At 
the  present  day,  the  adhesive  plaster  is  in  very  general  use ;  it  is  cut  into 
strips  from  eight  to  sixteen  inches  long,  according  to  the  size  of  the  chest, 
and  about  an  inch  and  a  half  in  width.  These  are  put  on  very  firmly, 
parallel  with  the  ribs,  and  overlapping  one  another  from  above  downw^tird,  each 
one  covering  about  one-third  or  one-quarter  of  the  width  of  the  preceding  one. 
By  Erichsen  and  others  it  is  advised  that  the  strips  should  surround  the  whole 
body  ;  but  this  will  be  found  to  impede  respiration  and  give  trouble.  It  is 
better  to  let  the  strips  extend  no  further  than  the  median  line  in  front  and 
at  the  back.  Before  applying  the  plaster,  any  marked  displacement  of  the 
fragments  should  be  corrected  by  suitable  pressure  and  manipulation,  the 
patient  being  directed  to  fill  the  chest  as  much  as  possible  during  these 
attempts.  My  own  practice  is  to  apply  the  strips  during  expiration ;  and 
the  pain  caused  by  the  act  of  breathing  ought  to  be  rnarkedly  relieved. 
When  the  fragments  project  outward,  a  compress  of  lint,  not  too  thick,  may 
be  placed  over  the  angle  before  the  plaster  is  put  on.    When  they  are  driven 

'  Op.  cit.,  p.  165.  2  St.  Thomas's  Hospital  Reports,  N.  S.,  vol.  i.  1870. 

*  Proceedings  of  the  Pathological  Society  of  Philadelphia,  vol.  ii.  p.  130. 
<  London  Medical  Gazette,  November,  1845. 


gg  INJURIES  OF  BONES. 

inward,  two  compresses  may  be  employed,  at  such  points  as  to  tilt  up  the 
ends  and  take  off  the  pressure  upon  the  parts  within.  Operative  interference 
for  the  purpose  of  prynig  up  a  fragment  by  means  of  the  linger,  a  lever,  or  a 
blunt  hook,  inserted  through  an  incision  of  the  skin,  has  been  suggested. 
Malgaio-ne  mentions  "  removal  of  a  piece  of  rib"  as  having  been  resorted  to 
by  Soranus  and  by  Eossi ;  but  these,  I  believe,  are  the  only  known  cases  of 
the  kind.  He  proposes  the  use  of  a  hook  curved  like  a  tenaculum,  inserted 
over  the  upper  border  of  the  bone ;  and  if  the  hook  were  blunt  this  could 
readily  be  done  without  wounding  the  pleura.  Such  a  procedure  could,  how- 
ever, very  rarely  be  called  for. 

Should  the  fracture  involve  several  ribs,  I  believe  advantage  would  be 
gained  by  the  use  of  a  short,  thin  slip  of  wood,  properly  covered,  and  applied 
across  the  posterior  portions  of  the  ribs,  so  as  to  act  as  a  splmt  as  well  as  a 
compress,  pushing  the  fragments  outward,  away  from  the  pleura  and  lung. 
It  might  of  course  be  held  ni  place  by  adhesive  plaster,  put  on  m  the  manner 
above  directed.  . 

When  a  bandage  is  used,  it  is  best  made  of  flannel,  about  three  inches 
wide ;  if  cut  obliquely,  or  "  bias,"  it  will  be  much  more  elastic  than  if  torn 
lengthwise  of  the  piece.  One  or  two  turns  round  the  shoulders  will  prevent 
it  slippiiig  downward,  and  a  few  strips  of  adhesive  plaster  across  it  on  either 
side  (not In  front),  running  down  as  far  as  the  pelvis,  will  keep  it  from  slip- 
ping upward. 

Emphysema  generally  disappears  of  itself,  without  treatment.  As  to  com- 
plications from  intra-thoracic  inflammation,  they  must  be  dealt  with  on  the 
principles  laid  down  in  works  on  the  practice  of  medicine.  I  may,  however, 
say  that  leeches,  applied  just  at  the  seat  of  injury,  or  cups  in  its  immediate 
neighborhood,  have  sometimes  seemed  to  me  to  be  of  great  service.  General 
bleeding  I  have  never  had  occasion  to  employ  in  cases  of  this  kind. 

Internal  hemorrhage,  in  the  recorded  cases,  has  usually  been  speedily  fatal, 
and  it  is  seldom,  if  ^ever,  amenable  to  treatment.  Should  opportunity  be 
given  for  the  employment  of  remedies,  ergot  and  acetate  of  lead  would  ^  be 
indicated,  and  advantage  might  be  derived  from  the  external  application 

of  cold.  ^  -  . 

lu  any  case  of  injury  of  the  chest,  when  fracture  of  one  or  more  ribs  is 
suspected,  but  cannot  be  clearly  made  out,  it  is  safer  to  adopt  the  same  course 
that  would  be  followed  if  the  bone  were  proved  to  have  given  way.  I  he 
enforced  rest  will  be  beneficial  if  there  is  mere  contusion,  and  still  more  so 
if  there  is  really  an  undetected  fracture. 

Fractures  of  the  costal  cartilages  are  very  rare,  and  not  always  easily 
distiucruishable  from  separations  at  the  junction  of  the  cartilages  with  the 
ribs.  "^They  are  apt  to  be  nearly  ti^ansverse,  and  are  generally  due  to  direct 
violence. 

Reed '  has  reported  the  case  of  a  man,  kicked  by  a  mule,  in  whom  there  was  separa- 
tion of  the  sternum  at  the  junction  of  the  first  and  second  pieces,  with  fractures  ot  the 
cartilages  of  the  second,  third,  fourth,  and  fifth  ribs  on  the  right  side,  as  well  as  of  those 
of  the  second,  third,  and  fourth  ribs  of  the  left  side.  The  pleural  cavities  were  filled 
with  blood.  The  right  clavicle  was  also  fractured.  This  extensive  injury  produced 
no  sign  until  tympany  came  on  (from  rupture  of  the  spleen),  and  the  respiration  became 
of  necessity  thoracic,  with  crepitus  and  displacement  of  the  fragments. 

A  man  was  brought  to  the  Pennsylvania  Hospital  in  1855,  who  had  fallen  from  a 
wharf,  strikincT  his  chest  on  the  edge  of  a  boat.  After  his  death  from  peritonitis 
(the  colon  having  been  ruptured),  it  was  found  that  the  sixtli  and  seventh  cartilages 

I  Proceedings  of  Path.  Society  of  Philadelphia,  vol.  ii.  p.  47. 


FRACTURES  OF  THE  RIBS,  COSTAL  CARTILAGES,  AND  STERNUM. 


87 


on  the  right  side  were  fractured  about  an  inch  from  tlie  sternum  ;  the  perichondrium 
was  entire  in  the  sixth,  but  torn  anteriorly  in  the  seventh. 

M.  Broca^  is  reported  to  have  mentioned  to  the  Societe  Anatomique  a  case  in  which 
tlie  sixth,  seventh,  and  eighth  cartilages  on  the  right  side  were  fractured  by  muscular 
action.  The  patient,  a  porter,  had  a  sack  of  peas  on  his  shoulder,  when  another  sack 
was  suddenly  laid  ui)on  him.  Tlie  weight  bore  him  forward,  and  in  raising  himself 
against  it  he  sustained  the  injury,  the  result  of  which  is  not  stated. 

Gurlt  quotes  from  Chaussier  the  case  of  an  officer,  aged  48,  who  had  a  diastasis  of  the 
cartilage  of  the  left  upper  false  rib,  produced  by  a  fit  of  coughing ;  there  was  a  hernia 
of  thelung  as  large  as  a  hen's  egg.  He  cites  also  Monteggia's  account  of  a  very  thin 
man,  aged^TO,  in  whom  the  cartilages  of  the  second  and  third  (true)  ribs  had  been 
separated  from  the  ribs  themselves,  also  by  coughing. 

When  these  fractures  do  not  prove  immediately  fatal  by  reason  of  the 
damao:e  involved  to  the  thoracic  viscera,  they  may  heal  like  other  lesions  of 
the  same  kind  in  other  parts.  Sometimes,  however,  they  result  in  serious 
impairment  of  respiration,  and  consequently  of  the  j_^eneial  health.  Ot  this 
the  following  case  aflbrds  a  good  example : — 

A  cavalry  officer'^  was  injured  in  the  right  side  by  a  fall  from  his  horse,  in  July, 
1864.  Three  months  later  his  case  was  reported  as  "fracture  of  the  ribs,  which  have 
not  yet  united."    In  1870,  he  was  examined  by  a  pension  surgeon,  who  certified  that 

the  sixth  and  seventh  ribs  on  the  right  side  were  fractured  and  dislocated  from  the 
sternum,  and,  not  being  properly  adjusted,  an  imperfect  cure  was  the  result.  There  is 
a  projection  of  two  inches  outward  from  the  chest  at  the  ends  of  those  two  fractured 
ribs,  which  are  not  joined  to  the  sternum.  The  muscles  which  move  the  arm  are 
weakened,  and  exercise  causes  pain."  Seven  years  afterwards,  it  was  noted  by  an  ex- 
amining board  that  the  pensioner  had  "  an  anxious  expression  of  countenance  ;  dis- 
tended "nasal  alie;  respiration  easily  disturbed  ;  loud  resonance  and  weak  respiration  in 
right  lung,  indicating  emphysema." 

Macleod^  mentions  the  case  of  a  man  "  hit  by  a  round  shot  on  the  edge  of  the  breast- 
plate, which  was  so  turned  inward  as  to  fracture  the  cartilages  of  the  fifth,  sixth,  and 
seventh  ribs  on  the  left  side,  close  to  the  sternum.  The  skin  was  not  wounded.  He 
walked  to  the  rear,  and  complained  but  little  for  two  hours,  when  he  was  seized  with  an 
acute  pain  in  the  region  of  the  heart.  His  pulse  became  much  accelerated,  and  he  grew 
faint  and  collapsed. A  distinct  and  sharp  bellows-sound  accompanied  the  heart's  action. 
He  died  in  seventy-two  hours  from  the  receipt  of  the  injury,  the  pain  and  dyspnoea, 
which  had  been  so  urgent  at  first,  having  abated  for  some  hours  before  death.  The 
heart  was  found  to  have  been  ruptured  to  an  extent  sufficient  to  allow  of  the  finger 
being  thrust  into  the  left  ventricle.  The  obHquity  of  the  openinor  had  prevented  the 
blood  escaping  into  the  pericardium,  which  contained  about  two  ounces  of  dark-colored 
serum." 

From  the  cases  now  quoted,  it  w^ill  be  perceived  that  the  injuries  in  ques- 
tion have  much  in  common  with  fractures  of  the  ribs. 

Union  takes  place,  according  to  Gurlt.  by  the  formation  of  spongy  bone 
around  both  fragments,  or  in  the  interspace  between  their  outer  walls,  the 
broken  ends  remaining  quite  passive.'  A  number  of  specimens  exist  in 
various  museums  illustrating  this.  Gurlt  says,  on  the  authority  of  Mal- 
gaigne  and  Klopsch,  that  in  dogs  and  rabbits  the  divided  cartilages  unite 
by  fibrous  or  .fibro-cartilaginous  substances ;  but  that  in  large  animals,  as  in 
the  horse,  the  rule  is  the  same  as  in  man. 

The  treatment  must  be  immobilization  by  means  of  adhesive  plaster.  Mal- 

'  Brit,  and  For.  Med.-Cliir.  Review,  Oct.  1856. 

«  Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion,  Part  III.  Surg.  Vol.,  p.  649. 
'  Notes  on  the  Surgery  of  the  War  in  the  Crimea,  etc.;  Am.  ed.,  p.  204. 

^  Interesting  and  instructive  articles  on  this  subject,  by  Prof.  Bennett,  may  be  found  in  the 
Dublin  Journal  of  Medical  Science  for  March,  1876,  and  for  October,  1877. 


88 


INJURIES  OF  BONES. 


gaigiie  recommends  an  instrument  like  a  trass,  having  a  spring  carrying  two 
pads,  one  to  be  applied  over  any  projecting  fragment,  the  other  at  the  back, 
and  mentions  a  case  in  which  he  employed  this  apparatus  with  success. 

Fractures  of  the  Sternum. — From  the  spongy  structure  and  exposed 
situation  of  this  bone,  one  might  expect  that  it  would  be  very  readily 
broken.  Yet  such  is  not  the  case  ;  it  is  not  often  fractured,  and  very  rarely 
by  direct  violence.  When  this  does  happen,  other  bones  in  the  neighbor- 
hood are  apt  also  to  be  involved.  A  good  many  instances,  however,  are  upon 
record  in  which  this  bone  has  given  way  to  indirect  force,  and  to  muscular 
action. 

A  longitudinal  fracture  of  the  sternum,  produced  in  a  mason  who  was 
buried  under  some  heavy  stones,  was  recorded  by  Barrau,  and  is  quoted  by 
Malgaigne  and  Gurlt ;  it  is  the  only  undoubted  case  of  the  kind,  as  far  as  is 
known.  Gurlt  quotes  two  instances  of  partial  fracture  of  this  bone,  the  pos- 
terior surface  alone  having  suffered ;  hemorrhage  had  taken  place  into  the 
mediastinum  in  each.  One,  seen  by  Senator,  was  from  the  kick  of  a  horse ; 
the  other,  by  Brotherston,  from  a  fall  of  about  ten  feet  upon  the  head. 

The  following  curious  case  is  mentioned  by  Malgaigne : — 

"  A  man  of  sixty-three  was  knocked  down  by  a  dray,  the  wheel  of  which  went  up  on 
the  left  side  of  the  chest,  but  not  getting  over  the  trunk,  passed  off  on  to  the  left  arm, 
which,  however,  was  uninjured.  Tlie  next  day  the  man  came  to  the  hospital ;  a  quite 
notable  swelling  occupied  the  upper  sternal  region  ;  and  the  first  piece  of  this  bone,  with 
the  cartilage  of  the  second  rib  on  each  side,  made  so  marked  a  prominence  in  front  that 
I  thought  1  had  to  deal  with  a  luxation,  or  with  a  transverse  fracture  with  overlapping. 
I  tried  various  manoeuvres  to  accomplish  reduction,  but  in  vain  ;  effusion  occurred  in 
the  pleura;  an  abscess  formed  above  the  fracture,  and  the  patient  succumbed  on  the 
thirty-third  day.  At  the  autopsy^  fractures  were  found  in  the  semi-ossified  cartilage  of 
the  first  rib  on  the  left  side,  as  well  as  in  the  second,  third,  and  fifth  ribs  of  the  same 
side  ;  these  had  not  been  suspected  at  all.  The  sternum  was  broken  transversely  at  the 
level  of  the  third  intercostal  space,  the  upper  fragment  being  slightly  inclined  backward; 
this  fracture  also  had  escaped  notice.  Lastly,  a  fracture,  situated  above  and  to  the 
left,  detached  from  the  bone,  as  if  with  a  knife,  a  sort  of  scale,  the  base  of  which  reached 
from  the  fourchette  to  the  level  of  the  second  costal  cartilage,  comprising  all  the  left 
sterno-clavicular  articulation,  and  the  cutting  edge  of  which  was  at  the  anterior  face  of 
the  bone  ;  the  abscess  had  formed  at  the  seat  of  this  fracture." 

Malgaigne  quotes  from  Duverney  a  case  in  which  a  ten-pin  player,  who 
bent  forward  to  watch  his  ball,  fell,  striking  a  large  stone ;  he  was  taken 
up  dead,  with  a  fracture  of  the  sternum.  I  must  say  that  this  account  is ' 
not  full  enough  to  be  satisfactory,  as  some  other  lesion  must  have  been  pre- 
sent. Gibson^  says  that,  in  1839,  he  saw^  in  the  museum  of  the  London  LTni- 
versify  a  heart,  the  right  ventricle  of  which  had  been  lacerated  by  a  fractured 
sternum  ;  and  he  cites  a  like  case  from  Sanson. 

A  number  of  instances  are  on  record  in  which  fracture  of  the  sternum 
would  seem  to  have  been  caused  by  the  impact  of  the  chin,  the  vertebrae 
giving  way  and  allowing  the  head  to  be  forced  forward  and  downward.  Four 
such  cases  were  observed  by  Hodgen;^  in  three  of  them  the  patients  had 
fallen  backward,  striking  on  the  shoulders.  Eivington^  mentions  a  case  in 
which — 

"  An  acrobat,  aet.  30,  in  turning  a  double  somersault,  fell  about  ten  feet  on  to  the  back 
-  of  his  head.    He  came  down  on  some  tan,  and  his  head  was  violently  flexed  on  to  his 
chest.    The  injury  caused  a  separation  between  the  sixth  and  seventh  cervical  vertebrae, 

1  Op.  cit.,  p.  253.  ^  Holmes's  System  of  Surgery,  Am.  ed.,  vol.  i.  p.  752. 

8  British  Medical  Journal,  January  31,  1874. 


FRACTURES  OF  THE  RIBS,  COSTAL  CARTILAGES,  AND  STERNUM. 


89 


and  ah  oblique  fracture  of  the  sternum,  sucli  as  might  have  been  produced  by  the  chin 
inclined  to  one  side." 

MichaeP  records  the  case  of  a  seaman  who  fell  into  a  hold,  sustaining  a  dislocation 
of  the  fifth  cervical  vertebra  on  the  sixth,  with  fracture  of  the  sternum,  the  periosteum 
remainino-  unruptured  in  front.  Spontaneous  reduction  of  the  luxation  took  place. 
There  was  laceration  of  the  lung,  and  the  mediastinum  became  emphysematous.  Death 
occurred  on  the  third  day. 

In  all  the  foregoing  cases  the  fracturing  force  acted  directly.  Indirect  vio- 
lence may  be  exerted  in  either  one  of  several  ways  :  by  the  forcible  bending 
backward  of  the  trunk,  or  by  falls  on  the  buttocks  or  on  the  feet.  Malgaigne 
suggests  that  some  of  the  fractures  ascribed  to  muscular  contraction  are  really 
due  to  the  first  of  these  causes — a  forcible  separation  of  the  upper  and  lower 
ribs,  carrying  with  them  their  respective  portions  of  the  sternum.  But 
in  all  cases,  I  think,  we  may  exclude  the  direct  pull  of  the  muscles  attached 
to  the  sternum  as  causes  of  its  fracture.  Gross'  gives  the  following  ac- 
count : — 

"In  1838  I  attended,  along  with  Dr.  Rohrer,  a  case  in  a  large,  heavy,  muscular 
man,  forty-six  years  of  age,  who  had  received  a  transverse  fracture  of  the  upper  |)art 
of  this  bone,  from  inordinate  contraction  of  the  sterno-cleido-mastoid  muscles,  in  jump- 
ing, in  a  state  of  intoxication,  off  a  shed  eleven  feet  high.  The  heels  striking  the 
ground  obliquely,  threw  the  body  violently  backward,  the  head  and  neck  coming  in 
contact  with  the  edge  of  a  board.  The  fracture  was,  doubtless,  occasioned  by  the  effort 
which  the  man  made*  to  regain  his  equilibrium." 

My  own  belief  is  that  here  there  was  sudden  flexion  of  the  body  backward, 
and  that  the  fracture  was  due  to  the  mechanism  before  spoken  of. 

A  number  of  instances  have  been  known  in  which  the  sternum  has  given 
.way  to  powerful  muscular  contraction  in  child-birth.  In  all  of  them,  as  far 
as  I  know,  the  trunk  is  stated  to  have  been  bent  strongly  backward.  Analo- 
o;ous  to  these  cases  would  be  that  often  quoted  from 
Faget,  in  which  a  mountebank,  as  a  feat  of  strength, 
was  leaning  back  and  trying  to  raise  a  weight  with 
his  teeth.  When  the  great  extent  of  muscular  struc- 
ture, connected  with  the  ribs,  which  Avould  thus  be 
put  into  forcible  play,  is  considered,  it  can  scarcely  be 
doubted  that  to  this,  and  not  to  the  mere  contraction 
of  the  muscles  attached  to  the  sternum  alone,  should 
the  production  of  the  fracture  be  ascribed. 

It  is  not  always  an  easy  matter  to  determine  whether 
the  lesion  is  an  actual  fracture,  or  merely  a  diastasis 
between  the  pieces  of  the  sternum  ;  but  the  question  is 
not  one  of  great  practical  importance.  Occasionally, 
as  in  the  specimen^  of  which  Fig.  818  is  a  representa- 
tion, the  line  of  fracture  clearly  runs  across  one  portion 
of  the  bone,  with  a  marked  degree  of  obliquity. 

Sometimes  the  displacement  is  very  slight,  but  it 
may  be  considerable  ;  and,  in  the  great  majority  of 
cases,  the  lower  fragment  projects  in  front  of  the  upper. 
Malgaigne  mentions  one  case  seen  by  Sabatier,  in  which 
an  old  man  had  been  subjected  to  great  violence,  and 
thrown  into  a  hole  thirty  feet  deep.    He  fell  on  his        Fracture  of  sternum. 

'  Maryland  Med.  .Journal,  Sept.  1,  1882.  2  Op.  cit.,  p.  956. 

3  In  the  Mutter  Museum  of  the  College  of  Physicians  of  Philadelphia  ;  the  specimen  has  no 
known  history. 


90 


INJURIES  OF  BONES. 


back ;  the  second  piece  of  the  sternum  was  broken  away  from  the  first,  and 
driven  in  behind  it. 

The  symi:)toms  of  this  injury  are  analogous  to  those  of  fractures  of  the  ribs 
and  their  cartilages.  Pain,  tenderness,  swelling,  and  ecchymosis  have  been 
noted  in  all  the  cases  not  immediately  fatal.  Cough  almost  always  occurs, 
and  emphysema  may  exist  independently  of  injury  to  the  lung.  Displacement 
and  crepitus  have  generally  been  more  or  less  distinctly  marked.  Suppuration 
has  occasionally  taken  place  in  the  anterior  mediastinum. 

Eiedinger^  says  that  repair,  v/hen  it  ensues,  is  effected  by  means  of  a  layer 
of  fibro-cartilaginous  material,  placed  between  two  other  layers  of  hyaline 
cartilage.  Very  probably  this  statement  may  apply  to  cases  of  disruption 
occurring  between  two  of  the  pieces  ;  but  when  a  true  fracture  takes  place 
in  this  bone,  it  is  repaired  in  the  ordinary  manner,  as  may  be  seen  in  many 
museum  specimens. 

The  treatment  of  these  injuries  does  not  differ  in  any  material  respect  from 
that  of  fractures  of  the  costo-sternal  cartilages.  When  displacement  exists  to 
any  marked  degree,  it  should  be  corrected  as  far  as  possible.  But  while  it  is 
eminently  proper  to  make  this  attempt,  it  must  be  remembered  that  the  dis- 
placement is  not  of  itself  a  source  of  danger.  Hammick^  says  that  "  if  the 
bone  were  allowed  to  remain  depressed,  it  would  extinguish  life ;"  but  there 
is  no  ground  for  this  statement.  Hence  operative  interference,  such  as  the 
introduction  of  gimlet-like  screws,  or  of  elevators  or  blunt  hooks,  for  the  pur- 
pose of  pulling  or  prying  up  the  depressed  fragment,  is  unjustifiable.  More- 
over, the  texture  of  the'  bone  is  too  spongy  to  afford  a  good  hold  to  such  in- 
struments. The  only  available  method  of  procedure  is  to  act  upon  the  lateral 
walls  of  the  chest,  by  causing  the  patient  to  alternately  fill  and  empty  the 
lungs  to  the  fullest  extent  possible  to  him,  and  by  raising  and  lowering  the 
arms,  while  the  surgeon  tries  to  push  in  the  projecting  fragment. 

The  deformity  having  been  thus  rectified  as  far  as  may  be  ^Dracticable,  the 
walls  of  the  chest  should  be  immobilized  by  means  of  adhesive  strips,  applied 
across  their  anterior  portion,  and  covering  in  the  whole  sternal  region.  A 
flannel  bandage  surrounding  the  whole  thorax  may  be  put  on  in  addition  to 
the  strips,  and  secured  so  that  it  shall  not  slip  upward.  Should  inflamma- 
tory or  other  complications  arise,  they  should  be  met  by  appropriate  treat- 
ment.   Absolute  rest  in  bed  should,  be  enjoined,  and  a  concentrated  diet. 

When  an  abscess  formes  behind  the  sternum,  if  its  presence  can  be  clearly, 
made  out,  there  is  no  positive  objection  to  penetrating  the  bone  in  the  median 
line  with  the  crown  of  a  small  trephine  ;  but  it  is  almost  certain  that  the  pus 
will  find  its  way  to  the  surface,  either  at  the  seat  of  fracture  or  in  one  or  more 
of  the  intercostal  spaces,  when  vent  can  •  be  given  to  it  by  a  simple  puncture 
of  the  skin. 


Fractures  of  the  Pelvis. 

Viewed  as  a  whole,  the  pelvis  constitutes  a  bony  ring,  interrupted  ante- 
riorly by  the  pelvic  synchondrosis,  and  posteriorly  on  either  side  by  that 
between  the  sacrum  and  the  ilium.  These  synchondroses,  by  the  arrange- 
ment of  the  walls  and  cancellous  structure  on  either  side  of  them,  are  adapted 
to  diminish  the  stress  put  upon  the  whole  framework,  either  by  ordinary  or 
by  extraordinary  forces.  It  may  further  be  said  that  the  pelvis  presents  not 
only  the  bony  ring  just  mentioned,  which  has  no  great  depth  below  the  brim 
of  the  lower  or  true  pelvis,  but  also  certain  appendages — the  iliac  expansions 


I  Gaz.  Med.  de  Paris,  12  Aout,  1882. 


2  Op.  cit.,  p  167. 


FRACTURES  OF  THE  PELVIS. 


91 


above  the  rami  of  the  pubis  and  ischium  below  and  on  either  side,  and  the 
downward  prolongation  of  the  sacrum  and  coccyx  behind  The  ligaments 
which  bridge  across  the  gaps  between  these  appendages  add  nothmg  to  the 
security  of  the  bone  against  fracturing  forces.  Of  the  whole  framework  the 
strono-est  part  is  that  where,  in  the  erect  position,  the  weight  ot  the  trunk  is 
transmitted  to  the  head  of  the  femur ;  the  sacrum,  although  thick  is  com- 
posed in  great  measure  of  sponiry  bone,  further  weakened  by  the  pei-torations 
for  the  sacral  nerves,  as  well  as  by  the  terminal  portion  ot  the  spinal  canal. 

Fracture  of  the  pelvis  is  not  common  in  men,  is  rarely  met  with  in 
women,  and  is  almost  unknown  in  children.  The  youngest  patient  I  re- 
member to  have  treated  for  such  an  injury  was  sixteen  years  old.  Bryant, 
however,  mentions  two  cases  seen  by  him  in  children,  and  a  few  others  are 
upon  record.  I  may  mention  here  that,  notwithstanding  tlie  rarity  of  frac- 
tures of  the  pelvic  bones,  three  cases  were  under  treatment  at  one  time  in  my 
wards  at  the  Episcopal  Hospital,  in  1882 ;  a  sort  of  coincidence  not  unfre- 
quently  met  with  in  practice.  . 

Fractures  of  the  appendages  may  occur  without  aftecting  the  continuity  ot 
the  pelvic  o-irdle  proper.  They  aVe  generally  due  to  direct  violence.  Thus 
the  crest  ot^the  ilium  may  be  broken  off,  in  one  or  more  pieces;  the  lower 
part  of  the  sacrum  may  be  fractured  more  or  less  transversely,  or  com- 
minuted ;  or  a  portion  of  the  ischium  may  be  separated,  this,  however,  being 
very  rare.    The  lines  of  fracture  vary  almost  indefinitely,  as  might  naturally 

be  expected.  .      .     ^  n  n  r 

When  a  crushing  force,  such  as  the  caving  m  of  a  mass  ot  earth,  a  tall  ot 
rock  or  of  coal  in  a  mine,  or  the  passage  of  a  heavy  wheel  over  the  lower 
part  of  the  body,  is  brought  to  bear  upon  the  whole  pelvis,  the  bone  may 
give  way  at  two  or  more  different  points.  One  or  the  other  side  of  the  ring 
may  be  especially  acted  upon,  or  the  stress  may  be  exerted  directly  across 
either  antero-posteriorly  or  laterally.  In  any  case,  however,  the  pubis  would 
seem  to  yield  first,  in  its  horizontal  ramus,  when  there  must  be  a  fracture 
also  somewhere  between  the  symphysis  pubis  and  the  tuber  ischii.  IText,  if 
the  force  acts  antero-posteriorly,  the  tendency  will  be  to  open  out  the  lateral 
arc  of  the  bone,  which  may  be  broken  at  or  near  the  sacro-ihac  junction. 
Thus  a  portion  of  the  sacrum  may  be  torn  away,  or  the  lesion  may  be  con- 
fined to  the  OS  innominatum.  Cases  of  the  former  kind  have  been  very  fully 
discussed  by  Voillemier,  in  two  instructive  jiapers.^  According  to  him,  ver- 
tical fractures  of  the  sacrum  very  generally  belong  m  the  category  of  "  frac- 
tures par  arrachement,"  or  what  we  should  now  call  "  spram-fractures. 
That  is,  by  the  immense  strain  brought  to  bear  upon  the  pelvic  ring,  the 
sacro-iliac' synchondrosis  being  too  strong  to  yield,  the  spongy  substance  of 
the  sacrum  is  actually  torn  across. 

The  mechanism  above  described  is  regarded  by  Tillaux^  as  that  which 
uniformlv  prevails  in  the  production  of  tlfese  fractures;  and  his  view  is  sup- 
ported by  the  fact  that  in  all  cases  of  multiple  fracture  of  the  pelvis  (and 
there  is  no  portion  of  the  skeleton  so  liable  to  this  form  of  injury),  the  ante- 
rior seo:ment  of  the  rins;  suffers.  The  annexed  cut  (Fig.  819),  taken  from  a 
specimen  (without  history)  in  the  :\[utter  Museum,  will  give  a  good  idea  of 
the  usual  characters  of  this  fracture.^  i  •  i 

A  few  years  ago  I  saw  a  case  in  which  double  fracture  of  the  pelvis  had 
been  produced  by  lateral  pressure  in  a  somewhat  curious  way.    The  man 

*  Clinique  Chirurgicale,  pp.  77  et  107. 

2  Traite  d'Anatomie  Topograpliique,  p.  829. 

»  Kusmin,  in  an  article  to  which  I  have  not  been  able  to  obtain  access  (Ueber  Beckenfrakturen 
Centralblatt  fiir  Chirurgie,  Jan.  6,  1883:  from  Wiener  med.  Jahrb.,  1882),  gives  the  results  of 
experimental  researches  on  the  mechanism  of  the  production  of  these  fractures. 


92 


INJURIES  OF  BONES. 


was  sitting  in  the  side  window  of  the  "  cab "  of  a  locomotive,  leaning  for- 
ward with  his  buttocks  projecting,  when  it  passed  through  the  narrow  door 

of  an  engine-house,  and  he  was  caught 
Fig.  819.  and  jammed.    After  his  death,  it  was 

found  that  the  bone  had  given  way  on 
each  side. 

Occasionally,  fractures  of  the  pelvis 
have  been  seen  as  the  result  of  falls  on 
the  feet,  and  even  from  much  slighter 
accidents.  Thus  Bouvier^  recorded  the 
case  of  a  man,  aged  71,  who  met  with 
a  slight  fall  out  of  bed,  and  fractured 
the  left  OS  innominatum,  from  the  ilio- 
pectineal  eminence,  down  through  the 
acetabulum  to  the  spine  of  the  ischium. 

Sometimes  the  force  acts  directly 
through  the  head  of  the  femur  upon 
Multiple  fracture  of  the  pelvis.  the  adjacent  portiou  of  the  OS  innomi- 

natum. Hutchinson^  records  an  in- 
stance of  starred  fracture  of  the  acetabulum,  the  head  of  the  femur  being 
driven  through  it  by  a  fall  on  the  trochanter.  Gama^  reported  the  case  of  a 
man,  aged  30,  who  fell  eighteen  feet,  striking  on  the  trochanter.  Death  occur- 
red from  peritonitis  on  the  tenth  day.  At  the  autopsy  it  was  found  that  there 
was  an  abscess  extending  from  the  hip  to  the  calf  of  the  leg,  and  into  the 
iliac  region  within  the  pelvis :  the  acetabulum  had  been  broken  into  three 
pieces,  the  smallest  of  which  was  placed  with  the  round  ligament  upon  it,  and 
unbroken,  on  the  head  of  the  bone ;  the  second  was  the  horizontal  ramus  of 
the  pubis,  which  was  separated  from  the  symphysis  pubis  and  ischium ;  and 
the  third  was  the  ischium,  which  was  no  longer  connected  with  the  ilium. 
Perhaps  the  most  remarkable  case  is  that  recorded  by  Lendrick,*in  which,  by 
afi  accident  many  years  previous,  the  head  of  the  femur  was  found  to  have 
been  driven  through  the  acetabulum,  and  to  be  covered  in,  partly  by  bone, 
partly  by  fibrous  tissue ;  the  os  pubis  had  been  fractured  and  united  with 
shortening,  entangling  a  portion  of  intestine,  which  remained  within  a  bony 
cavity  as  a  sort  of  hernia ;  the  ischium  also  had  been  fractured  and  united. 

It  not  unfrequently  happens  that  the  anterior  portion  only  of  the  pelvis 
suffers,  perhaps  at  numerous  points.  Lodge  ^  saw  six  fractures  thus  located, 
as  the  result  of  the  caving  in  of  a  bank  of  earth  upon  the  patient ;  and  Peaslee^ 
a  case  in  which  seven  fractures  had  been  caused  by  the  patient  being  jammed 
in  a  narrow  space  between  a  railroad  car  and  a  platform.  Rupture  of  the 
bladder  had  occurred  in  both  cases. 

In  one  instance,  reported  by  Letenneur,'^  it  was  claimed  that  fracture  of  the 
pubis  had  been  caused  by  muscular  action  ;  the  patient,  a  woman,  was  lifting 
some  large  stones  in  unloading  a  boat,  and  felt  something  give  way;  but 
as  it  is  expressly  stated  that,  at  that  moment,  she  rested  a  stone,  weighing 
over  one  hundred  and  fifty  pounds,  on  the  pubis,  there  must  at  least  be  some 
doubt  whether  the  fracture  might  not  be  more  justly  attributed  to  the  direct 
pressure  thus  exerted.  Coates^  has  recorded  a  case  in  which  the  os  pubis 
was  fractured  in  a  very  analogous  way,  a  coach  in  which  the  patient  was 

1  Am.  Journal  of  the  Med.  Sciences,  February,  1839. 

2  Med.  Times  and  Gazette,  February  24,  1866. 

'  American  .Journal  of  the  Medical  Sciences,  May,  1838,  from  Gaz.  Med,  de  Paris. 
^  Londcm  Medical  Gazette,  March,  1839. 

6  Am.  .Journ.  of  the  Med.  Sciences,  Oct.  1865.  «  Ibid.,  April.  1850. 

'  Medical  Times  and  Gazette,  November  28,  1868.  ^  Med.-Clxir.  Trans.,  vol.  xi. 


FRACTURES  OF  THE  PELVIS. 


93 


travelliiio-  havins;  been  overturned,  and  the  anterior  part  of  her  pelvis  having 
been  forced  against  the  seat  by  the  weight  of  several  of  the  other  passengers 
thrown  over  upon  her. 

Fractures  of  the  Acetabulum. — Fractures  of  the  rbn  of  the  acetabidum  are 
by  no  means  uncommon  ;  they  owe  their  im})ortance  chiefly  to  the  fact  that 
they  are  apt  to  allow  the  head  of  the  femur  to  slip  out  of  place,  and,  although 
it  is  easily  reduced,  it  escapes  again  with  equal  readiness.  A  number  ot 
instances  of  this  kind  are  given  ^by  Sir  A.  Cooper,^  one  of  which,  observed 
at  St.  Thomas's  Hospital  inlTOl,  is,  I  think,  the  earliest  on  record.  McTyer^ 
published  several  cases;  R.  W.  Smith,^  one;  Lonsdale,  one;  Holmes,4one; 
Eve,*  two  ;  Gurlt^  gives  a  wood-cut,  representing  a  fracture  of  the  upper  part 
of  the  rim  of  the  acetabulum,  which  allowed  of  a  very  curious  luxation— 
the  trochanter  major  lying  in  the  acetabulum,  and  the  trochanter  minor  being 
applied  to  the  outer  edge  of  the  tuber  ischii. 

Favell,  in  an  address  before  the  British  Medical  Association,^  detailed  a 
case  which  occurred  under  the  care  of  Mr.  Wheelhouse,  in  which  a  fracture 
of  the  rim  of  the  acetabulum  gave  rise  to  subsequent  dislocation  of  the  femur 
upon  the  dorsum  ilii— the  symptoms  of  the  latter  lesion  being  manifested 
only  some  months  after  the  accident,  when  the  patient  got  up  and  bore  his 
weio'ht  on  the  limb.  The  case  became  the  subject  of  legal  proceedings,  but 
the  result  is  not  stated.  MorrisMjas  reported  an  instance  of  unreduced  dorsal 
dislocation  of  the  femur,  with  fracture  of  the  rim  of  the  acetabulum,  in  a 
young  and  active  man,  the  displacement  coming  on  gradually  during  a  period 
of  about  ten  weeks. 

The  mechanism  ot  this  fracture  must  be  sufficiently  obvious. 

Fracture  of  the  Sacrum. — Fracture  of  the  sacrum  by  itself  is  not  of  com- 
mon occurrence,  although  the  spongy  character  of  this  bone,  before  spoken 
of,  renders  it  really  the  least  resistant  portion  of  the  pelvis ;  and  occasionally 
violence  is  applied  to  it  directly.  Lee^  has  recorded  the  case  of  a  man  in 
whom,  by  a  fall  from  a  height  of  forty  feet,  the  sacrum  was  broken  across ; 
the  displacement  of  the  lower  fragment  forward  was  corrected  by  means 
of  a  flnger  in  the  rectum.  At  the  autopsy,  "  the  sacrum  was  found  com- 
minuted, a  large  fragment  of  the  left  ala  being  broken  off  longitudinally  and 
displaced  to  a  considerable  extent." 

In  a  very  remarkable  case  reported  by  Burlingham./°  the  patient,  a  railroad 
conductor,  was  thrown  into  the  air,  fell  on  the  top  of  a  car,  striking  on  his 
back,  and  then  rolled  down  an  embankment  a  distance  of  over  eighty  feet. 
He  sustained  a  compound  fracture  of  the  sacrum,  the  posterior  surface  of  the 
bone  at  least  being  comminuted  ;  and  through  the  wound  in  the  back,  urine 
flowed  for  many  months.^^ 

»  Dislocations  and  Fractures  of  the  Joints,  6tli  ed.    London,  1842. 
*  Glasgow  Medical  Journal,  February,  1831. 
8  Archives  Gen.  de  Mfedecine,  1838. 

<  Transactions  of  Pathological  Society  of  London,  vol.  xi.,  1860. 

Med.-Chir.  Transactions,  vol.  Ixiii.,  1880.  «  Op.  cit.,  Bd.  i.,  S.  320. 

^  British  Medical  Journal,  August  5,  1876.  ^  Lancet,  February  18,  1882. 

8  Proceedings  of  Pathological  Society  of  Philadelphia,  vol.  ii.  p.  116. 
^0  American  Journal  of  the  Medical  Sciences,  April,  1868. 

"  In  the  account  of  this  case,  it  is  stated  that  about  three  weeks  after  the  accident  "  a  probe 
could  be  passed  from  about  an  inch  above  the  base  of  the  coccyx,  and  about  three-quarters  of  an 
inch  to  the  right  of  the  median  line,  across  the  pelvis,  forward  and  slightly  downward,  a  distance  of 
five  inches,  until  it  was  obstructed  by  bone,  denuded  or  fractured."  This  fact,  taken  together 
with  the  injury  to  the  bladder,  seems  to  me  to  indicate  that  a  fracture  had  occurred  anteriorly 
also  ;  but,  as  the  patient  recovered,  the  diagnosis  could  not  be  placed  beyond  doubt. 


94 


INJURIES  OF  BONES. 


Fracture  of  the  coccyx  is  spoken  of  bj  authors  ;  but  the  consolidation  of 
the  several  pieces  takes  place  only  in  advanced  age,  and  without  this  a  true 
fracture  could  scarcely  occur.  No  unquestionable  cases  are  upon  record  in 
which  this  bone  alone  has  been  broken,  and  the  probability  is  that  the  lesion 
involved  to  the  surrounding  soft  parts  w^ould  be  of  far  more  importance. 
Should  trouble  arise  in  any  such  cases  from  inflammatory  thickening  and  con- 
traction of  the  tissues,  it  would  be  proper  to  divide  the  latter  with  the  knife  ; 
and  failing  relief  from  this,  excision  of  the  bone  might  be  practised,  although 
the  experience  recorded  by  Mursick^  is  not  such  as  to  warrant  great  expecta- 
tions of  success. 

A  case  is  reported^  in  which  the  coccyx,  "  fractured  and  standing  at  a  right 
gle  with  the  sacrum,"  was  removed  by  means  of  the  "  surgical  engine,"  by 
Dr.  Garretson.  The  history  given  of  the  case  is  simply  that  the  patient,  a 
lady,  had  suffered  from  coccygodynia  for  thirteen  years.  The  periosteum  was 
incised  and  laid  open  so  as  to  expose  the  bone,  which  was  then  drilled  away. 
The  ultimate  result  is  not  stated. 


an 


Fracture  of  the  Crista  Ilii. — Fracture  of  the  crest  of  the  ilium  is  by  no 
means  uncommon.  I  have  seen  it  caused  by  a  fall  from  a  horse,  the  patient 
striking  on  his  hip  against  some  railroad  iron  piled  at  the  side  of  the  street. 
At  the  Episcopal  Hospital,  in  1882,  I  had  in  the  w^ards  a  man  aged  21,  who 
had  fallen  about  twelve  feet,  striking  on  a  rafter ;  the  left  crista  ilii,  from 

near  the  sacrum  to  a  point  near  the 
Fig.  820.  anterior  superior  spinous  process,  was 

broken  off.  In  this  case  there  w^as,  for 
some  weeks,  severe  pain  along  the 
course  of  the  anterior  crural  Dcrve ; 
and  it  seemed  probable  that  its  trunk 
had  been  pinched  or  torn. 

A  rarer  form  of  fracture  of  the 
ilium  is  shown  in  Fig.  820,  taken 
from  a  specimen  (without  history)  in 
the  Miitter  Museum.  The  bone  has 
been  separated  nearly  vertically,  and 
transversely  as  well,  the  two  lines  of 
fracture  representing  an  inverted  y. 

Hamilton  states  that  he  has  seen 
about  three  inches  of  the  ilium,  in- 
cluding the  anterior  superior  spinous 
process,  torn  off  by  muscular  action  ; 
the  patient,  a  man  aged  70,  having 
merely  risen  from  his  seat  in  a  railroad 
car,  when  he  felt  "something  wrong."    Eiedinger^  claims  that  musculai 
action  plays  a  much  more  important  part  in  the  production  of  fractures  of 
the  pelvis  generally  than  has  been  ascribed  to  it  by  most  writers. 

Fractures  of  the  ischium  alone  are  very  rare,  the  six  cases  collected  by 
Malgaigne  being  the  only  ones  known.  Three  of  them  were  due  to  violent 
falls  on  the  buttocks,  and  all  to  direct  violence. 

Malgaigne  has  devoted  a  special  section  to  what  he  calls  '^double  vertical 
fracture  of'  the  pelvis."    This  he  defines  as     a  combination  of  two  vertical 

1  American  Journal  of  the  Medical  Sciences,  January,  187G. 

2  Philadelphia  Med.  Times,  February  11,  1882. 

3  Arch,  fur  klin.  Chirurgie,  Bd.  xx.  Heft  2  :  American  Journal  of  the  Medical  Sciences,  April, 
1877 


X-fracture  of  the  ilium 


FRACTURES  OF  THE  PELVIS. 


05 


fractures,  separating  at  one  side  of  the  pelvis  a  middle  fragment  comprising 
the  hip-joint ;  according  as  this  fragment  is  carried  upward  or  inward,  the 
femur  follows  its  movements,  and  hence  result  changes  in  the  length  and^ 
direction  of  the  limb  which  have  often  misled  practitioners."  An  injury  of 
this  kind  might  readily  be  mistaken,  at  iirst  sight,  for  fracture  of  the  ncc;k  of 
the  femur,  as  there  would  be  crepitus,  some  degree  of  shortening— although 
in  one  case,  according  to  Larrey,  there  was  lengthening — of  the  limb,  and 
very  probably  impairment  of  motion;  certainly  inability  to  walk  or  stand. 
Careful  examination,  however,  into  the  precise  seat  of  the  crej)itus  and  diffi- 
culty of  movement  would,  in  most  cases,  be  apt  to  reveal  the  true  nature  of 
the  lesion. 

Besides  the  fractures  of  the  various  portions  of  the  pelvis  w^hich  have  been 
enumerated,  there  are  certain  cases  of  more  extensive  injury  in  this  region, 
the  whole  framework  being  broken  up,  as  in  some  mining  accidents.  I  have 
seen  the  os  innominatum  on  either  side  broken  through  nearly  or  quite  verti- 
cally, both  anteriorly  and  posteriorly,  making  four  principal  fragments.  Such 
injuries  are  in  themselves  extremely  grave,  from  the  amount  of  shock  which 
they  involve. 

One  of  the  three  cases  before  referred  to  as  treated  in  my  wards  at  the 
Episcopal  Hospital,  in  1882,  was  that  of  a  laborer,  aged  50,  upon  whom  a  bank 
of  earth  had  caved  in.  The  os  innominatum  on  either  side  had  been  broken, 
as  above  described,  close  to  the  sacro-iliac  junction,  as  well  as  through  the  os 
pubis  ;  there  were  profound  shock,  retention  of  urine  for  several  days,  and 
subsequent  peritonitis.  The  man  complained  of  severe  pain  in  the  right  leg 
from  the  hip  to  the  toe  ;  but  this  gradually  subsided  along  with  his  other 
symptoms.  As  he  recovered,  the  diagnosis  above  given  could  not  of  course 
be  verified  beyond  question  by  an  autopsy;  but  the  mobility  of  the  fragments, 
the  crepitus,  and  the  long-continued  tenderness  upon  pressure  at  the  points 
indicated,  seemed  to  warrant  my  statement  of  the  case. 

Another  was  that  of  a  young  man,  aged  16,  who  had  fallen  about  sixteen 
feet.  Pressure  on  his  pelvis  from  side  to  side,  or  over  the  pubis,  caused  him 
great  pain,  as  did  also  a  slight  blow  on  the  knee  if  the  thigh  was  flexed.  He 
suffered  less  from  shock  than  the  patient  first  mentioned,  but  had  retention  of 
urine  for  four  days.    He  also  recovered. 

The  symptoms  of  fracture  of  the  pelvis  need  scarcely  be  dwelt  upon  at 
length.  There  is  alw^ays  more  or  less  pain,  sometimes  very  severe  ;  it  is  apt 
to  be  greatly  aggravated  by  any  attempt  at  moving  in  bed.  When  the  sacrum 
is  fractured,  the  act  of  defecation  is  productive  of  great  pain  ;  and  urination 
is  similarly  interfered  with  when  the  pubis  has  given  way.  In  either  case 
the  patient's  suffering  is  increased  by  coughing  or  sneezing.  Crepitus  can 
usually  be  felt  if  pressure  be  so  applied  as  to  cause  grating  of  the  fragments 
upon  one  another,  but  it  is  often  by  no  means  distinct.  Ecchymosis  may  or 
may  not  be  present,  as  sometimes  the  fracture  affects  portions  of  the  bone  very 
deeply  situated,  and  the  vessels  torn  may  be  at  the  inner  surface.  Often  the 
fragments  are  scarcely  at  all  displaced,  and  hence  no  deformity  is  caused. 

It  may  readily  be  perceived,  therefore,  that  the  diagnosis  of  injuries  of  this 
kind  may  present  a  good  deal  of  obscurity;  and  even  when  the  fact  of 
fracture  is  clearly  to  be  made  out,  it  may  be  a  matter  of  much  difficulty 
to  determine  the  exact  line  of  separation,  especially  in  stout  or  fat  persons. 
Examination  by  the  rectum,  and  in  females  by  the  vagina,  may  enable  the 
surgeon  to  arrive  at  greater  certainty  in  this  respect.    But  even  the  most 


96 


INJURIES  OF  BONES. 


careful  and  thorough  exploration  nia}^  fail  to  ascertain  the  full  extent  of  the 
injury.  Malgaigne  quotes  from  Lyon  a  case  in  which  "  seven  or  eight  frac- 
tures were  discovered  by  dissection,  although  no  crepitation  had  been  per- 
ceptible during  life,  from  any  movement  whatever  of  the  pelvis."  I  myself 
know  of  an  instance  in  which  a  fracture  of  the  horizontal  ramus  of  the  pubis 
on  each  side,  of  the  ascending  ramus  of  the  ischium  on  each  side,  and  of  the 
sacrum  vertically,  with  much  comminution  of  its  lower  extremity  and  partial 
separation  of  the  right  sacro-iliac  symphysis,  entirely  escaped  detection  during 
life.  The  urethra  was  ruptured  across,  and  this  lesion  caused  the  patient's 
death  a  day  or  two  after  the  accident. 

The  gravity  of  fractures  of  the  pelvis  is  due  to  the  complications  apt  to 
attend  them,  rather  than  to  the  injury  inllicted  on  the  bone.  Several  cases 
have  been  mentioned  in  which  death  was  the  result  of  rupture  of  the 
bladder  or  urethra.  It  is  not  always  easy  to  explain  how  the  bladder  is  in- 
volved, as  in  some  instances  the  fracture  of  the  pubis  is  so  far  from  the  median 
line  that  the  fragments  can  scarcely  be  supposed  to  have  lacerated  it,  unless 
greatly  distended,  and  still  more  difficult  is  it  to  understand  in  what  way 
the  urethra  is  torn  across.  Yet  very  possibly  the  fracturing  force  may  greatly 
displace  the  fragments,  which  subsequently  are  restored  to  their  natural  posi- 
tion, or  nearly  so,  by  the  elasticity  of  the  bony  structure  ;  or  the  urethra  may 
be  subjected  to  violent  stress  between  a  foreign  body  below  and  the  pubic 
arch  above — a  supposition  rendered  more  likely  by  the  contused  and  bruised 
condition  of  the  tissues  of  the  perineum  in  some  of  these  cases. 

Swan^  relates  several  interesting  cases  of  fracture  of  the  pelvis,  in  one  of 
wdiich  two  inches  of  the  urethra  were  found  at  the  autopsy  to  have  been  torn 
away.  The  patient  had  fallen  from  a  horse,  breaking  the  right  pubis  through 
its  body  and  ramus,  and  separating  it  at  the  symph^^sis.  In  another  case,  the 
patient  having  been  run  over  by  a  loaded  wagon,  the  fracture  involved  the 
arch  of  the  pubis,  several  other  portions  of  the  ischium  and  pubis,  the  right 
acetabulum,  and  the  right  sacro-iliac  symphysis.  The  bladder  had  a  large 
rent  in  its  anterior  part,  and  the  urethra  w^as  torn  completely  through. 

Earle^  records  a  very  curious  case,  in  which,  by  a  fall  from  a  carriage,  "  the 
symphysis  pubis  was  separated  to  the  extent  of  three  inches,  and  the  sacro- 
iliac symphysis  on  the  left  side  was  nearly  separated  and  gaped  to  the  extent 
of  more  than  an  inch.  The  prostate  gland  had  been  torn  away  from  the 
bladder,  leaving  a  large  aperture  communicating  directly  with  the  cavity  of 
that  viscus.  The  urethra  still  retained  its  connection  with  the  ligament  on 
the  right  side  of  the  pubis,  and  the  prostate  gland  hung  loose  in  a  cavity  filled 
with  coagulum.    An  extensive  laceration  communicated  with  the  rectum." 

Fragments  of  the  fractured  pubis  have  been  known  to  make  their  way  into 
the  bladder.  Tillaux^  saw  such  a  case,  and  quotes  one  from  Lenoir,  in  which 
the  bit  of  bone  became  the  nucleus  of  a  stone.  He  mentions  also  that  ^N'elaton 
once  extracted,  through  the  vagina,  a  fragment  which  had  wounded  the  blad- 
der. By  mere  pressure,  a  displaced  fragment  may  obstruct  the  passage  of  a 
catheter. 

The  great  vessels  are  not  often  wounded  in  cases  of  fracture  of  the  pelvis, 
although  it  would  seem  as  if  they  readily  might  be.  Earle*  reports  a  case, 
,  in  which,  by  a  fall  from  a  third  story  window,  the  left  os  innominatum  was 
separated  at  the  symphysis  pubis  and  sacro-iliac  junction,  and  "  was  forced 
upward  to  a  considerable  extent.  The  common  iliac  vein  on  that  side  had 
been  torn  through,  and  the  pelvis  was  filled  with  blood."    The  patient,  who 


'  Mcd.-Cliir.  Trans.,  vol.  xii. 
8  Op.  cit.,  p.  830. 


2  Ibid.,  vol.  xix.  p.  257. 
*  Loc.  cit.,  vol.  xix.  p.  262. 


FRACTURES  OF  THE  PELVIS. 


97 


had  sustained  other  injuries  also,  died  an  hour  after  the  accident.  Lucas* 
records  three  cases,  in  one  of  which  the  right  internal  iliac  vein  was  wounded, 
while  in  another  the  right  external  iliac  artery  was  divided,  and  in  the  third 
the  left  external  iliac  vein  was  lacerated. 

Lente^  has  reported  a  case  in  which  the  small  intestine  was  wounded  b}^  a 
sharp  fragment  of  the  ill um.3 

Another  danger  which  occasionally  attends  these  injuries,  is  that  of  exten- 
sive suppuration.  Of  this  an  instance  has  been  mentioned  in  a  preceding 
page,  and  others  are  upon  record. 

With  regard  to  the  treatment  of  fractures  of  the  pelvis,  there  is  not  very  much 
to  be  said, "although  the  subject  is  one  of  great  practical  importan(;e.  Abso- 
lute rest  in  bed  is'generally  a  necessity  clearly  perceived  by  the  patient ;  and 
his  comfort  is  often  promoted  by  a  broad  bandage  firndy  applied  around  the 
pelvis,  a  thick  layer  of  raw  cotton  being  placed  next  the  skin.  AVhen  there 
is  a  tendency  to  displacement  inward  of  a  fragment,  as  for  instance  of  the 
iliac  crest,  the  pressure  of  the  bandage  may  do  harm,  and  it  should  either  be 
more  loosely  fastened,  or  cut  away  at  this  part,  or  even  dispensed  with  alto- 
gether. 

Shock,  if  it  be  present,  as  it  is  apt  to  be  in  the  early  stage  of  the  case,  should 
be  combated  by  stimulants — alcohol,  carbonate  of  ammonium,  hypodermic 
injections  of  ether,  and  external  heat. 

If  there  be  any  difficulty  in  urination,  the  bladder  should  be  carefully 
emptied  by  means  of  the  catheter,  and,  if  the  urine  thus  drawn  off  be  bloody, 
we  may  suspect  a  wound  of  the  bladder  or  urethra.  When  the  instrument 
cannot  be  readily  introduced,  if  the  patient  have  not  previously  been  the  sub- 
ject of  stricture,*^ injury  to  the  urethra  is  probably  present,  and  extravasation 
of  urine  must  be  looked  for.  Upon  the  first  evidence  of  this  complication, 
free  incisions  should  be  made  in  the  perineum. 

Wounds  of  the  large  vessels  are  apt  to  be  fatal  from  internal  hemorrhage 
before  there  is  any  clear  indication  of  the  nature  of  the  trouble ;  but,  if  this 
could  be  made  out,  the  obvious  course  would  be  to  cut  down  at  the  usual 
point,  and  apply  a  ligature. 

In  case  of  abscess,  incisions  should  be  made  at  such  points  as  to  allow  of 
the  readiest  escape  of  pus,  and  the  use  of  drainage-tubes  may  be  of  great  ad- 
vantage. 

The  comfort  of  the  patient  is  often  greatly  promoted  by  the  use  of  a  frac- 
ture-bed, as  the  unavoidable  disturban-ce  caused  by  the  insertion  of  a  bed-pan 
is  apt  to  produce  pain.  Should  the  treatment  be  prolonged,  the  occurrence 
of  bed-sores  must  be  carefully  guarded  against,  although  this  may  be  a  matter 
of  much  difficulty  ;  a  Avater-bed,  or  air-cushions,  may,  however,  be  used  with 
hope  of  success. 

In  the  cases  of  "double  vertical' fracture,"  before  alluded  to,  it  may  be 
necessary  to  prevent  the  riding  up  of  the  acetabular  fragment  by  applying 
extension  to  the  foot ;  and  this  is  to  be  done  by  the  weight  and  pulley,  to 
be  hereafter  described  in  connection  with  the  treatment  of  fractures  of  the 
femur. 

Mention  has  been  made  of  the  influence  of  muscular  action  in  the  ])roduc- 
tion  of  fractures  of  the  pelvic  bones  ;  and  if  this  can  be  ascertained  as  a  cause 
of  displacement  of  the  fragments,  the  necessity  of  oln-iating  it  by  position 

'  Lancet,  March  9,  1878.  '  New  York  Journal  of  Medicine,  .January,  1851. 

3  The  reader  will  find  some  interesting  and  instructive  cases  recorded  by  Lidell,  in  a  paper 
on     Ruptures  of  Pelvic  and  Abdominal  Viscera,"  in  the  Am.  Journal  of  the  Medical  Sciences  for 
April,  1867  ;  and  may  consult  with  advantage  a  monograph,  published  in  1851,  by  Dr.  Stephen 
Smith,  on  "  Rupture  of  the  Bladder." 
VOL.  IV. — 7 


^8 


INJURIES  OF  BONES. 


will  be  evident.  Flexion  of  tlie  thighs  on  the  trunk,  as  well  as  of  the  body 
forward,  will  be  indicated  in  any  such  case. 

A  few^  words  ma}-  finally  be  said  as  to  the  prognosis  in  fractures  of  the 
pelvis.  In  simple,  uncomplicated  cases,  there  may  be  no  grave  symptoms 
from  first  to  last,  and  entire  recovery  may  take  place.  When  the  bladder  or 
urethra  has  sustained  injury,  the  risk  is  greatly  increased ;  and  the  more  so 
the  nearer  the  lesion  is  to  the  cavity  of  the  peritoneum.  Complete  rupture  of 
the  urethra  has  always,  as  far  as  I  know,  proved  fatal.  Peritonitis  constitutes 
a  very  serious  complication,  but,  as  in  one  of  my  cases  above  mentioned,  may 
yield  to  treatment.  The  other  concomitant  injuries  refen^ed  to  have  always 
hitherto  resulted  in  death. 

In  non -fatal  cases  there  has  sometimes  been  permanent  lameness,  but  not 
very  great,  nor  involving  serious  disability. 

Occasionally,  when  recovery  takes  place  from  fracture  of  the  pelvis,  un- 
pleasant after-effects  manifest  themselves.  Thus,  in  the  Pennsylvania  Hos- 
pital Museum,  there  is  a  specimen,^  taken  from  a  man  who  had  been  crushed 
by  a  moving  car,  and  who  was  discharged  cured,  to  be  readmitted  eighteen 
months  afterward ;  he  was  then  "  suffering  from  severe  sciatic  pain,  but  was 
able  to  w^alk  with  canes,  sitting  down,  however,  only  with  difficulty.  An 
examination  rendered  it  probable  that  there  was  a  large  amount  of  callus 
pressing  upon  the  sciatic  nerve,  with,  perhaps,  a  fracture  of  the  femur.  An 
operation  was  performed  for  removing  the  head  of  the  femur.  Subsequent 
to  the  operation,  suppurative  fever  or  pyaemia  supervened,  and  death  followed 
on  the  ninth  day."  The  specimen  shows ''that  the  pelvis  had  sustained  a 
fracture,  separating  the  pubic  portion  of  the  bone  from  the  ilium,  passing 
from  about  the  sciatic  notch  posteriorly  to  the  acetabulum.  This  is  firmly 
united,  but  along  the  line  of  the  fracture,  extending  forward  into  the  acetabu- 
lum, and  posteriorly  covering  more  than  half  the  sciatic  nerve,  are  abundant, 
firm,  but  porous  exostoses.  From  the  spine  of  the  ischium  is  a  hook-like 
projection,  partially  surrounding  the  track  of  the  sciatic  nerve.  At  the  junc- 
tion of  the  ilium  and  the  ramus  of  the  pubis  is  a  groove  measuring  nearly  an 
inch  in  depth,  which  carried  the  tendons  of  the  iliacus  and  psoas  muscles. 
The  head  of  the  femur  cannot  be  replaced  in  its  socket,  and,  at  the  time  of 
the  operation,  w^as  found  resting  in  the  sciatic  region." 

Fractures  of  the  Clavicle. 

The  clavicle,  by  its  articulation  with  the  sternum,  affords  the  upper  extrem- 
ity its  only  fixed  connection  with  the  skeleton  of  the  trunk.  Its  outer  end 
has  a  seemingly  large,  but  really  quite  limited  range  of  motion,  and  is  fast- 
ened to  the  scapula,  not  only  by  the  small  acromio-clavicular  joint,  but  hy  the 
wide  and  strong  coraco-clavicular  ligament. 

At  its  sternal  end  this  bone  is  thickest ;  thence  to  near  the  middle  it  is 
rounded  ;  here  it  is  flattened  below,  and  turns  upward  ;  toward  the  outer  end 
it  becomes  very  broad  and  flat,  curving  forward.  The  degree  of  curve  varies 
in  different  bones,  as  docs  also  the  irregularity  of  shape  just  noted,  and  the 
size  and  thickness  of  the  whole  bone.  Besides  the  double  curve,  there  is  a 
more  or  less  marked  double  twist  in  the  clavicle. 

As  to  its  muscular  attachments,  this  bone  is  mainly,  indeed  almost  wholly, 
an  intermediate  bone ;  being  placed  between  the  clavicular  portion  of  the 
sterno-cleido-mastoid  and  the  costo-clavicular  ligament,  the  latter  being  really 

1  No.  1116^*,  Catalogue  (Suppleiueiit),  p.  22. 


FRACTURES  OF  THE  CLAVICLE. 


99 


the  tendon  of  origin  of  the  muscle  ;  while  most  of  the  remainder  of  its  length 
is  simply  interposed  between  the  trapezius  and  deltoid.  The  connection  of 
the  pectoralis  major  with  it  is  only  accessory.  The  only  muscle  which  acts 
directly  upon  the  clavicle  itself  is  the  subclavius,  and  the  function  of  this  is 
rather  to  limit  the  mobility  of  the  clavicle,  than  to  impress  motion  upon  it. 

Fractures  of  the  clavicle  are  among  those  of  most  frequent  occurrence. 
They  are  met  with  at  all  ages,  eveii  in  intra-uterine  life.  In  children  they  are 
very  common ;  out  of  316  cases  of  fracture  treated  at  the  Children's  Hospital 
in  Philadelphia,  in  seven  years,  the  clavicle  was  affected  in  94,  or  nearly  30 
per  cent.  Between  the  ages  of  15  and  65,  according  to  Malgaigne,  the  frac- 
tures of  this  bone  form  about  one-quarter  of  the  whole  number ;  and  only 
one-fourth  of  the  patients  are  females.  At  a  more  advanced  age,  however, 
he  noted  that  eleven  out  of  eighteen  cases  were  those  of  women. 

By  most  authors,  fractures  of  the  clavicle  are  divided  into  those  of  the 
inner,  middle,  and  outer  thirds  of  the  bone.  This,  although  a  convenient 
arrangement,  is  not  strictly  accurate,  as  some  oblique  fractures,  which  occupy 
the  outer  portion  of  the  inner  third,  in  part,  traverse  both  this  and  the  mid- 
dle third.  I  prefer  to  speak  of  fractures  of  the  body  of  the  bone,  of  those 
near  the  sternal  end,  and  of  those  near  the  acromial  extremity.  Fractures  of 
the  body  of  the  bone,  which  may  concern  the  middle  third  _only,  or  may 
encroach  also  upon  the  inner  or  more  rarely  upon  the  outer  third,  are  by  far 
the  most  numerous.  They  are  very  generally  oblique,  although  occasionally 
nearly  or  even  quite  transverse. 

Compound  fractures  of  the  clavicle  are  almost  never  met  with,  unless  they 
become  so  secondarily  by  a  sharp  fragment  penetrating  the  skin,  which  hap- 
pens extremely  seldom ;  and  they  are  not  often  comminuted,  at  least  to  such 
a  degree  as  to  influence  the  result.  Incomplete  fractures  of  this  bone  have, 
however,  been  repeatedly  observed,  and  not  a  few  instances  in  which,  the 
periosteum  being  untorn,  the  fragments  have  remained  in  place.  Several 
such,  occurring  "in  young  subjects,  have  been  recorded  by  Blandin*  and 
Robert,2  and  a  number  are  quoted  by  Malgaigne  from  different  authors. 
Hamilton  mentions  several  seen  by  himself  in  adults;  one  of  his  patients,  a 
woman,  was  eighty  years  old.  A  number  of  such  cases  are  on  record,  in 
which  the  fact  of  fracture  has  been  unrecognized  until  after  the  occurrence 
of  union. 

Fractures  of  the  clavicle  may  be  caused  by  direct  force,  as  by  a  blow,  by  the 
recoil  of  a  gun,  by  the  fall  of  a  heavy  body  upon  the  shoulder ;  by  indirect 
force,  as  by  a  fall  on  the  point  of  the  shoulder,  or  upon  the  hand ;  or  by  mus- 
cular action,  as  by  the  effort  to  pull  down  the  brace  of  a  carriage-top ,3  or  in 
striking  a  blow  with  a  whip."* 

In  inquiring  into  the  mechanism  of  the  production  of  fracture  under  either 
of  these  conditions,  it  must  not  be  forgotten  that  the  inner  or  sternal  end  of 
the  bone  is  firmly  fixed,  and  that,  as  before  stated,  the  range  of  motion  of  the 
acromial  end  is  but  limited.  There  is  another  anatomical  fact,  pointed  out 
by  me  many  years  since,^  which  I  believe  to  be  of  much  importance  in  con- 
nection with  this  subject.  It  is  the  close  relation  which  often  subsists  between 
the  clavicle  and  the  first  rib  ;  by  reason  of  which,  when  the  outer  end  of  the 
former  bone  is  forced  downward,  the  bone  itself  becomes  a  lever  of  the  first 
order,  the  rib  being  the  fulcrum.  In  some  persons  the  upper  part  of  the 
thorax  comes  much  more  nearly  to  a  point  than  in  others,  the  arch  of  the 

•  Am.  Journ.  of  the  Med.  Sciences,  April,  1843  ;  from  Journal  de  Med.  et  de  Chir.  Pratiques,  ■ 
Juillet,  1842. 

*  Ibid.,  Jan.  1859  ;  from  L'Union  Medicale. 

8  Hamilton,  op.  cit.,  p.  1-93.  "*  Parker,  New  York  Journal  of  Medicine,  July,  1852. 

'  New  York  Medical  Journal,  Oct.  1866. 


100 


INJUKIES  OF  BONES. 


first  rib  being  smaller,  and  the  bone  itself  more  delicate.  Again,  in  some 
persons  the  clavicle  is  much  straighter,  and  stands  out  more  directly  from  the 
sternum  than  in  others.  I  think  that  these  two  conditions  usually  correspond. 
When  the  first  rib  forms  a  wide  and  strong  arch,  and  the  collar-bone  runs 
somewhat  backward  as  well  as  closer  to  the  rib,  the  two  bones  may  even  be 
almost  in  contact  as  far  nearly  as  to  the  middle  of  the  clavicle.  In  such  a 
case,  a  blow,  the  recoil  of  a  gun,  or  any  force  driving  or  dragging  the  outer 
portion  of  this  bone  downward,  or  downward  and  backward,  would  act 
on  the  bone  as  a  lever,  and  tend  to  break  it  at  any  point  where  it  might  be 
weakest.  The  rib,  being  a  strongly  stayed  arch,  pressed  upon  at  its  convexity, 
would  not  give  way ;  while  the  clavicle  would  be  at  a  disadvantage,  being 
subjected  to  a  force  at  its  concavity,  tending  to  increase  its  curvature.  I 
think  that  this  was  clearly  the  mechanism  of  the  following  case,  mentioned  by 
Malgaigne:  "I  have  seen  an  incomplete  fracture  of  the  clavicle  resulting 
from  the  pressure  of  a  burden  which  slipped  from  the  shoulder  down  on  the 
arm,  and  thus,  pulling  downward  on  the  outer  end  of  the  bone,  bent  and 
broke  it  at  about  the  middle." 

Very  possibly  this  leverage  over  the  first  rib  may  have  something  to  do 
with  some  fractures  by  indirect  violence,  as  when  a  man  falls  forward  on  his 
outstretched  hand,  and  the  scapula,  forced  backward  by  the  head  of  the 
humerus,  carries  the  acromial  end  of  the  clavicle  along  with  it. 

There  are  cases  in  which  it  would  seem  that  the  clavicle  is  broken  by  the 
forcing  upward  of  its  acromial  end ;  and  these  can  only  be  explained  by  the 
firmness  of  its  ligamentous  attachment  to  the  sternum,  and  the  unyielding 
character  of  the  rhomboid  or  costo-clavicular  ligament.  Perhaps,  however, 
more  accurate  information  as  to  the  circumstances  would  set  this  theory 
aside.  Often  the  surgeon  has  to  be  content  wath  very  vague  statements  on 
the  part  of  the  patient  or  his  friends,  and  caution  is  needful  in  drawing  con- 
clusions from  premises  which  may  be  wholly  or  in  part  incorrect. 

When  the  clavicle  gives  way  to  a  force  acting  at  its  outer  extremity,  as  in 
the  case  of  a  fall  on  the  point  of  the  shoulder,  it  may  be  easily  seen  that  the 
mechanism  is  simply  the  exaggeration  of  the  normal  curves,  carried  so  far  as 
to  overcome  the  resistance  of  the  bony  structure.  And  the  more  suddenly 
the  stress  comes,  the  more  likely  is  the  bone  to  be  broken.  The  point  at 
which  the  fracture  shall  occur  is  determined  by  the  exact  direction  of  the 
force,  and  perhaps  in  some  degree  by  the  action  of  the  muscles  at  the  moment. 
But  in  the  very  large  majori'ty  of  cases  the  line  of  fracture  runs  obliquely 
through  the  body  of  the  l3one,  from  within  outward  and  from  before  back- 
ward. The  relation  of  the  obliquity  to  the  upper  and  lower  surfaces,  I  do  not 
know  ;  it  is  probably  not  a  constant  one. 

Symptom.s  of  Fractured  Clavicle. — Upon  the  occurrence  of  fracture  of  the 
clavicle,  if  the  periosteum  yields,  there  is  generally  marked  displacement 
And  this  may  be  either  a  mere  prominence  of  the  inner  fragment,  or  a  posi- 
tive projection,  the  outer  fragment  being  carried  behind  the  inner  so  as  to 
make  the  latter  start  forward.  This  is  the  almost  universal  rule ;  but  cases 
have  been  observed  in  which  the  outer  fragment  has  been  in  front  of  the 
inner.  The  annexed  cut  (Fig.  821)  represents  the  clavicle  of  a  patient  in  my 
wards  at  the  Episcopal  Hospital  in  1882,  in  whom  the  outer  fragment  was 
directly  below  the  inner.  The  man  was  a  German  teamster,  and  said  he  had 
fallen  down,  striking  his  shoulder ;  he  could  give  no  details  of  the  accident, 
and  at  the  time  when  1  saw  him  there  was  no  bruise  or  other  indication  of 
the  exact  point  of  impact.  The  complete  reduction  of  the  fracture  was  im- 
possible, but  a  good  recovery  ensued,  with  some  superabundance  of  callus.  I 


FRACTURES  OF  THE  CLAVICLE. 


101 


cannot  offer  any  explanation  of  these  exce[)tions ;  but  it  will  be  seen  that  in 
my  case  the  fracture  involved  the  sternal  third  of  the  bone. 

Sometimes,  when  the  cause  of  the  fracture  has  been  direct  violence,  it  is 
sufficiently  obvious  that  the  outer  fragment  has  been  driven  back  from  the 


inner.  But  there  must  be  a  further  reason  for  the  very  general  existence  of 
this  displacement,  and  I  believe  it  is  to  be  found  in  the  changed  position  of 
the  scapula.  Upon  the  loss  of  the  stay  afforded  by  the  unbroken  clavicle, 
the  serratus  magnus  and  peetoralis  minor  muscles  pull  the  scapula  forward 
and  inward,  while  perhaps  the  rhomboidei  muscles  draw  up  its  lower  angle. 
The  acromion  is  thus  brought  nearer  to  the  median  line,  and  tilted  down- 
ward ;  the  effect  of  which  is  to  push  the  distal  fragment  of  the  broken  clavicle 
inward,  and  to  depress^  its  outer  end.  This  seems  to  me  to  afford  an  ample 
explanation  of  the  very  constant  occurrence  of  this  form  of  displacement. 
Very  possibly  the  fibres  of  the  subclavius  may  also  draw  upon  the  outer  frag- 
ment, and  aid  in  the  production  of  the  deformity.  The  forcing  of  the  outer 
fragment  behind  the  inner  will  tilt  the  latter  upward  and  forward  ;  and  my 
belief  is  that  to  this,  and  not  to  the  action  of  the  clavicular  portion  of  the 
sterno-cleido-mastoid,  is  due  the  projection  of  the  inner  fragment  so  com- 
monly present.  The  action  of  the  last-named  muscle,  indeed,  is  from  below 
upward  (the  Germans  call  it  "Kopf-nicker,"  that  is,  head-nodder),  and  through 
the  rhomboid  or  costo-clavicular  ligament  it  gets  an  origin  from  the  first  rib. 
This  ligament  would  of  itself  prevent  the  drawing  up  of  the  inner  fragment, 
unless,  as  sometimes  happens,  it  should  be  itself  ruptured. 

By  all  authors  we  are  told  that  the  shoulder  falls  forw^ard,  inw^ard,  and 
downward,  and  that  this  displacement  is  due  to  the  weight  of  the  shoulder 
and  of  the  upper  extremity.  It  is  true  that  the  shoulder  does  thus  change 
its  position ;  yet  the  muscles  which  support  it  are  not  impaired,  and  the 
mei'e  lifting  of  the  w^eight  does  not  remedy  the  deformity.  When  the  scapula 
itself  is  drawn  back  into  position,  and  only  then,  does  the  outer  fragment  of 
the  clavicle  resume  its  normal  relation  to  the  inner. 

The  explanation  now  given  of  the  cause  of  deformity  in  fracture  of  the 
clavicle  finds  strong  confirmation,  I  think,  in  the  condition  observed  when 
the  bone  is  broken  near  the  acromial  extremity.  Here  the  short  outer  frag- 
ment is  pushed  round  forward  and  inward,  so  as  to  form  almost  or  quite  a 
right  angle  with  the  inner,  the  broken  end  of  the  former  even  coming  in  con- 
tact with  the  anterior  v/all  of  the  latter.  Many  museum  specimens  exist  in 
proof  of  this  statement,  and  two  such  are  in  the  ^liitter  collection  in  this 
city.  Malgaigne  mentions  two  cases  of  fracture  very  near  the  acromial  end, 
in  which  union  had  taken  place.  In  each  of  them,  "  the  shoulder  was  de- 
pressed, and  carried  forw^ard  and  inward  ;  .  .  .  and  to  this  inclination  of 
the  shoulder  there  corresponded  posteriorly  a  notable  prominence  of  the  infe- 
rior angle  and  posterior  edge  of  the  scapula."  Both  the  patients  had  perfect 
motion  of  the  arm,  except  backward.  Here  it  seems  to  me  quite  plain  that 
the  change  of  shape  is  to  be  accounted  for  as  follows :  partly  by  the  action  of 
the  clavicular  part  of  the  trapezius,  drawing  up  both  fragments,  and  favored 
in  so  doing  by  its  attachment  to  the  natural  convexity  of  the  bone;  partly 


Fig.  821. 


Fracture  of  clavicle  with  downward  displacement  of  outer  fragment. 


102 


INJURIES  OF  BONES. 


by  the  tilting  upward  and  backward  of  the  lower  angle  of  the  scapula  by  the 
rhomboideus  major  muscle,  aided  by  the  weight  of  the  arm  dragging  on  the 
upper  and  outer  angle  of  the  bone,  and  through  the  acromion  on  the  outer 
end  of  the  clavicle  ;"but  chiefly  by  the  serratus  magnus  and  pectoralis  minor 
carrying  the  whole  scapula  forward  and  inward  around  the  side  of  the  thorax, 
and  thus  bringing  the  outer  fragment  into  exactly  the  position  described  with 
regard  to  the  inner. 

A  case  mentioned  by  Malgaigne  so  strongly  illustrates  the  theory  now 
stated,  that  I  venture  to  quote  it  at  length : — 

The  patient  had  sustained  a  fracture  of  both  clavicles  by  a  fall  from  a  window  fifteen 
feet  high.  Non-union  had  occurred  in  both  bones,  and  the  impairment  of  function 
was  such  that  he  could  not  resume  his  former  occupation  as  a  tinsmith,  but  became  a 
tailor. 

"  Both  clavicles  had  been  broken  at  the  middle  ;  the  two  inner  fragments  were  nearly 
horizontal,  and  very  distinct  beneath  the  skin  ;  the  outer  fragments  had  also  a  nearly 
horizontal  direction,  but  were  buried  behind  and  below  the  others,  to  which  they  seemed 
to  have  no  adhesions  of  any  kind.    The  overlapping  was  considerable. 

"  When  he  stood  up  the  two  shoulders  seemed  lower,  as  well  as  carried  further  forward 
and  inward,  than  in  a  healthy  person.  The  one  on  the  right  side  was  higher,  and  at 
the  same  time  closer  to  the  sternum,  than  the  other.  Posteriorly  the  scapulas  were  sepa- 
rated from  the  spinal  column  by  three  or  four  inches,  and  inclined  forward  and  out- 
ward ;  and,  on  the  whole,  the  thorax  seemed  contracted  at  its  upper  part. 

"  He  could  draw  the  shoulders  back  a  little,  but  not  enough  to  overcome  their  appa- 
rent prominence  anteriorly.  On  the  other  hand,  he  could  draw  them  together  forward 
so  that  they  seemed  like  wings  covering  the  chest,  and  leaving  between  them,  in  front 
of  the  sternum,  only  three  inches  of  space.  In  this  movement  the  scapulae to  the 
sides  of  the  trunk,  and  the  back  seemed  rounded  from  one  side  to  the  other,  almost  like 
that  of  a  skeleton  deprived  of  its  upper  extremities.  The  shoulders  could  be  raised  also 
at  will,  but  not  to  any  extent,  from  want  of  muscular  power." 

Professor  Gordon,  of  Belfast,  has  expressed^  views  in  regard  to  the  dis- 
placement in  fractures  of  the  clavicle,  exactly  the  same  as  my  own.  ^  As  he 
has  not  referred  to  my  paper,  I  presume  that  he  is  not  aware  of  its  existence. 
Though  these  views  have  not  as  yet  received  the  general  assent  of  surgical 
writers,  my  belief  is  that  they  are  correct,  and  that  they  w^ill  ultimately 
obtain  acceptance. 

Prof.  Moore,  of  Rochester,  N.  Y.,^  regards  the  relaxation  of  the  clavicular 
fibres  of  the  pectoralis  major  muscle,  and  the  consequently  unopposed  action 
of  the  sterno-cleido-mastoid,  as  the  great  cause  of  the  displacement;  but  it 
does  not  seem  to  me  that  this  view  is  tenable. 

I  say  nothing  of  rotary  displacement,  because  nothing  of  the  kind  has 
ever  occurred  in  the  cases  under  my  notice,  and  I  do  not  think  it  exists. 

Pain  is  an  almost  constant  symptom  of  fracture  of  the  clavicle.  When  the 
line  of  separation  is  oblique,  as  in  most  cases,  this  is  obviously  due  partly  to  the 
pressure  of  the  ends  of  the  fragments,  especially  of  the  inner,  against  the  skin. 
According  to  Tillaux,  it  is  the  filaments  of  the  supra-clavicular  nerve,  in  the 
platysma  myoides  muscle,  which  are  thus  irritated  ;  but  the  fact  that  there 
are  often  pain  and  numbness  down  the  arm,  and  even  in  the  fingers,  afibrds 
proof  that  the  large  trunks  of  the  brachial  plexus  are  also  interfered  with. 
In  order  to  obtain  relief,  patients  are  very  apt  to  assume  a  position  which, 
by  some  authors,  has  been  considered  almost  a  diagnostic  sign ;  they  support 
tlie  arm  of  the  injured  side  by  placing  the  other  hand  under  the  forearm, 
and  incline  the  head  toward  the  aftected  shoulder. 

»  Dublin  Quarterly  Journ.  of  Med.  Science.  Nov.  1859.  Also  in  a  Treatise  on  Fractures  of  the 
Lower  End  of  the  Radius,  on  Fractures  of  the  Clavicle,  and  on  the  Reduction  of  the  Recent  Inward 
Dislocations  of  the  Shoulder-joint.    London,  1875. 

«  Trans,  of  Med.  Soc.  of  State  of  N.  Y.,  1870,  p.  107. 


FRACTURES  OF  THE  CLAVICLE. 


103 


Swelling  is  very  apt  to  occur,  especially  in  fractures  caused  by  direct  vio- 
lence, and  attended  with  much  bruising  of  the  soft  parts ;  but  it  is  not  often 
so  marked  as  in  some  other  regions,  nor  does  it  generally  mask  the  condition 
of  the  bone  so  completely,  by  reason  of  the  sniall  amount  of  subcutaneous 
areolar  tissue  existing  here. 

Ecchymosis  may  or  may  not  be  present,  according  to  the  character  of  the 
fracture  and  the  amount  of  injury  to  the  small  veins  of  the  skin.  It  is  very 
rare  to  have  the  deep  staining  of  the  surface,  coming  on  slowly  and  very 
gradually  subsiding,  which  is  often  met  with  in  the  case  of  the  larger  bones. 

Crepitus  is  very  generally  to  be  felt.  It  suffices  to  gently  i)ress  the  point 
of  the  shoulder  forward,  the  fingers  of  the  surgeon's  other  hand  being  lightly 
laid  over  the  bone,  to  develop  a  sufficient  sound.  Sometimes,  indeed,  this  is 
the  only  symptom  present.  M.  Guerin^  has  reported  the  case  of  a  man  aged 
60,  whose  clavicle  was  broken  by  a  fall  of  earth.  During  life  the  only  posi- 
tive symptom  of  the  injury  was  slight  crepitus.  After  the  patient's  death 
(from  pneumonia)  the  fragments  could  be  made  to  project  by  means  of  the 
linger  passed  behind  the  bone. 

Alono-  with  the  crepitus,  and  shown  by  the  same  manoeuvre,  there  is  often 
perceptfble  an  abnormal  mobility  at  the  seat  of  fracture.  The  degree  of  this 
will  be  dependent  upon  the  completeness,  not  only  of  the  fracture,  but  of  the 
tearing  of  the  periosteum,  as  well  as  upon  the  direction  of  the  line  of  break- 
age, and  often  upon  the  amount  of  serration  of  the  fragments.  But  whether 
slight  or  otherwise,  it  is  an  unmistakable  proof  of  the  character  of  the  lesion. 

Fractures  of  the  sternal  j)ortion  of  the  clavicle  are  much  less  frequent  than 
those  of  the  acromial  extremity,  and  very  rare  indeed  as  compared  with 
those  of  the  body  of  the  bone.  They  have  attracted  but  little  notice,  an 
article  by  Delens^  being  the  fullest  source  of  information  in  regard  to  them 
up  to  the  present  time.  This  author  states  that  while  they  have  been  observed 
as  the  result  of  both  direct  and  indirect  violence,  muscular  action  is  by  far 
their  most  frequent  cause.  One  instance  of  the  latter  kind  has  been  reported 
by  Heath  :— ^  • 

A  boy  of  fourteen,  "  whilst  raising  his  arm  violently  to  bowl  at  cricket,  felt  something 
give  way  at  liis  collar-bone.  The  inner  end  of  the  clavicle  was  found  to  be  unduly 
prominent,  and  presented  a  sharp  edge  beneath  the  skin,  quite  unlike  the  smooth  end  of 
a  bone  covered  with  articular  cartilage.  The  supra-sternal  notcli  was  quite  distinct, 
and  equally  defined  on  both  sides,  and  a  thin  lamella  could  be  felt  on  the  right  side, 
intervening  between  it  and  the  gap  caused  by  the  starting  forward  of  the  inner  end  of 
the  clavicle.  The  treatment  consisted  in  laying  tlie  patient  down,  when  the  bone  at 
once  dipped  into  place,  and  Avas  retained  by  a  plaster-of-Paris  bandage."  This  cannot 
have  been,  as  was  suggested,  a  separation  of  the  epiphysis,  since  no  such  formation 
takes  place,  according  to  anatomists,  before  the  twentieth  year ;  and  perhaps  it  miglit 
more  correctly  be  placed  under  the  head  of  sprain-fracture. 

Of  fractures  by  indirect  violence,  the  clearest  instance  is  that  recorded  by 
Willis:—* 

A  man,  aged  54,  slipped  off  a  hay-rick,  falling  on  his  outstretched  right  hand,  and 
striking  his  riglit  shoulder.  On  examination,  there  was  discovered  a  simple  fracture  of 
the  right  clavicle  within  a  quarter  of  an  inch  of  the  sternal  head  of  the  bone.  The 
direction  of  the  fracture  was  obliquely  downward  and  outward.  The  outer  fragment 
was  tilted  up,  partly  by  the  direct  action  of  some  of  the  fibres  of  the  sterno-cleido-mas- 
toid,  partly  by  tlie  weight  of  the  arm  dragging  the  acromial  end  downward  ;  it  wjis 
very  sharp,  and  threatened  to  pierce  tlie  skin.  Much  difficulty  was  experienced  in  coap- 
tation of  the  ends,  which  could  only  be  fully  effected  by  strongly  raising  the  arm — 


»  Gaz.  Hebdom.,  20  Sept.  1867. 

3  Brit.  Med.  Journal,  Nov.  18,  1882. 


*  Arcli.  Gen.  de  Medecine,  Mai,  1873. 

*  Lancet,  Dec.  2,  1882. 


104 


INJURIES  OF  BONES. 


a  position  which  the  patient  either  could  not  or  would  not  long  tolerate.  A  sling,  and 
a  compress  over  the  clavicle,  were  employed  ;  and  a  year  subsequently,  the  sharp  frag- 
ment had  been  greatly  rounded,  and  fibrous  union  had  occurred. 

Willis  thinks,  and  with  reason,  that  in  this  case  the  rhomboid  or  costo-clavicular 
ligament  was  ruptured. 

A  case  has  been  published^  (w^ithout  the  reporter's  name)  as  occurring  at 
the  Mount  Sinai  Hospital,  in  New  York,  in  which  the  clavicle  was  broken 
about  an  inch  from  the  sternum.  The  cause  of  the  injury  is  not  mentioned ; 
but  it  is  stated  that  the  inner  fragment  was  Vertical,  and  the  other  "  down 
upon  the  chest."  The  deformity  caused  no  inconvenience,  and  was  not  reme- 
died. The  reporter  ascribes  it  to  the  action  of  the  sterno-cleido-mastoid.  I 
quote  this  report,  notwithstanding  its  vagueness,  because  it  seems  to  me  to 
be  illustrative  of  the  proper  division  of  these  injuries ;  the  lesion  was  really, 
although  near  the  inner  end,  simply  a  fracture  of  the  body  of  the  bone,  in 
which  the  displacement  was  of  the  ordinary  kind,  and  due  to  the  same  causes 
as  before  mentioned  ;  but  was  exaggerated  by  the  shortness  of  the  inner  frag- 
ment. Possibly,  the  rhomboid  ligament  being  torn,  the  muscle  may  have 
contributed  to  the  elevation  of  the  inner  fragment,  but  I  do  not  think  it  alone 
could  have  produced  it. 

The  view  I  wish  to  maintain  is,  that  the  mechanism  of  fractures  of  the 
inner  third  of  the  clavicle  is  the  same  as  that  of  fractures  of  the  middle  third, 
and  that  the  displacement  occurs  in  the  same  way;  and  hence  I  would  simply 
class  them  with  fractures  of  the  body  of  the  bone. 

Fractures  involving  the  sternal  end  of  the  clavicle  are,  however,  distin- 
guished by  certain  features,  as  may  be  readily  seen  in  the  instances  before 
quoted  from  Heath  and  Willis.  Lonsdale^  mentions  the  case  of  a  boy,  aged  3, 
who  fell  and  struck  his  shoulder  against  the  edge  of  a  step,  fracturing  the 
clavicle  about  half  an  inch  from  the  sternum ;  he  says  that  the  crepitus  of 
fracture  could  be  distinctly  felt,  and  the  end  of  the  bone  moved  from  its 
natural  position." 

Fractures  of  the  acromial  extremity  of  the  clavicle  embrace  all  those  which 
affect  the  bone  anywhere  between  the  acromio-clavicular  joint  and  the  inner 
edge  of  the  coraco-clavicular  ligament.  They  may  be  caused  by  direct  or 
indirect  violence ;  it  is  difficult  to  see  how  they  could  result  from  muscular 
action,  and  I  know  of  no  record  of  any  such  case.  Indeed,  the  clinical  his- 
tory of  these  lesions  is  very  meagre  ;  but  specimens  in  which  union  has  taken 
place  are  by  no  means  rare.  Ossification  of  the  coraco-clavicular  ligament, 
more  or  less  complete,  has  been  noted  in  some  of  the  cases. 

It  has  been  already  stated,  in  speaking  of  the  mechanism  of  fractures  of 
the  body  of  the  clavicle,  that  the  condition  observed  when  the  outer  third  of 
the  bone  is  broken,  is  dependent  upon  the  dragging  forward  and  inward  of  the 
scapula,  by  the  action  of  the  serratus  magnus  and  pectoralis  minor  muscles. 

Occasionally  the  clavicle  is  broken  at  more  than  one  point.  Malgaigne 
mentions  and  figures  a  remarkable  specimen,  without  history,  in  which  one 
fracture  is  near  the  sternal  end  and  the  other  near  the  acromial.  He  speaks 
of  the  case  of  a  little  girl  who  had  a  double  fracture,  the  middle  fragment, 
less  than  an  inch  in  length,  being  tilted  up  in  a  vertical  position  between  the 
others,  so  that  it  could  not  be  reduced.  Conner^  says  that  he  obtained  at  an 
autopsy,  Siv  the  Charity  Hospital  at  'New  Orleans,  "  a  right  clavicle  which 
had  been  broken  in  two  places,  the  union  being  ligamentous  at  both." 

Simultaneous  fracture  of  both  clavicles  has  sometimes  been  met  with.  One 
case  recorded  by  Malgaigne  has  already  been  quoted,  in  illustration  of  the 

«  New  York  Med.  Journal,  Jan.  1877.  2  Op.  cit.,  p.  206. 

3  Holmes's  System  of  Surgery,  Am.  ed.,  vol.  i.  p.  848. 


FRACTURES  OF  THE  CLAVICLE. 


105 


/nechanisrn  of  the  displacement.  Gurlt  gives  fifteen,  all  produced  by  very 
great  violence.  Besides  these,  Lane,^  Burr ,2  and  Wight^  have  published  cases 
of  the  kind.  Wight's  patient  had  good  union  in  the  bone  of  the  left  side, 
but  only  ligamentous  in  the  right ;  yet  he  could  work  as  well  as  ever.  These 
cases  have  a  special  interest,  to  be  further  referred  to,  in  view  of  the  difficul- 
ties presented  in  their  treatment. 

Diagnosis. — The  diagnosis  of  fracture  of  the  clavicle  is  for  the  most  part 
easy ;  the  attitude  of  the  patient,  the  loss  of  power  in  the  arm,  the  seat  of 
pain,  the  projection  of  the  fragment  or  fragments  which  can  often  be  both 
seen  and  felt,  the  crepitus,  and  the  abnormal  mobility — all  these  signs,  with 
the  history  of  a  fall  on  the  hand,  or  on  the  point  of  the  shoulder,  or  of  vio- 
lence applied  to  the  part,  or  of  stress  put  upon  the  bone  by  sudden  muscular 
exertion,  w^ill  generally  lead  even  a  non-professional  person  to  a  true  construc- 
tion of  the  case. 

When,  as  in  transverse  fractures,  with  little  or  no  displacement,  deformity 
is  wanting,  pain  is  slight,  and  crepitus  is  hardly  to  be  perceived,  the  existence 
of  tenderness  at  a  special  point,  developed  either  by  direct  pressure  oi-  by  a 
push  or  tap  on  the  acromial  end  of  the  bone,  should  suffice  to  indicate  the 
nature  of  the  injury. 

The  caution  given  in  regard  to  some  other  cases,  as  to  undue  zeal  in  the 
eliciting  of  symptoms,  may  be  emphasized  here ;  as  there  are  instances  on 
record  in  which,  in  able  hands,  incomplete  fractures  have  been  made  com- 
plete, of  course  increasing  the  risk  of  deformity.  Should  there  be  any  doubt, 
it  would  be  right  to  treat  the  case  as  one  of  fracture ;  keeping  the  arm  and 
shoulder  at  as  perfect  rest  as  possible,  and  watching  for  the  occurrence  of 
more  positive  symptoms. 

Complications. — Examples  of  complicated  fracture  of  the  clavicle,  although 
not  by  any  means  of  frequent  occurrence,  have  been  often  enough  recorded  to 
make  it  surprising  that  Malgaigne  should  have  known  of  no  such  cases.'^ 
These  complications  may  consist  in  injuries  of  the  artery,  veins,  or  nerves ; 
of  the  lungs ;  or  of  other  bones.  They  may  ensue  immediately,  or  may  be 
among  the  later  phenomena ;  and  they  differ  greatly  in  the  degree  of  their 
gravity,  of  the  suffering  which  they  cause,  and  of  their  amenability  to  treat- 
ment. 

Evans^  reports  a  case  in  which  an  aneurism  of  the  iyinominate  artery  was 
ascribed  to  a  fracture  of  the  right  clavicle  sustained  by  the  patient,  a  sailor, 
many  months  before  he  came  under  surgical  observation.  Dupuytren  is  said 
by  Delens^  to  have  given,  in  a  clinical  lecture  in  1831,  several  cases  of  aneu- 
rism from  a  like  cause. 

Injury  of  the  'veins  is  somewhat  more  frequent.  Holmes^  says,  ''I  have 
once  seen  death  result  from  this  injury  in  consequence  of  the  fragment  hav- 
ing lacerated  the  internal  jugular  vein."  Hulke  and  Flower^  mention  a  speci- 
men (perhaps  from  the  same  case)  of  like  injury.  They  also  refer  to  the  case 
of  Sir  Robert  Peel,^  in  which  there  was  "  a  comminuted  fracture  of  the  left 
clavicle,  below  which  a  swelling  as  large  as  the  hand  could  cover,  and  which 
pulsated  synchronously  with  the  contractions  of  the  auricles  of  the  heart, 

1  Lancet,  July,  1876.  *  2  Medical  Record,  May  6,  1882. 

«  Med.  Gazette  (New  York),  1882.  ^  Op.  cit.,  p.  471  ;  translation,  p.  382. 

^  Transactions  of  Pathological  Society  of  London,  vol.  xvii.  1866. 

^  Arch.  Gren.  de  Medecine,  Aout,  1881. 

'  Surgical  Treatment  of  the  Diseases  of  Infancy  and  Childhood,  1st  ed.,  p.  248. 
*  Holmes's  System  of  Surgery,  2d  ed.,  vol.  ii.  p.  769  ;  Am.  ed.,  vol.  i.  p.  848. 
^  Lancet,  July  6,  1850  (editorial  article). 


106 


INJURIES  OF  BONES. 


formed."  It  seemed  probable,  from  the  pain,  that  some  cords  of  the  axillary 
plexus  had  also  been  injured. 

Boone^  reports  a  case  in  which  a  fragment  from  a  comminuted  fracture  of 
the  clavicle  produced  somewhat  serious  symptoms  by  pressure  upon  the  sub- 
clavian vein  and  adjacent  nerves.  Erichsen^  gives  a  similar  case,  in  which, 
however,  death  ensued  from  gangrene  of  the  arm.  Maunoury^  records  an 
instance  of  fracture  of  the  clavicle  with  rupture  of  the  subclavian  vein  ;  great 
swelling  having  occurred,  an  incision  was  made,  and  death  immediately 
resulted  from  hemorrhage  and  entrance  of  air  into  the  vein. 

Of  injuries  of  the  nerves  a  good  many  instances  are  recorded,  only  a  few  of 
which  need  be  quoted  here.  Gibson*  saw  a  young  man,  who  had  sustained  a 
comminuted  fracture  of  the  clavicle  by  direct  violence ;  "  the  fragments  had 
been  driven  behind  and  beneath  the  level  of  the  first  rib,  and  so  compressed  the 
plexus  of  nerves  as  to  wedge  them  into  each  other,  and  by  the  subsequent  inflam- 
mation to  blend  them  inseparably  together.  Complete  paralysis  and  atrophy 
of  the  whole  arm  ensued."  The  patient  desired  to  obtain  relief  by  operation, 
but  Gibson  deemed  the  chance  of  success  too  small,  and  declined  to  attempt 
it.  Surgeons  of  the  present  day  would  probably  have  taken  a  more  hopeful 
view,  and  cases  will  be  hereafter  mentioned  in  which  operative  interference 
has  been  attended  with  good  results. 

Chalot^  reports  that  "  in  the  case  of  a  man  of  35,  disturbances  of  innervation  showed 
themselves  in  the  right  arm  as  a  result  of  fracture  of  the  clavicle.  Beginning  with  a 
sensation  of  deadness,  formication,  and  pricking,  particularly  in  the  palm  of  the  hand, 
the  affection  went  on  to  extreme  anaesthesia.  Very  slight  irritation  of  the  finger-tips, 
or  the  hollow  of  the  hand,  or  somewliat  greater  movements  of  the  flexor  surface  of  the 
forearm,  brought  o-n  nausea,  gagging,  and  vomiting,  with  occasional  severe  diaphrag- 
matic cramp  and  thoracic  oppression  (Beklemmung).  The  patient  became  first  pale, 
thfen  red  ;  a  cold  sweat  covered  the  forehead  on  the  affected  side.  Irrigation  with  cold 
water  caused  the  symptoms  to  appear  to  a  more  marked  degree,  while  warm  water  made 
them  milder.  The  extremity  became  smaller,  colder  than  the  healthy  side,  the  skin 
everywhere  dry  except  in  the  hollow  of  the  hand,  there  wet  with  perspiration.  The  mus- 
cles reacted  weakly.  Pressure  upon  the  branches  of  the  nerves  brought  on  swimming  in 
the  head  and  faintness.  Pressure  upon  the  callus  at  the  point  of  fracture  of  the  clavicle, 
which  had  united  with  considerable  deformity,  was  quite  painful,  and  gave  rise  to  dia- 
phragmatic cramp.  Pressure  upon  the  nerves  of  the  face,  throat,  and  nape  of  the  neck, 
on  the  affected  side,  caused  similar  symptoms."  The  further  history  of  the  case  is  not 
given. 

Gross^  mentions  a  case  of  partial  paralysis  of  the  upper  extremity,  with 
atrophy  and  permanent  contraction  of  some  of  the  muscles,  in  a  boy  of  fif- 
teen, the  clavicle  having  been  broken  by  the  recoil  of  a  shot-gun  four  months 
and  a  half  previously. 

Delens^  records  a  case  in  which  the  superabundant  callus  of  a  fractured 
clavicle  (two  ribs  also  having  been  broken)  exerted  such  pressure  on  the  sub- 
clavian vessels  and  nerves  as  to  impair  the  nutrition  and  muscular  power  of 
the  limb.  Relief  was  afibrded  by  a  subperiosteal  resection.  Two  other 
instances,  in  which  resection  of  the  fragments  was  practised,  one  observed  b}^ 
Gosselin  and  the  other  by  Perier,  are  referred  to  in  this  article. 

Perhaps  it  may  be  remarked  here  that  care  is  to  be  taken  not  to  confound 

»  Medical  Record,  November  15,  1873.  2  British  Medical  Journal,  June  7,  1873. 

3  Progres  Medical,  1882,  tome  x.  p.  302.  Reference  is  here  made  also  to  a  monograph  by  Cham- 
pomier,  "  Contribution  a  I'etude  des  lesions  des  troncs  veineux  de  la  base  du  cou  dans  les  fractures 
de  la  clavicule."    Paris,  1882. 

*  Op.  cit.,  vol.  i.  p.  254. 

6  Philadelphia  Medical  Times,  March  27,  1880,  from  Centralbl.  fiir  Chirurgie. 

6  Op.  cit.,  vol.  i.  p.  946.  '  Arch.  Gen.  de  Med.,  Aout,  1881. 


FRACTURES  OF  THE  CLAVICLE. 


107 


nerve-lesions  due  to  the  original  injury  with  those  which  may  be  brought  on 
by  the  pressure  of  apparatus,  as  pointed  out  especially  by  Hamilton,  and  to 
be  further  discussed  in  connection  with  treatment. 

Wound  of  the  lung  is  said  to  have  been  several  times  noticed  in  connection 
with  fracture  of  the  clavicle,  but  I  am  not  aware  that  it  has  ever  been  veri- 
fied by  an  autopsy  except  once.  Ilammick^  speaks  of  a  man  who  had  had  a 
fracture  of  the  clavicle  three  days  before  he  came  under  observation  ;  he  died 
of  pneumonia,  and  on  dissection  it  was  found  that  tlie  fractured  portion  was 
so  depressed  as  to  have  wounded  the  pleura  and  torn  the  lung.  Gibier^  reports 
a  case  in  which  the  acromial  fragment  wounded  the  lung,  and  produced  em- 
physema; the  patient  recovered,  but  with  non-union  of  the  fracture.  Mer- 
cier'*  gives  a  similar  case,  and  refers  to  several  others. 

The  uncertainty  in  all  these  cases  in  which  recovery  takes  place,  is  not  with 
regard  to  the  wound  of  the  lung,  which  is  sufficiently  established  by  the  oc- 
currence of  emphysema,  and  occasionally  by  haemoptysis,  but  as  to  the  mode 
of  its  production — whether  there  is  not  a  fracture  of  a  rib  as  well  as  of  the 
clavicle.  It  is  not,  how^ever,  a  matter  of  serious  importance ;  the  relation  of 
the  apex  of  the  lung  to  the  clavicle  is,  in  most  persons,  such  that  a  wound  of 
the  former  might  readily  occur  by  a  fragment  of  the  broken  bone. 

The  complication  of  fracture  of  the  clavicle  with  that  of  other  hones  some- 
times presents  itself.  It  is  chiefly  of  interest  in  connection  with  treatment, 
and  will  be  considered  under  that  head. 

Prognosis. — As  a  general  rule,  the  prognosis  in  fracture  of  the  clavicle  is 
favorable.  Union  takes  place,  in  children  especially,  with  great  rapidity. 
Berry states  that  in  six  cases,  the  ages  ranging  between  five  months  and 
five  years,  the  clavicle  was  found  united  firmly  in  from  nine  to  fourteen  days; 
the  longest  time  being  noted  in  the  youngest  child.  Bouchut^  says  that 
Cloquet  saw,  at  the  Hospice  de  I'Humanite  at  Rouen,  a  broken  clavicle  in  a 
girl  aged  six,  consolidated  on  the  ninth  day.  In  adults,  consolidation  takes 
place  more  slowly,  averaging  perhaps  twenty-five  or  twenty-eight  days. 

Xon-union  is  sometimes  met  with,  as  has  already  appeared  in  the  preceding 
pages ;  but  it  is  not  by  any  means  as  common  as  in  some  of  the  other  bones. 
A  "case  is  mentioned^  of  "a  girl  aged  nine,  who  had  broken  her  clavicle  a 
month  before,  and  had  had  no  treatment ;  the  sternal  fragment  projected 
upward  at  an  angle  of  45°,  its  sharp  extremity  forming  a  visible  prominence 
in  the  side  of  the  neck.  The  other  fragment  was  fully  an  inch  below  this, 
and  connected  with  it  by  what  appeared  to  be  a  band  of  fibrous  tissue,  pass- 
ing nearly  vertically  between  them."  Even  when  the  fragments  fail  to 
become  solidly  united,  the  usefulness  of  the  arm  seems  to  be  but  little  im- 
paired, according  to  the  testimony  of  Hamilton  and  others. 

As  to  the  avoidance  of  deformity  after  fractures  of  the  clavicle,  it  must  be 
confessed  that  perfect  success  is  very  rarely  obtained.  In  almost  every 
instance  there  remains  a  perceptible  projection  of  the  inner  fragment,  even 
after  time  enough  has  elapsed  for  the  disappearance  of  all  swelling  due  to 
callus  ;  and  in  some  cases  the  deformity  thus  produced  is  very  marked.  But 
as  a  general  thing  the  complete  restoration  of  the  usefulness  of  the  limb  is 
not  interfered  with,  although  HureU  assigns  the  shortening  of  the  bone  as 
the  cause  of  the  loss  of  power  sometimes  noted.    Every  experienced  surgeon, 

1  Op.  cit.,  p.  159. 

*  Bull,  de  la  Soc.  Clinique  de  Paris,  1881. 

These  de  Pans,  "  Des  complications  des  fractures  de  la  clavicule,  et  en  particiilier  de  la 
blessure  du  poumon,"  1881. 

4  New  England  Medical  Monthly,  March  15,  1883.  s  Op.  cit.,  p.  757. 

*  Holmes's  System  of  Surgery,  2d  ed.,  vol.  ii.  p.  766  ;  Am.  ed.,  vol.  i.  p.  846. 
'  Considerations  sur  les  Fractures  de  la  Clavicule.    Paris,  1867. 


108 


INJURIES  OF  BONES. 


however,  has  seen  old  fractures  of  this  bone  united  with  great  overlapping, 
but  with  no  apparent  weakening  of  the  member. 

The  amount  of  injury  done  to  the  soft  parts  can  scarcely  be  left  out  of  the 
account  in  forming  a  prognosis,  since  bruising  of  the  large  nerve  trunks 
passing  beneath  the  bone  may  interfere  seriously  with  the  nutrition  and 
functions  of  the  arm  and  hand,  perhaps  even  permanently.  Of  this  there  is 
obviously  most  risk  in  fractures  due  to  direct  violence. 

TreMtment — The  treatment  of  fractures  of  the  clavicle  is  a  subject  upon 
which  a  great  deal  has  been  written,  and  a  vast  amount  of  study  expended. 
Hamilton  justly  says,  in  regard  to  the  varieties  of  apparatus :  "  A  catalogue 
of  the  names  only  of  the  men  who  have,  upon  this  single  point,  exercised 
their  ingenuity,  would  be  formidable,  nor  would  it  present  any  mean  array 
of  talent  and  of  practical  skill." 

I  shall  endeavor  to  set  forth  the  principles  involved,  and  the  means  devised 
for  carrying  them  out,  as  briefly  and  clearly  as  possible,  referring  the  reader 
to  other  sources  for  more  detailed  descriptions  of  such  contrivances  as  are  not 
now"  in  general  use.  Cases  occasionally  do  well  even  without  any  treatment 
at  ail.  ivTewton^  has  recorded  one  in  a  soldier,  and  Porter  ^  one  in  a  doctor  ; 
in  each  the  result  is  said  to  have  been  "  good." 

As  in  the  case  of  other  fractures,  the  treatment  of  the  broken  clavicle 
consists  in  its  reduction,  or  the  correction  of  the  deformity,  and  in  keeping 
the  fragments  in  proper  position  until  their  union  is  accomplished.  The  first 
of  these  processes  varies  greatly  in  the  degree  of  difficulty  attending  it  in 
different  cases ;  being  sometimes  effected  with  the  utmost  readiness,  while  it 
is  occasionally  impossible.  Oblique  fractures,  as  a  general  rule,  are  more 
easily  reduced  than  transverse ;  and  those  attended  with  but  little  irregu- 
larity of  the  ends  of  the  fragments,  give  less  trouble  than  those  in  which 
they  are  deeply  serrated.  When  the  displacement  is  readily  overcome,  how- 
ever, it  is  apt  to  be  as  readily  reproduced  ;  or,  in  other  words,  the  difficulty 
of  reduction  and  that  of  retention  are  inversely  proportionate. 

Some  writers,  and  Malgaigne  among  them,  have  described  various  modes 
of  procedure  for  the  replacement  of  the  fragments ;  such,  for  example,  as  for 
the  surgeon  to  apply  his  knee  between  the  patient's  shoulders,  while  with 
his  hands  he  pulls  the  shoulders  backward.  Unless  the  views  I  have  pre- 
sented as  to  the  mechanism  of  the  displacement  are  at  fault,  manoeuvres  of 
this  kind  are  needlessly  forcible ;  and  in  my  own  experience  I  have  found 
that  reduction  is  best  effected  by  grasping  the  scapula,  and  bringing  it  back 
around  the  thorax  toward  the  median  line.  Generally  it  will  be  found  that 
as  the  acromion  is  thus  shifted  it  carries  w^ith  it  the  outer  fragment  of  the 
clavicle,  and  that  the  line  of  the  latter  bone  is  restored. 

"When  the  patient  is  very  muscular,  or  the  fragments  are  strongly  inter- 
locked, it  may  be  well  for  the  surgeon  to  commit  the  management  of  the 
scapula  to  an  assistant,  and  to  employ  his  own  hands  in  gently  moulding  and 
pressing  the  fragments,  which  will  often  yield  to  this  coaxing  process,  and 
the  bone  will  thus  resume  its  normal  shape.  Such  a  procedure  is  especially 
applicable  to  fractures  seated  at  or  close  to  the  sternal  end  of  the  bone. 

By  most  authors  it  has  been  laid  down  as  the  great  principle  of  treatment 
of  fracture  of  the  clavicle  that  the  shoulder  must  be  carried  upward,  out- 
ward, and  backward.  My  only  objection  to  this  statement  is  that  it  is  not 
quite  precise  enough ;  it  is  the  acromion^  upon  the  position  of  which  the 
retention  of  the  fragments  must  depend.  That  this  is  quite  a  different  mat- 
ter may  be  readily  shown. 


1  Medical  Record,  March  4,  1882. 


2  Ibid.,  April  8,  1882. 


FRACTURES  OF  THE  CLAVICLE. 


109 


Let  a  pad  be  put  into  the  axilla,  and  pushed  up  so  as  to  carry  the  shoulder 
upward  and  outward,  while  the  elbow  is  brought  strongly  forward  so  as  to 
bear  across  the  pad,  and  by  leverage  to  carry  the  shoulder  backward  ;  all  this 
can  be  done  with  a  sound  clavicle,  and  the  change  in  the  shape  and  position 
of  the  shoulder  apparently  effected.  But,  in  fact,  all  that  has  been  done  is  to 
put  the  soft  parts  on  the  stretch ;  the  head  of  the  humerus,  and  this  only, 
has  been  forced  outward  and  backward,  the  capsular  ligauient  of  tlie  joint 
and  the  muscles  yielding  before  it,  while  the  folds  of  the  axilla  are  pressed 
upward  by  the  pad. 

When,  however,  the  scapula  is  grasped  and  drawn  around  backward,  toward 
the  median  line,  it  will  be  found  that  the  sound  clavicle  must  follow  it ;  and 
the  motion  will  be  checked  as  soon  as  the  acromial  end  of  the  latter  bone  has 
reached  the  limit  of  its  range. 

I  feel  assured  that  the  recognitiou  of  this  principle  aud  its  application  to 
the  treatment  of  these  fractures,  will  lead  to  the  securing  of  better  results 
than  have  been  hitherto  obtained.  Indeed,  as  I  shall  presently  try  to  show, 
the  ai)paratus  employed  in  these  cases  is  often  capable  of  effecting  only  the 
apparent  change  above  referred  to  ii]  the  shoulder,  and  does  not  act  upon  the 
broken  bone  at  all. 

When  a  patient  with  a  broken  clavicle  is  laid  flat  on  his  back  on  a  firm  and 
even  mattress,  it  will  often  be  found  that  the  deformity  disappears  simply  by 
reason  of  the  pressure  on  the  posterior  border  of  the  scapula ;  sometimes, 
however,  this  must  be  aided  by  the  hand  of  the  surgeon  bearing  backward 
(downward)  against  the  injured  shoulder,  or  pushing  the  head  of  the  humerus 
inward  (toward  the'  median  line).  Advantage  has  been  taken  of  this  fact,  and, 
in  a  number  of  cases,  cures  without  deformity  have  been  obtained  by  simply 
keeping  the  patients  on  their  backs  in  bed  until  union  has  occurred.  The 
irksomeness  of  this  plan  of  treatment,  and  the  difficulty  of  carrying  it  out,  are 
sufficient  objections  to  it  in  all  but  exceptional  cases.  Women  will  sometimes 
undergo  it  for  the  sake  of  avoiding  an  unsightly  lump  on  the  neck ;  but  for 
the  most  part  patients  prefer  the  application  of  apparatus  with  which  they 
can  move  about,  and  pursue  some  at  least  of  the  ordinary  avocations  of  life. 

Much  the  same  principle  has  been  had  in  view  in  all  the  forms  of  back- 
splint,  from  the  croix  de  fer  of  Heister  (or  Arnaud)  to  those  of  Keckeley^ 
and  Grewcock.2  It  appears  also,  but  somewhat  modified,  in  the  figure-of-8 
bandages  and  oflier  appliances  for  drawing  the  shoulders  together  at  the  back. 

In  modern  times  the  tendency  has  been  to  depend  upon  bandages  and  slings 
of  difierent  forms,  with  or  without  axillary  pads.  Of  these,  that  of  Desault, 
although  cumbersome,  difficult  of  application,  and  apt  to  become  disarranged, 
long  enjoyed  a  confidence  due  rather  to  the  prestige  of  its  author's  name 
than  to  its  own  merits;  it  has  now  been  superseded, and  its  description,  which 
may  be  found  in  many  works  of  easy  access,  need  hardly  be  repeated  here. 

Mayor^  proposed  a  very  simple  dressing,  which  may  answer  a  good  purpose 
as  a  temporary  resource,  but  is  scarcely  to  be  relied  ujion  as  a  permanent  mode 
of  treatment.  It  consists  of  two  triangular  pieces  of  linen  ;  the  elbow  being 
carried  inward  and  forw^ard,  one  triangle  is  applied  over  it,  its  base  upward, 
and  corresponding  to  the  level  of  the  lower  third  of  the  arm,  its  point  hanging 
below  and  in  front  of  the  elbow;  the  two  ends  are  carried  round  the  chest^and 
meet  to  be  tied  or  pinned  at  the  sound  side.  The  point  of  the  triangle  is  now 
brought  up,  passed  between  the  arm  and  the  chest,  and  drawn  strongly  up- 
ward toward  the  sound  shoulder.    Xow,  the  middle  of  the  second  triangle 

'  American  Journal  of  the  Medical  Sciences,  Nov.  1834. 

2  British  Medical  Journal,  Nov.  7,  1868. 

3  Noaveau  Syst^me  de  Deligation,  etc.    Zurich^  1833. 


110 


INJURIES  OF  BONES. 


is  sewed  to  the  portion  of  the  first  which  is  behind  the  back,  and  its  ends  are 
brought  up  over  the  shoulders,  one  to  be  tied  to  the  point  of  the  first,  and 
the  other  to  come  over  the  broken  clavicle  and  down  to  the  base  of  the  first 
triangle,  to  which  it  is  firmly  fastened. 

Fox's  apparatus,  which  has  been  extensively  used  in  the  United  States 
since  1828,  and  is  still  employed  by  many  surgeons,  consists  of  a  padded  ring 
for  the  sound  shoulder,  an  axillary  pad  of  wedge  shape,  and  a  sling  for  the 
elbow  of  the  injured  side ;  the  pad  and  sling  being  furnished  with  tapes  in 
front  and  behind  for  attachment  to  the  ring. 

Levis's  apparatus^  (Fig.  822),  is  constructed  on  the  same  principle,  but 

the  padded  ring  for  the  sound  shoul- 
Fig.  822.  der  is  dispensed  with,  a  band  over  the 

back  of  the  neck  and  front  of  the 
sound  shoulder  being  substituted  for 
it.  To  this  the  elbow-sling  is  attached 
by  a  band  across  the  patient's  back, 
and  two  across  the  chest.  Dr.  Levis 
uses  straps  and  buckles  instead  of 
tapes,  and  keeps  the  elbow  by  the  side 
— not  drawn  forward. 

Professor  Moore  has  proposed'  a 
bandage,  which  he  calls  "  the  figure- 
of-8  of  the  elbow."  He  keeps  the  arm 
parallel  to  the  axis  of  the  body, with  the 
elbow  close  to  the  trunk,  and  uses  "  a 
shawl  or  piece  of  cotton  cloth,  which 
Avhen  folded  like  a  cravat,  eight  inches 
in  breadth  at  the  centre,  should  be 
about  two  yards  long.  Placing  this 
at  the  centre  across  the  palm  of  the 
surgeon,  he  seizes  with  this  hand  the 
elbow  of  the  patient  which  corre- 
sponds with  the  broken  clavicle.  The 
two  ends  of  the  bandage  hang  to  the  floor.  The  one  falling  inward  toward 
the  patient  is  carried  upward,  in  front  of  the  shoulder  and  over  the  back, 
making  a  spiral  movement  in  front  of  the  shoulder ;  this  is  entrusted  to  an 
assistant.  The  outer  end  is  then  carried  across  the  forearm,  behind  the  back, 
over  the  opposite  shoulder,  and  around  the  axilla.  This  meets  the  other  end, 
which  may  be  carried  under  the  axilla  and  over  the  shoulder  of  the  opposite 
side,  thus  making  the  figure-of-8  turn  around  the  sound  shoulder.  This 
twist,  it  will  be  seen,  makes  also  the  figure-of-8  turn  around  the  elbow  of  the 
afi'ected  side."  The  forearm  is  to  be  supported,  with  the  elbow  acutely 
flexed,  by  means  of  a  sling.  Hale^  has  modified  this  dressing  by  the  addi- 
tion of  an  adjustable  back-sling,  to  be  tightened  during  the  day,  and  loosened 
at  night. 

What  is  known  as  Sayre's  apparatus*  consists  of  two  broad  bands  of  adhe- 
sive plaster ;  one  surrounds  the  upper  part  of  the  arm  of  the  injured  side, 
and  thence  runs  across  the  back  and  round  the  thorax  ;  the  second,  beginning 
in  front  of  the  sound  shoulder,  passes  over  it,  and  diagonally  across  the  back 
to  the  opposite  elbow,  thence  up  again,  embracing  the  whole  forearm  and 
hand,  to  be  fastened  at  or  near  the  point  of  starting.    A  longitudinal  slit 

*  Am.  Journal  of  the  Medical  Sciences,  Jan.  1856. 

"  Transactions  of  the  Medical  Society  of  the  State  of  New  York,  1870. 
3  Medical  Record,  May  27,  1882. 

*  Bellevue  and  Charity  Hospital  Reports,  1870. 


Levis's  apparatus  for  fracture  of  the  clavicle. 


FRACTURES  OF  THE  CLAVICLE. 


Ill 


in  this  strip  receives  the  elbow,  which  is  to  t'ig.  823. 

be  drawn  well  forward  and  inward. 

Satterthwaite^  has  proposed  the  substitu- 
tion of  the  rubber  bandage  for  adhesive 
plaster,  and  the  use  of  a  horseshoe-shaped 
dilatable  bag,  to  be  filled  with  water,  as  an 
axillary  pad.  The  exact  advantages  to  be 
derived  from  this  change  do  not  clearly 
appear,  and  the  risk  of  excoriation  would 
seem  to  be  increased. 

Hamilton  describes  his  own  method  as 
follows : — 2  • 

"The  arm  hanging  perpendicularly  beside 
the  body,  a  sling  is  "placed  under  the  elbow 
and  forearm,  and  tied  over  the  opposite 
shoulder.  An  axillary  pad,  composed  of 
cotton  batting  inclosed  in  a  cloth  cover,  is 
placed  well  up  in  the  axilla,  and  the  elbow 
is  then  secured  firmly  to  the  side  of  the 
body  with  several  turns  of  a  roller." 

In  addition  to  the  somewhat  numerous  American  devices  already  spoken 
of,  I  may  merely  mention  those  of  Brown  ,3  Chisolm,*  Palmer,^  and  Bradner  f 
all  of  these  have  the  advantage  of  simplicity,  and  it  is  claimed  by  their  in- 
ventors that  good  results  have  been  obtained  by  their  use. 


Dr.  Sayre's  dressing  for  fractured  clavicle  ; 
application  of  first  strip. 


Fig.  824. 


Fig.  825. 


Dr.  Sayre's  dressing  for  fractured  clavicle  completed. 
Front  view. 


The  same.   Back  view. 


Professor  Gordon,  of  Belfast,  the  agreement  of  whose  views  with  my  own 
has  been  before  mentioned,  describes  an  apparatus  of  his  own  devising,  consist- 
ing; of  a  breast-plate  and  arm-splint,  connected  by  means  of  a  rod — the  idea 
being  to  substitute  the  broken  bone  by  this  rod.  Without  questioning  the 
theoretical  value  of  this  contrivance,  or  the  statements  of  Professor  Gordon 


»  Medical  Record,  September  27,  1879. 
'  Am.  Medical  Recorder,  Oct.  1821. 
^  Am.  Journal  of  the  Med.  Sciences 
6  Medical  Record,  June  17,  1882. 


July, 


2  Op.  cit.,  6th  ed.,  p.  218. 
*  Charleston  Medical  Journal,  March,  1858. 
1863. 


112 


INJURIES  OF  BONES. 


as  to  the  results  obtained  with  it  by  him,  I  think  that  its  complexit}^,  and 
the  fact  that  it  can  only  be  made  by  a  skilled  mechanic,  will  preclude  its 
adoption,  and,  to  a  very  great  extent,  its  trial  by  other  surgeons. 

Professor  Byrd,  of  Baltimore,  has  published  *  an  account  of  an  apparatus 
successfully  used  by  him,  consisting  of  two  padded  plates  which  are  applied 
over  the  scapulae ;  these  are  connected  by  a  flat  steel  bar,  carrying  a  lever 
which  arches  over  the  shoulder,  and  which  has  at  its  anterior  end  another 
padded  plate,  to  press  the  shoulder  backward.  The  apparatus  is  adjustable 
by  screws,  and  kept  in  place  by  straps  and  buckles. 

O'Connor 2  has  recently  proposed  the  use  of  plaster  of  Paris,  somewhat  as 
in  the  Bavarian  splint  (see  p.  55),  so  as  to  make  a  sort  of  mould  of  the  shoul- 
der, the  fracture  being  first  reduced. 

By  some  surgeons,  compresses  are  applied  to  the  prominence  of  the  outer 
end  of  the  sternal  fragment,  with  a  view  of  forcing  it  back  into  place.  And 
this  may  be  done  with  advantage,  provided  the  reduction  has  first  been  com- 
pletely eftected,  if  the  projection  still  persists.  If,  however,  the  cause  of  the 
deformity  is  the  pushing  in  of  the  inner  end  of  the  distal  fragment  behind 
the  outer  end  of  the  sternal — as  I  believe  it  to  be  in  the  majority  of  cases — 
the  pressure  of  a  compress  can  only  force  back  both  fragments,  and  serious 
harm  may  result.    I  have  certainly  seen  it  productive  of  severe  pain. 

With  the  view  of  rendering  the  fragments  immovable,  it  was  proposed  by 
Guerin  (de  Vannes)  to  fix  the  sound  arm  against  the  side  by  means  of  a  body- 
bandage,  and  to  apply  a  dextrinated  bandage  to  the  head  and  affected  shoul- 
der, the  face  being  averted  from  the  latter.  He  recommended  along  with 
this  the  use  of  Desault's  apparatus,  starched  or  dextrinated.  It  is  not  stated 
by  Malgaigne  that  this  plan  w^as  ever  put  into  practice ;  but  probably  few 
patients  would  be  willing  to  submit  to  such  an  encasement,  which  would  in- 
volve extreme  discomfort. 

Malgaigne  suggested  "  surrounding  and  confining  the  two  fragments  by 
two  steel  hooks,  like  the  forceps  of  Museux;  just  as  in  the  serrated  fracture 
with  an  angle  upward,  I  thought,"  he  says,  "  of  passing  in  at  the  summit  of 
the  angle  a  double  hook,  which  by.  means  of  a  strap  and  band  could  be  drawn 
toward  the  elbow,  thus  exerting  all  the  necessary  pressure."  But  he  very 
justly  remarks  that  the  idea  needs  maturing ;  and  I  do  not  know  that  he 
ever  followed  it  out  any  further. 

Modern  surgery  has  more  than  equalled  the  hardihood  of  Malgaigne. 
Langenbuch  is  reported  ^  to  have  treated  a  fracture  of  the  clavicle  by  cutting 
down  upon  it,  and  suturing  the  fragments  together  with  silver  wire,  the 
periosteum  being  also  sewed  with  catgut.  A  very  just  criticism  of  this 
procedure  has  been  published^  by  Dawson,  w^ho  maintains  that  the  results 
obtained  by  ordinary  means  are  sufficiently  satisfactory  to  forbid  running  the 
risk  involved  in  making  the  fracture  compound,  especially  in  the  neighborhood 
of  such  important  and  vulnerable  structures. 

There  are  instances,  however,  in  which  an  operation  is  entirely  proper. 
Whitson^  reports  the  case  of  a  boy,  aged  fifteen,  who  was  knocked  down  and 
run  over  by  a  reaping-machine,  sustaining  a  compound  fracture  of  the  right 
clavicle,  and  a  compound  fracture  of  the  right  humerus.  On  the  sixth  day, 
a  thick  wire  suture  was  passed  through  the  fragments  of  the  former  bone, 
and  good  union  was  obtained. 

When,  as  in  the  last  mentioned  case,  fracture  of  the  clavicle  is  complicated 
by  fractures  of  the  neighboring  bones,  the  treatment  may  be  variously  modi- 

'  Medical  News,  October  21,  1882.  2  British  Med.  Journal,  March  3,  1883. 

8  Medical  News,  Feb.  25,  1882.  ^  Medical  Record,  May  '20,  1882. 

6  British  Med.  Journal,  Jan.  6,  1883. 


FRACTURES  OF  THE  SCAPULA. 


113 


fied.  Thus  Schiieck^  reports  an  instance  in  which  a  little  girl  five  years  of  age 
sustained,  by  the  kick  of  a  colt,  a  fracture  of  the  clavicle  near  its  middle, 
and  of  the  humerus  near  the  shoulder.  Fox's  ai)paratus  was  applied,  and  a 
hollowed  wooden  splint  along  the  outer  side  of  the  arm,  with  a  girth  sur- 
rounding this  and  the  child's  body.  The  clavicle  was  united  in  two  weeks, 
and  the  humerus  in  four,  w^ithout  perceptible  shortening  or  deformity. 

Having  now  passed  in  brief  review  the  principal  plans  which  have  been 
proposed  or  employed  in  the  treatment  of  fractures  of  the  clavicle,  it  remains 
for  me  to  sum  up  the  subject  by  a  few  practical  directions.  And  in  the  first 
place  I  w^ould  say  that  the  secret  of  success  lies  not  so  much  in  the  employ- 
ment of  any  special  method  of  treatment,  as  in  the  recognition  of  the  condi- 
tions to  be  met  in  each  case,  and  in  the  adoption  of  means  suited  to  them — in 
tact,  judgment,  and,  above  all,  in  careful  attention.  All  fractures  of  the 
clavicle  are  not  alike,  nor  can  they  all  be  treated  in  one  way. 

When  there  is  much  inflammation  about  the  shoulder,  as  occasionally  hap- 
pens in  fractures  due  to  direct  violence,  the  patient  should  be  laid  flat  on  the 
back,  on  a  firm  mattress,  with  his  head  low  ;  and  local  applications,  such  as 
dilute  lead-water  and  laudanum,  evaporating  lotions,  or  simple  fomentations 
of  hot  water,  should  be  employed  for  a  few  days. 

After  the  inflammation  has  subsided,  if  there  remain  any  malposition  of 
the  fragments,  it  should  be  carefully  rectifled  as  far  as  possible  ;  and  to  main- 
tain reduction,  I  think  Say  re's  plan  will  be  found  the  most  eflicient  means; 
but  excellent  results  may  be  had  with  either  Fox's  or  Levis's  apparatus. 
Whichever  is  used  must  be  carefully  adapted  to  the  exact  requirements  of 
each  case.  The  forcing  the  elbow  forward,  so  much  insisted  on  by  some 
authors  a  few  years  since,  is  in  my  opinion  a  mistake. 

Should  compresses  be  required  to  push  back  the  sternal  fragment,  I  would 
recommend  the  use  of  a  well-padded  ring,  neither  too  large  nor  too  small, 
maintained  accurately  in  place  by  means  of  the  best  procurable  adhesive 
plaster. 

When  an  axillary  pad  is  used,  it  should  not  be  too  thick,  nor  too  strongly 
forced  up  into  the  armpit,  lest  undue  pressure  he  made  upon  the  large  nerves. 
Hamilton  mentions  a  number  of  instances  in  which  harm  was  thus  done. 

Having  had  no  experience  in  any  of  the  grave  complications  of  fracture  of 
the  clavicle,  I  shall  not  discuss  their  treatment.  Non-union  "W'ould  seem  to 
be  productive  in  most  cases  of  so  little  inconvenience,  that  a  resort  to  opera- 
tive measures  need  seldom  be  had  ;  although  the  bone  is  so  superficial  as  to 
be  easily  reached,  and,  if  the  cervical  fascia  be  not  torn,  there  will  be  but 
little  risk  of  deep-seated  inflammation. 

Fracture  of  both  clavicles  would  seem  to  me  to  be  best  treated  by  keeping 
the  patient  flat  on  his  back,  with  an  arrangement  on  the  principle  of  a  double 
truss,  to  keep  the  shoulders  pressed  gently  backward.  Of  course  the  upper 
extremities  should  be  kept  at  the  most  perfect  rest. 

Fractures  of  the  Scapula. 

The  scapula  is  not  often  broken,  partly  by  reason  of  its  mobility,  and 
partly  because  of  the  degree  of  protection  aftbrded  to  its  flat  portions  by  the 
layers  of  muscle  in  which  it  is  imbedded,  while  its  spine,  its  neck,  and  the 
coracoid  process,  are  but  little  exposed  to  violence.  Of  the  recorded  instances, 
the  great  majority  w^ere  in  male  adults ;  about  one  in  five  were  in  women. 
Among  the  816  cases  of  fracture  before  mentioned  as  treated  at  the  Chil- 

>  Am.  Journal  of  the  Med.  Sciences,  April,  1858. 

VOL.  IV. — b 


114 


INJURIES  OF  BONES. 


Fig.  826. 


dren's  Hospital  in  Philadelphia  in  seven  years,  the  scapula  was  afiected  in 
only  three. 

In  by  far  the  greater  number  of  cases,  fractures  of  the  scapula  are  due  to 
direct  violence.  There  was  a  man  in  my  wards  at  the  Episcopal  Hospital  in 
1882,  who,  while  working  in  a  dye-house,  had  been  jammed  in  a  narrow 
space  under  a  roller  weighing  500  pounds,  by  Avhich  the  body  of  the  right 
shoulder  blade  was  broken  across.  Many  years  ago  I  saw  a  railroad  laborer 
who  had  had  the  bone  comminuted  by  a  blow  from  the  rapidly  revolving 
crank  of  a  hand-car.  A  not  unfrequent  cause  is  a  fall  from  a  height,  the 
patient  striking  on  the  back  and  shoulders. 

Muscular  action  has  been  assigned  as  the  cause  of  fracture  of  the  scapula 
in  two  cases.  One  of  these,  quoted  by  Callaw^ay,^  as  observed  b}^  Dr.  Heylen, 
is  given  in  detail,  and  admits  of  no  doubt ;  the  patient,  a  man  of  49,  hung 
by  one  hand  to  a  cart  while  the  horse  ran  a  distance  of  about  one  hundred 
yards ;  the  diagnosis  of  fracture  w^as  clear,  and  there  was  no  bruise  or  other 
indication  of  a  blow  on  the  part.  The  other  case  is  very  briefly  reported  by 
Mr.  M.  Morris  f  it  was  that  of  a  locomotive  engineer,  Vv^ho  was  making 
some  exertion,  and  fell  forward,  striking  his  chest  against  the  lever ;  he  felt 
at  the  same  time  a  crack  in  his  shoulder,  and  the  scapula  Avas  found  to  have 
been  broken.  The  fracture  is  said  to  have  been  through  the  spine,  about  an 
inch  from  the  triangular  surface  over  w^hich  the  trapezius  plays.  Union  took 
place,  but  a  ridge  was  left  at  the  seat  of  injury. 

Fracture  may  occur  at  different  portions  of  this  bone.  Fig.  826  shows  a 
not  unfrequent  form,  the  spine  and  the  body  of  the  bone  being  affected.  As 

in  the  case  of  other  flat  bones,  fissures  are  often 
seen  in  connection  with  complete  fractures. 
iN'o  instance  is  on  record  of  a  fracture  involv- 
ing the  spine  alone,  although  the  acromion  pro- 
cess has  occasionally  been  broken  off,  either 
by  a  blow  from  above,  or  by  the  humerus  being 
forcibly  driven  upward.  The  loicer  angle  of  the 
bone  is  sometimes  separated.  When  the  Jine 
of  breakage  is  higher  up,  it  is  apt  to  be  more 
irregular,  and  the  bone  may  be  comminuted. 
Callaway  gives  a  representation  of  a  fracture 
produced  by  the  fall  of  a  mass  of  slate  on  the 
patient ;  one  line  runs  across  the  bone  just 
below  the  base  of  the  spine,  terminating  at  the 
root  of  the  coracoid  process,  w^hich  is  broken 
ofl";  another  runs  oft*  from  near  the  mid-point 
of  this  line,  downward  and  outward  to  a  point 
perhaps  an  inch  from  the  lower  margin  of  the 
glenoid  cavity.  The  bone  is  thus  broken  into 
four  pieces :  one  comprising  the  upper  angle, 
the  spine,  and  a  strip  of  the  body  ;  a  second,  the  lower  angle  with  part  of 
the  body ;  a  third,  the  glenoid  cavity,  neck,  and  part  of  the  body ;  and, 
lastly,  the  coracoid  process. 

A  fw  instances  are  upon  record  in  which  the  coracoid  process  has  itself 
been  broken  off.  One  such  occurred  under  my  own  observation  many  years 
since,  in  the  person  of  an  elderly  woman,  who  fell  backward  in  a  narrow 
])assage,  striking  on  her  elbow,  and  thus  forcing  the  head  of  the  humerus 
upward  and  forward. 


Fracture  of  the  scapula. 


•  A  Dissertation  npon  Dislocations  and  Fractures  of  the  Clavicle  and  Shoulder  Joint.  London, 
1849. 

«  British  Med.  Journal,  Sept.  16,  1876. 


FRACTURES  OF  THE  SCAPULA. 


115 


Fractures  of  the  neck  of  the  scapula  have  been  by  some  authors  regarded 
as  of  more  common  occurrence  than  they  really  are.  In  fact,  the  neck  of 
the  scapula  as  described  by  anatomists — the  constricted  part  of  the  bone 
close  to  the  glenoid  cavity — has  never  been  found  fractured  upon  dissection. 
A  few  cases,  however,  have  been  studied,  and  among  them  one  reported,  and 
the  specimen  figured,  by  Callaway,^  in  which  the  line  of  breakage  has  run 
from  some  point  in  the  upper  margin  of  the  bone,  so  as  to  include  the  supra- 
scapular notch  and  coracoid  process,  downward  and  outward  to  some  point 
in  the  outer  margin,  more  or  less  close  to  the  glenoid  cavity. 

Upon  an  examination  of  a  normal  scapula,  it  will  be  found  that  such  a 
line  of  separation,  running  as  in  Callaway's  case  for  example,  first  downward 
and  then  outward,  would  surround  a  portion  of  the  bone  which  constitutes 
really  its  thickest  part.  A  portion  of  the  root  of  the  spine  is  included  in  it. 
By  Gnrlt  and  others  it  is  proposed  to  call  this  the  "surgical  neck''  of  the 
scapula,  while  to  the  narrowed  portion  just  around  the  glenoid  cavity  is  given 
the  name  "anatoiiiical  neck."  The  extreme  improbability  of  a  fracture 
through  this  last-named  part  will  be  obvious  at  once  to  any  one  wiio  looks 
at  a  vertical  section  displaying  the  arrangement  of  the  bony  texture,  and  who 
considers  the  relations  it  bears  to  surrounding  parts ;  the  former  being  such 
as  to  diffuse  as  much  as  possible  any  stress  brought  to  bear  upon  the  bone,  in 
any  way  whatever,  and  the  latter  being  such  as  to  render  its  fixation,  so  that 
a    cross-breaking  strain"  could  be  exe'rted  upon  it,  impossible. 

I  think,  therefore,  that  it  may  be  asserted  that  the  neck  of  the  scapula, 
surgically  speaking,  corresponds  to  the  line  above  mentioned  ;  and  that  when 
fracture  occurs  in  this  part  of  the  bone,  it  follow^s  very  nearly  the  direction 
thus  marked  out.    With  this  view  clinical  facts  are  entirely  in  accord. 

In  order  to  arrive  at  a  clear  understanding  of  the  mechanism  of  the  dis- 
placement in  fractures  of  the  scapula,  the  attachment  of  the  muscles  to  it 
must  be  carefully  studied.  Let  it  be  remembered  that  this  bone  finds  its  sole 
direct  connection  with  the  thorax  through  its  articulation  with  the  clavicle. 
Apart  from  this,  it  is  merely  supported  by  muscles. 

When  fracture  takes  place  across  the  flat  part  below  the  spine,  the  low^er 
fragment  tends  to  ride  up,  either  in  front  of  the  upper  or  behind  it,  according 
to  the  action  of  the  fracturing  force  ;  and  this  tendency  is  favored  by  the  con- 
traction of  the  rhomboidei  and  teres  major;  the  latter  aided  by  some-,  at  least, 
of  the  fibres  of  the  serratus  magnus.  A  number  of  museum  specimens  which 
I  have  examined,  as  well  as  several  figured  by  Gurlt,  and  two  by  Malgaigne, 
illustrate  this.  In  one  case,  recorded  by  Easley,^  wdiere  a  longitudinal  frac- 
ture of  the  body  was  caused  by  great  violence,  the  patient  having  been  run 
over  by  a  wagon  the  wheel  of  which  passed  lengthwise  over  the  scapula,  the 
displacement  from  muscular  action  was  very  marked. 

When  the  upper  angle  is  broken  off',  the  tilting  action  of  the  levator  anguli 
scapulae  is  quite  distinct,  as  in  a  bone  represented  by  Gurlt  ;^  a  gap  is  even 
left  at  the  posterior  edge  between  the  fragments. 

When  the  fracture  affects  the  body  and  spine,  as  in  the  case  seen  by  me, 
from  which  Fig.  826  w^as  taken,  the  fragments  may  be  so  nearly  balanced  by 
the  contraction  of  opposing  muscles,  as  to  be  in  reality  very  slightly  disturbed 
in  their  relations  to  one  another. 

In  the  cases  of  fracture  of  the  neck  of  the  bone,  it  appears  that  there  is 
sometimes  very  little  displacement.  Thus,  in  an  instance  reported  by  Ash- 
Imrst,*  in  a  boy  five  years  old,  the  diagnosis  could  only  be  made  by  exclusion. 

1  Op.  cit.,  p.  93.    Plate  I.  fig.  1. 

2  Am.  Journal  of  the  Med.  Sciences,  Jan.  1878.  3  Op.  cit.,  Bd.  ii.  S.  528,  Fig.  45. 
»  Trans,  of  Coll.  of  Phys.  of  Philadelphia,  3d  s.  vol.  i.  1875. 


116 


INJURIES  OF  BONES. 


This  may  be  explained  in  great  measure  by  tbe  fact  that  the  fragment  is 
supported  by  the  coraco-clavicular  and  coraco-acromial  ligaments,  as  well  as 
to  some  extent  by  the  long  head  of  the  biceps.  But  the  tenden<^y  is  for  the 
fragment  to  be  merely  tilted  downward  by  the  action  of  the  coraco-brachialis, 
the  short  head  of  the  biceps,  and  the  middle  head  of  the  triceps ;  with  the 
result  of  somewhat  flattening  the  shoulder,  and  thus  producing  an  appearance 
at  first  sight  simulating  downward  luxation  of  the  head  of  the  humerus. 

This  fracture  may  be,  as  in  the  case  quoted  by  Gurlt  from  Duverney,  com- 
plicated by  fractures  of  the  ribs  ;  and  from  the  violence  requisite  to  cause  it, 
other  bones  also  in  the  neighborhood  are  apt  to  sufler. 

Fracture  of  the  glenoid  cavity  has  been,  in  most  of  the  recorded  cases, 
observed  in  connection  with  luxation  of  the  shoulder,  the  latter  being  the 
lesion  seemingly  of  most  importance.  But  in  one  instance,  re^^orted  by 
Assakyi  to  the  Societe  Anatomique,  the  history  is  given  as  follows :  "  A 
man,  aged  65,  got  a  fall,  striking  his  shoulder  against  a  beam  lying  on  the 
ground  ;  he  was  taken  to  the  Hopital  de  la  Charite,  where  the  interne  thought 
he  detected  and  reduced  a  subcoracoid  luxation.  About  a  month  afterward 
the  man  died  of  pleuro-pneumonia ;  and  at  the  autopsy  there  was  found  a 
stellated  fracture  of  the  glenoid  cavity,  the  fissures,  three  in  number,  extend- 
ing back  into  the  substance  of  the  neck  of  the  bone,  w^here  union  had  occurred 
with  superabundant  callus,  composed  of  fibrous  tissue  with  osseous  deposits. 
A  fracture  of  the  acromion  also  existed,  at  which  suppuration  had  taken 
place ;  there  were  some  irregular  bony  deposits  in  the  neighborhood." 

The  diagnosis  of  these  fractures  has  been  incidentally  referred  to  in  con- 
nection with  their  symptoms.  It  is  generally  not  difiicult  to  determine  the 
fact  of  the  bone  being  broken,  by  the  tenderness  on  pressure,  the  loss  of  cer- 
tain motions  of  the  upper  arm — especially  those  upward  and  backward,  the 
abnormal  mobility  of  the  bone  when  grasped  above  and  below,  the  detection 
of  distinct  irregularities  of  outline,  and  the  crepitus  elicited,  especially  by 
rotating  the  arm.  But  to  make  out  the  precise  line  or  lines  of  separation  is 
a  matter  of  far  more  difiiculty.  I  had  in  my  ward  at  the  Episcopal  Hospital, 
in  1882,  a  man  who  had  had  a  heavy  beam  fall  on  his  shoulder,  in  whom  a 
fracture  could  be  plainly  felt  at  the  posterior  edge  of  the  scapula,  but  it  could 
not  be  traced  any  further  forw^ard. 

Fracture  of  the  neck  of  the  bone  is  distinguished  from  luxation  by  the  facts 
that  the  humerus  is  freely  movable  in  every  direction ;  that  the  hand  can 
be  placed  on  the  opposite  shoulder,  the  elbow  being  kept  at  the  side ;  that 
the  displacement  is  readily  corrected,  but  as  readily  reproduced ;  and  that 
crepitus  is  present.  The  analogy  between  these  cases  and  those  of  double 
vertical  fracture  of  the  pelvis  is  very  marked. 

When  the  coracoid  jjrocess  alone  is  broken,  the  fragment  can  be  grasped 
and  felt  to  be  movable  upon  the  rest  of  the  bone ;  the  crepitus,  if  perceived, 
gives  the  sensation  of  smallness  of  the  surfaces  in  contact ;  and  the  action  of 
the  biceps  and  coraco-brachialis  muscles  is  lost.  Hamilton  cites  a  number  of 
instances  in  which  the  diagnosis  was  clearly  established,  both  by  himself  and 
by  others ;  and  dissections  have  been  made,  which  set  beyond  a  doubt  the 
fact  that  this  fracture  may  occur.  Yet  very  careful  examination  is  requisite 
before  it  can  be  asserted  to  exist  in  any  case. 

Fracture  of  the  acromion^  w^hen  it  takes  place,  is  not  diflacult  of  detection, 
by  means  simply  of  the  pain,  tenderness  on  handling,  loss  of  power  (from 
pain),  mobility,  awd  crepitus.    Many  of  the  museum  specimens,  which  are 


>  Le  Progres  Medical,  11  F^v.  1882. 


FRACTURES  OF  THE  HUMERUS. 


117 


supposed  to  exhibit  non-union  after  fracture  of  this  process,  are  in  fact  merely 
examples  of  want  of  consolidation  of  the  epiphysis. 

In  regard  to  prognosis^  it  may  be  said  that  fractures  of  the  scapula  in 
general  unite  readily,  and  often  without  perceptible  displacement ;  and  that 
the  functions  of  the  arm  are  seldom  permanently  impaired. 

Very  little  can  be  done  in  the  way  of  treatment  of  these  injuries.  The  arm 
should  be  supported  with  a  sling,  in  such  a  position  as  in  each  case  may  be 
found  best  adapted  to  obviate  whatever  displacement  exists  ;  and  the  shoulder 
should  be  confined  by  adhesive  plaster  applied  so  as  to  steady  and  control 
the  fragments.  In  fractures  of  the  neck  of  the  bone,  an  axillar}^  pad  may 
be  of  service;  but  it  should  not  be  too  large,  lest  it  should  aggravate,  by 
pressure  on  the  muscles,  the  very  condition  it  is  intended  to  relieve. 

Fractures  of  the  Humerus. 

These  injuries  are  by  no  means  infrequent,  but  the  testimony  of  those 
authors  who  have  offered  statistics  on  the  subject  is  not  uniform ;  and  it  is 
probable  that  the  experience  of  different  surgeons,  or  the  records  of  different 
hospitals,  would  be  found,  as  in  other  matters,  to  vary  somewhat.  Thus 
Gurlt,  quoting  those  of  the  London  hospitals,  says  that  out  of  22,616  frac- 
tures treated  during  twenty  years,  there  were  1651,  or  7.3  per  cent,  affecting 
the  humerus.  But  Malgaigne,  among  2358  fractures  observed  at  the  Hotel 
Dieu,  found  317  of  the  humerus — over  13  per  cent.;  and  of  the  316  cases 
derived  by  me  from  reports  of  the  Children's  Hospital  in  Philadelphia  for 
seven  years,  there  were  72,  or  about  22.6  per  cent.  I  do  not,  however,  pro- 
pose to  dwell  upon  these  statistical  points,  and  mention  them  merely  in  illus- 
tration of  the  difficulty  of  arriving  at  conclusions  in  regard  to  questions  of 
this  kind. 

Very  marked  differences  exist  between  different  portions  of  the  humerus 
in  their  liability  to  fracture ;  but  before  discussing  these,  the  anatomy  of  the 
bone  must  be  briefly  sketched. 

The  head  of  the  humerus,  nearly  hemispherical,  looks  upward,  inward,  and 
slightly  backward ;  a  very  shallow  constriction  at  its  circumference,  made 
apparently  deeper  by  the  prominence  of  the  greater  and  lesser  tuberosities,  is 
called  the  anatomical  neck.  Just  below  this,  beginning  at  the  upper  margin 
of  the  tuberosities^  and  extending  to  the  insertion  of  the  teres  major  muscle, 
is  the  surgical  neck  ;  the  tapering  of  this  portion  of  the  bone  from  above 
downward  should  be  speciall}^  noted.  Below  this  is  the  shaft ;  cylindrical 
above,  and  flattening  out  at  its  low^er  part,  it  widens  .greatly  towards  the 
elbows  The  lower  end  of  the  bone  is  turned  somewhat  forward,  and  presents 
the  pulley-like  surface  on  which  the  ulna  plays,  with  a  rounded  eminence  at 
the  outer  side  of  this  for  the  head  of  the  radius.  Above  the  trochlea.,  at  the 
inner  margin  of  the  bone,  projects  the  process  called  the  internal  condyle  or 
epitrochlea,  and  corresponding  to  it  on  the  outer  margin  is  a  smaller  promi- 
nence, the  outer  condyle,  sometimes  called  the  epicondyle. 

The  upper  epiphysis  of  the  humerus,  which  unites  wdth  the  shaft  at  about 
the  twentieth  year  of  life,  is  somewhat  dome  or  cap-shaped,  and  comprises 
the  head  and  tuberosities,  developing  from  tw^o  centres.  The  lower  epiphysis, 
having  four  centres,  comprises  the  portion  below  the  sigmoid  cavity,  and 
corresponds  quite  closely  in  extent  with  the  articulating  portion  of  the  bone, 
although  the  epicondyles,  internal  and  external,  are  on  a  slightly  higher  level 
on  either  side. 


118 


INJURIES  OF  BONES. 


A  thorough  familiarity  with  the  muscular  attachments  afforded  by  the 
humerus,  will  enable  the  student  of  the  fractures  of  this  bone  to  comprehend 
much  more  readily  the  mechanism  of  their  production,  as  well  as  of  the 
resulting  displacement.  This  matter  will  be  further  referred  to  in  connection 
with  the  fractures  of  different  portions  of  the  bone. 

Fractures  of  the  humerus  may  be  divided  roughly,  and  for  general  pur- 
poses, into  those  of  the  upper  end,  those  of  the  shaft,  and  those  of  the 
low^er  end.  Under  each  of  these  heads  are  comprised  several  varieties,  distinct 
in  their  anatomical  and  clinical  features.  But  before  entering  upon  the  dis- 
cussion of  these,  I  would  call  attention  to  the  curious  statistics  presented  by 
Gurlt^  as  to  the  influence  of  age  and  sex  upon  their  relative  frequency.  Of 
194  cases  of  fracture  of  the  humerus,  there  were — 

Between   1  and  10  years  of  age,  62  cases,  or  over     31  per  cent. 


11  ' 

'  20 

42  " 

21  " 

21  ' 

'  30 

22  " 

11 

31  ' 

'  40 

16  " 

nearly   9  " 

"      41  ' 

'  50 

9  " 

"      51  ' 

'  60 

22  " 

over     11  " 

61  ' 

'  70 

16  " 

nearly    9  ** 
3 

71  ' 

'  80 

5  " 

Malgaigne's  statistics  present  a  different  view.  He  says  that  of  310  cases 
of  simple  fracture  of  the  humerus,  there  were — 

From   2  to  20  years  of  age,    45  cases,  or  over  14  per  cent. 
"    20  "  40  "  80    "  "  25 

40  "  60  "         105    "  "    33  " 

"    60  "  80  and  over         80    "  "  25 

The  remarkable  discrepancy  between  these  two  sets  of  figures  must  be  at 
once  apparent,  but  I  confess  that  no  explanation  of  it  Occurs  to  me. 

'Now  as  to  the  relative  frequency  of  fractures  of  the  various  portions  of  the 
bone  at  different  ages,  Gurlt  gives  the  following : — 


Age. 

Upper  end. 

Shaft. 

Lower  end. 

Between  1  and  10 
"       11    "  20 
"      21    "  30 
"      31    "  40 
41    "  50 
51    "  60 
"       61    "  70 
71   "  80 

4  =  over  6  per  cent.^ 
11  =    "  26 

3=    "  13 

3  =    "   18  " 

6=   "  66 
11=    "  50 

8=    "  50 

2  =   "  40 

48 

14  =  over     22  per  cent. 

10  =  25 

13=  59 
5  =  over     31  " 
2=    "  22 
9=    "  40 
7  =  nearly  44      ' ' 
2  =           40  " 

62 

44  =        70  per  cent. 

21  =  50 
6  =  over  27  " 
8  =  50 
1=        11  " 
2=  9 
1  =  over  6  " 
1  =  20 

84 

194 

The  reader  will  scarcely  fail  to  observe  the  great  preponderance  of  frac- 
tures at  the  lower  end  of  the  humerus  in  the  first  two  decades  of  life,  and  the 
increase  of  those  of  the  upper  end  of  the  bone  between  the  ages  of  51  and  60 — 
the  time  when,  although  active  pursuits  are  not  yet  abandoned,  the  ability  to 
avoid  falls  is  diminished. 

As  to  the  influence  of  sex,  I  will  merely  say  that  the  males  are  very  largely 
in  excess  of  the  females  hi  every  portion  of  Gurlt 's  table  except  four ;  in  the 
first  decade  of  life  the  fractures  of  the  shaft,  and  between  71  and  80  years 
those  of  the  upper  end  as  well  as  of  the  shaft,  show  equal  numbers  for  the  two 

»  Op.  cit.,  Bd.  ii.  S.  653. 

2  It  should  be  noted  that  the  percentages  in  the  above  table  refer  to  the  totals  for  the  different 
ages,  given  in  the  first  table  quoted  from  Gurlt. 


FRACTURES  OF  THE  HUMERUS. 


119 


sexes,  while  in  the  latter  period  the  only  fracture  of  the  lower  end  of  the 
bone  was  in  a  female. 

Fractures  of  the  Upper  End  of  the  Humerus. — Fractures  of  the  upper 
portion  of  the  humerus  include  those  of  the  liead,  of  the  anatomical  neck, 
of  the  tuberosities  (the  greater  being  the  only  one  clearly  made  out  to  have 
been  broken  off),  ancl  of  "the  surgical  neck.  Under  the  last  head  are  embraced 
separations  of  the  upper  e[)iphysis. 

Fracture  of  the  head  of  the  huifierus  by  itself  is  certainly  very  rare.  Dorsey^ 
speaks  of  one  case  seen 'by  him  in  which  the  lesion  was  "within  the  capsular 
lio-ament,  the  fracture  extending  through  the  head  of  the  bone."  Gross^  says 
that  he  has  seen  "an  instance  of  the  kind,  wdiicli  had  been  mistaken  by  the 
attendants  for  a  fracture  of  the  acromion  process,  and  tlie  true  nature  of  wdiich 
was  not  detected  until  several  years  after  the  occurrence  of  the  accident,  \vhen 
the  man,  who  w^as  upwards  of  forty  years  of  age,  died  of  disease  of  the  liver. 
The  fracture,  as  was  shown  on  dissection,  had  extended  obliquely  from  above 
downward  throuo;h  the  head  of  the  bone ;  and  although  it  had  become  per- 
fectly consolidated,  there  were  several  rough  prominences  which,  while  they 
unmistakably  indicated  the  seat  of  the  injury,  had  greatly  impeded  the 
movements  of  the  shoulder-joint.  The  accident  had  been  caused  by  a  fall 
from  a  carriage." 

Mal2:aio:ne  records  and  figures  several  cases  in  which  the  head  of^  tlie  bone 
was  more'^or  less  distinctly  broken,  but  in  connection  with  other  injuries. 

Our  sources  of  information  in  regard  to  these  lesions  (and  in  fact  in  regard 
to  very  many  injuries  in  the  neighborhood  of  joints)  are  narrowed  by  the 
difficulty  of  accurate  diagnosis.  When  the  patients  recover,  the  real  char- 
acter of  the  damage  done  must,  of  course,  always  remain  open  to  some  doubt. 
And  even  dissection,  except  in  cases  in  which  the  fatal  result  has  occurred 
soon  after  the  hurt,  may  fiiil  to  clear  the  matter  up,  the  condition  of  the  parts 
being  often  such  as  might  have  resulted  from  disease,  inflammatory  or  other- 
wise, altogether  independent  of  fracture. 

These  fractures  would  seem  to  be  always  due  to  direct,  crushing  violence, 
the  head  of  the  bone  being,  perhaps,  most  frequently  driven  against  the 
glenoid  cavity,  by  a  force  acting  in  such  a  direction  as  to  take  it  at  a  dis- 
advantage. 

A  greater  or  less  degree  of  arthritis  of  the  shoulder  must  almost  certainly 
ensue'^with  pain  and  "swelling  in  the  part,  and  loss  of  power  in  the  limb. 
Displacement  is  not  noted  in  any  of  the  recorded  cases,  and,  if  it  did  occur, 
would  be  attributable  to  the  fracturing  force,  since  there  is  no  muscular 
action  which  could  cause  it.  Fraser^  reports  a  case  which  he  regarded  as 
fracture  of  the  head  of  the  humerus,  complicated  with  a  laceration  of  the 
axillary  vein.  The  vessel  was  tied  above  and  below  the  opening  in  it,  and 
a  portion  of  bone— exactly  what  part  of  the  humerus  is  not  clearly  stated — 
was  sawed  off.  A  tedious  convalescence  ensued,  but  the  ultimate  result 
seems  to  have  been  excellent.  Holmes^  mentions  a  case  of  fracture  of  the 
anatomical  neck  of  the  humerus,  in  whi(;h  a  subordinate  line  of  fracture  ran 
upward  into  the  joint.  There  was  partial  rupture  and  obstruction  of  the 
axillary  artery,  leading  to  gangrene  of  the  arm,  and  necessitating  amputation 
at  the  shoulder-joint. 

Fractures  of  the  anatomical  neck  of  the  humerus  are  by  no  means  uncommon. 
They  are  often  spoken  of  as  intracapsular,  although  it  is  likely  that  the  line  of 


>  Elements  of  Surgery,  vol.  i.  p.  141. 

2  System  of  Surgery,*  6th  edition,  vol.  i.  p.  980. 

3  Lancet,  July  8,  1848.  *  Principles  and  Practice  of  Surgery,  Am.  ed.  p.  260. 


120 


INJURIES  OF  BONES. 


separation  seldom  lies  Avholly  within  the  joint.  Elderly  persons  are  the  most 
frequent  subjects  of  these  injuries,  the  mechanism  of  which  it  is  not  easy  to 
determine  with  certainty.  My  own  belief  is  that  a  blow  either  on  the  front 
or  back  of  the  shoulder,  or  perhaps  the  forcing  of  the  humerus  upward  against 
the  acromion,  may  in  many  cases  be  assigned  as  the  cause. 

Very  curious  displacements  of  the  fragment  have  been  noted.  Gross^ 
records  two:  one  in  which  the  head  of  the  bone  was  "turned  upside  down, 
the  centi-e  of  the  articulating  surface  corresponding  with  the  outer  border  of 
the  shaft,"  and  the  other  in  which  the  fragment  was  "  tilted  over  the  greater 
tuberosity  against  the  posterior  surface  of  the  bone."  Firm  union  had  taken 
place  in  i3oth. 

E.  W.  Smith^  gives  some  very  singular  instances :  one  in  which  the  head 
of  the  bone  w^as  simply  sunk  deep  into  the  cancellous  structure  of  the  other 
fragment,  and  two  in  which  it  had  been  so  completely  rotated  as  to  have  its 
rounded  articular  surface  applied  to  the  same  part;  he  quotes  a  third  case 
of  the  same  kind  as  having  been  observed  by  iSTelaton,  and  a  fourth  as  recorded 
by  Malgaigne. 

Occasionally  these  fractures  of  the  neck  of  the  humerus  are  complicated 
by  actual  luxation  of  the  head  of  the  bone  downward,  or  downward  and 
forward.  At  least  two  of  Smith's  cases  were  of  this  character.  Cock^  men- 
tions a  case  treated  by  Poland,  which  was  thought  to  be  a  dislocation  into 
the  axilla ;  but  under  chloroform  a  fracture  was  detected ;  the  head  of  the 
bone  could  not  be  replaced  ;  and  the  patient  finally  left  the  hospital  with  the 
arm  shortened  about  two  inches.  He  is  said  to  have  "  regained  considerable 
use  of  the  limb."  Dr.  Fraser,  of  Michigan,"*  reports  a  case  in  which  a  boy 
aged  15,  being  caught  in  some  machinery,  sustained,  among  other  severe 
injuries,  a  fracture  of  the  anatomical  neck  of  the  left  humerus^with  disi3lace- 
ment  downward  of  the  head.  It  is  simply  stated  that  the  luxation  was 
reduced  under  chloroform,  and  that  "  perfect  recovery"  took  place  in  forty- 
five  days.  ^  Bennett^  reports  five  cases  of  dislocation  of  the  humerus,  com- 
plicated with  fracture,  beginning  at  the  anatomical  neck  and  passing  obliquely 
into  the  shaft,  detaching  the  les^ser  tuberosity  along  with  the  head.  He  sug- 
gests that  the  luxation  occurs  first,  and  that  the  fracture  is  produced  by 
pressure  against  the  edge  of  the  glenoid  cavity.  This  explauation  is  much 
more  probable  than  that  oftered  by  Hutchinson,^  who  thinks  that  the  sup- 
posed cases  of  fracture  with  dislocation  are  really  instances  of  fracture  very 
high  up,  in  which  the  head  of  the  bone  has  gradually  travelled  downward  to 
a  new  articular  facet,  by  what  mechanism  does  not  appear. 

A  case  recently  occurred  at  the  Pennsylvania  Hospital,  in  a  man  of  about 
seventy-six,  who  fell  down  stairs  and  sustained  a  fracture  of  the  neck  of  the 
humerus,  with  displacement  of  the  head  of  the  bone  into  the  axilla,  where  it 
gave  so  much  trouble  that  Dr.  Morton  excised  it ;  the  result  was  satisfactory. 

Fractures  of  the  greater  tuberosity  of  the  hmnerus  have  been  observed  mainly 
in  connection  with  other  injuries,  either  fractures  of  the  anatomical  neck  of 
the  bone,  the  upper  fragment  having  been  forced  down  into  the  lower  so  as 
to  split  it,  or  luxations,  in  which  stress  must  have  been  put  upon  the  muscles 
attached  to  the  process  in  question.  In  a  few  instances,  however,  the  tube- 
rosity has  been  separated  by  itself;  and  in  three,  according  to  Gurlt,  the  lesser 
tuberosity  has  been  in  like  manner  detached.  It  seems  to  me  that  these  lesions 
may  be  appropriately  classed  with    sprain-fractures ;"  and  I  venture  to  refer 

1  Op.  cit.,  vol.  i.  p.  981.  2  Op.  cit.,  pp,  187  et  seq. 

8  (xuy's  Hospital  Reports,  3d  s.,  vol.  i. 

4  Am.  Journal  of  the  Med  Sciences,  April,  1869. 

5  British  Med.  Journal,  Aug.  28,  1880. 

6  Med.  Times  and  (razette,  March  10,  1866. 


FRACTURES  OF  THE  HUMERUS. 


121 


the  reader  to  the  very  full  discussion  of  them  by  Gurlt,  merely  remarking 
that  the  influence  of  muscular  action  is  distinctly  traceable  in  the  displace- 
ment of  the  fragments  in  these  cases.  11.  W.  Smith^  has  recorded  a  case 
examined  by  him  after  death,  in  which  the  greater  tuberosity,  together  with 
a  very  small  portion  of  the  outer  part  of  the  head  of  the  bone,  had  been 
completely  separated  from  the  shaft  of  the  humerus.  This  })ortion  of  the 
bone  occupied  the  glenoid  cavity,  the  head  of  the  humerus  having  been  drawn 
inward  so  as  to  project  upon  the  inner  side  of  the  coracoid  process ;  it  was 
still,  however,  contained  within  the  capsular  ligament.  Nothing  was  known 
of  the  history  of  the  injury,  which  was  of  ancient  date. 

In  all  these  cases  of  fracture  occurring  in  the  immediate  neighborhood  of 
the  shoulder-joint,  there  is  apt  to  be  a  very  abundant  deposit  of  new  bone  in 
irregular,  stalactiform  shapes,  and  this  is  one  chief  cause  of  the  impaired  free- 
dom of  motion  which  generally  ensues  upon  such  injuries.  In  this,  as  in 
many  other  respects,  there  is  a  very  marked  analogy  between  fractures  in  this 
region  and  those  which  affect  the  corresponding  portion  of  the  femur. 

Along  with  the  separation  of  the  greater  tuberosity,  and  in  consequence  of 
it,  there  is  apt  to  be  a  displacement  of  the  tendon  constituting  the  long  head 
of  the  biceps  muscle.  If  the  lesser  tuberosity  is  also  broken  off,  the  tendon 
may  slip  forward  and  allow  the  head  of  the  bone  to  be  pushed  outward ; 
otherwise  the  subscapularis  will  tend  to  rotate  the  whole  humerus  inward, 
and  thus  add  to  the  appearance  of  depression  below  the  acromion,  as  well  as 
to  the  increase  in  breadth  of  the  shoulder. 

Epiphyseal  disjunctions  are  sometimes  met  w^ith  at  the  upper  part  of  the 
humerus.  About  the  fifth  year  of  life,  the  head  and  tubercles  become  con- 
solidated, and  the  mass  thus  formed  unites  with  the  shaft  at  or  near  the 
twentieth  year.  Examination  of  a  vertical  section  of  a  young  l)one  shows 
that  the  line  marking  the  epiphysis  begins  at  the  axillary  margin  of  the  head, 
and  runs  across,  rising  slightly  toward  the  centre,  in  a  direction  nearly  hori- 
zontal, to  terminate  at  the"  outer  side  just  below  the  tuberosity.  Hence  it  is 
evident  that  the  epiphysis,  like  a  cap,  rests  with  its  concavity  upon  the  con- 
vex end  of  the  shaft. 

Below  this  the  bone  tapers  somewhat  decidedly ;  and,  as  before  said,  the 
surgical  neck  of  the  humerus.,  in  the  adult  bone,  comprises  all  between  the 
upper  part  of  the  tuberosities  and  the  insertion  of  the  teres  major,  the  lower 
boundary  being  but  ill-defined. 

Fractures  of  this  part  have  so  much  in  common  with  epiphyseal  separa- 
tions, that  I  have  thought  it  best  to  discuss  them  together,  merely  pointing 
out  the  clinical  difi:erei'ices  existing  between  the  two. 

Bouchut  mentions  that  Foucher  saw,  in  a  girl  aged  13,  the  upper  epiphysis 
of  the  humerus  separated  by  muscular  action,  in  taking  a  frame  down  from 
a  wall  above  her  head.  An  abscess  formed,  and  death  ensued  in  about  seven 
weeks,  when  the  diagnosis  was  verified  by  an  autopsy.  Hutchinson^  mentions 
a  case  in  which,  by  a  fall  from  a  mast,  both  the  upper  and  lower  epiphyses 
of  the  humerus  were  detached.  A  somewhat  similar  case  is  reported  by 
Macnaughton  Jones  f  a  double  fracture  of  the  humerus,  near  the  neck  and 
near  the  elbow,  with  separation  of  a  longitudinal  fragment  from  either  ex- 
tremity of  the  shaft. 

All  fractures  of  the  humerus  between  the  tuberosities  and  the  shaft  proper 
of  the  bone,  present  the  peculiarity,  that  there  is  a  short  upper  fragment, 
acted  upon  by  strong  muscles,  the  supra-spinatus,  infra-spinatus,  subscapularis, 
and  teres  minor,  the  eflect  of  which  is  to  roll  the  head  of  the  humerus  over 


1  Op.  cit.,  p.  178.  2  Med.  Times  and  Gazette,  March  10,  1866. 

3  Britisli  Med.  Journal,  Dec.  24,  1881. 


122 


INJURIES  OF  BONES. 


inward,  and  thus  to  tilt  up  the  lower  end  of  the  upper  fragment,  so  that  its 
fractured  surface  tends  to  look  outward.  The  lower  fragment  is  at  the  same 
time  drawn  inward  by  the  muscles  attached  to  its  upper  end,  while  it  is 
pulled  upward  by  the  deltoid,  biceps  (short  head),  coraco-brachialis,  and  sca- 
pular head  of  the  triceps.  Hence,  the  moment  that  there  is  any  engagement 
of  the  two  fragments  in  their  changed  relation,  the  tendency  of  the  muscles 
is  to  keep  up,  and  even  to  increase,  the  disturbance  of  the  upper  fragment. 

The  line  of  separation  in  epiphyseal  disjunctions  has  already  been  spoken 
of ;  in  fractures  through  the  surgical  neck,  I  think  it  is,  as  a  general  rule, 
from  without  inward  and  downward,  or  nearly  parallel  with  the  plane  of  the 
anatomical  neck — a  circumstance  which  tends  to  lessen  the  degree  of  the 
deformity,  since  the  long  point  of  the  upper  fragment  within,  and  that  of 
the  lower  fragment  without,  are  in  the  way  each  of  the  other's  displacement. 
When,  however,  there  is  an  obliquity  also  from  before  backward,  or  from  • 
behind  forward,  the  upper  fragment  may  be  so  tilted  as  to  point  outward. 

Of  this  form  of  displacement  one  notable  example  exists  in  the  Miitter 
Museum,  in  a  specimen  of  epiphyseal  disjunction,  the  lower  fragment  over- 
lapping the  other  inwardly,  and  in  close  contact  with  it,  while  the  latter 
is  so  tilted  by  the  action  of  the  scapular  muscles,  that  a  space,  filled  up, 
however,  by  callus,  is  left  between  the  two  fragments  at  the  outer  part  of  the 
fracture. 

This  is  by  no  means  an  isolated  instance.  In  the  majority  of  the  speci- 
mens figured  by  Sir  A.  Cooper,  Malgaigne,  Gurlt,  and  other  authors,  and 
notably  in  one  illustration  first  given  by  Moore,  and  borrowed  by  Hamilton 
and  others,  the  same  mechanism  is  clearly  traceable ;  and  this  evidence  is 
the  stronger,  in  that  it  is  altogether  unintentional  on  the  part  of  those  pre- 
senting it.  Malgaigne,  indeed,  says :  "  The  upper  fragment  is  in  a  position 
answering  to  the  greatest  elevation  of  the  arm  in  its  normal  state." 

A  striking  illustration  of  this  tilting  action  once  came  under  my  notice  in 
a  case  of  railroad  injury,  the  humerus  being  crushed  to  within  a  few  inches 
of  the  shoulder.  While  the  patient  was  being  etherized  preparatory  to  the 
removal  of  the  limb,  the  point  of  the  upper  fragment  was  repeatedly  thrust 
strongly  against  the  inner  surface  of  the  deltoid  by  the  muscles  mentioned. 

Further  confirmation  of  this  view  is  aftbrded  by  the  fact  that  in  most  cases 
of  fracture  in  this  region  there  is,  after  recovery,  a  limitation  of  the  move- 
ment of  the  arm  directly  upward,  by  reason  of  the  approximation  of  the 
points  of  insertion  of  the  scapular  muscles  to  their  origins. 

Sometimes,  along  with  fractures  in  this  region,  the  head  of  the  bone  becomes 
dislodged  from  the  axilla.  Hingeston's  case,*  in  which  the  neck  of  the  hone 
was  broken  into  six  pieces,  which  became  united  again,  is  a  very  remarkable 
one.  Dr.  J.  Watson^  reports  two  cases,  in  both  of  which  the  cause  of  injury 
was  direct  violence ;  in  one  the  fracture  was  through  the  surgical  neck(?) 
"midway  between  the  upper  end  of  the  bone  and  the  insertion  of  the  deltoid," 
and  in  the  other  "near  the  tubercles."  Reduction  was  efiected  immediately 
in  both,  without  splinting  the  limb ;  in  the  latter  case  the  arm  was  drawn 
out  at  right  angles  with  the  body,  and  the  head  of  the  bone  coaxed  into  the 
glenoid  cavity  by  manipulation  with  the  fingers.  Eichet^  has  placed  on 
record  a  case  of  fracture  of  the  surgical  neck  of  tSie  left  humerus,  with  luxation 
of  the  head  of  the  bone  into  the  axilla.  Eeduction  was  effected  by  manipu- 
lation with  the  fingers,  a  few  days  after  the  accident,  and  ultimately  the  shape 
and  usefulness  of  the  limb  were  entirely  regained.    I^orris*  reports  a  case 

1  Guy's  Hospital  Reports,  1st  S.,  vol.  v.,  1840.         2  New  York  Mediqal  Times,  July,  1854. 

*  Quoted  in  Am.  Journal  of  the  Med.  Sciences,  April,  1854. 

*  Am.  Journal  of  the  Med.  Sciences,  Jan.,  1855,  and  Summary  of  Transactions  of  College  of 
Physicians  of  Philadelphia,  N.  S.,  vol.  ii.  No.  6. 


FRACTURES  OF  THE  HUMERUS. 


123 


under  his  care,  which  had  been  treated  for  fracture  for  twenty-six  days,  when 
jt  was  discovered  that  the  head  of  the  humerus  was  in  the  axilhi.  S'o  effort 
vras  made  at  reduction.  One  other  case,  which  had  occurred  in  the  Pennsyl- 
vania Hospital,  rei3orted  by  Ihirtshorne,  is  referred  to,  as  well  as  others 
recorded  by  Ilouzelot,  Dupuytren,  Earle,  Peyrani,  and  A.  Cooper.  Walton* 
has  reported  the  case  of  a  man,  aged  48,  in  whom  a  fracture  of  the  neck  of 
the  humerus  was  treated,  but  a  distocation  downward  was  not  recognized  for 
ten  weeks.  Union  of  the  fracture  had  then  occurred,  but  the  displaced  head 
of  the  bone  gave  great  pain.  The  reduction  was  effected  by  extension  con- 
tinued for  three-quartei^  of  an  hour,  the  whole  arm- being  very  carefully  and 
firmly  put  up  in  splints  beforehand.  "  A  good  deal  of  local  and  general 
disturbance  followed,  but  at  the  end  of  three  weeks  passive  motion  was  com- 
menced, and  at  the  end  of  six  weeks  the  arm  could  be  used  nearly  as  well  as 
the  other." 

The  s]/mptoms  of  separation  of  the  upper  epiphysis  of  the  humerus  are 
often  somewhat  obscure.  There  is  pain  and  loss  of  power,  with  some  swell- 
ing ;  and  a  rather  rough  ridge  is  apt  to  be  felt  across  the  front  of  the  joint, 
atVhich  crepitus  is  more  or  less  distinctly  felt  on  rotating  the  arm.  In  the 
few  cases  which  I  have  seen  the  ridge  has  been  less  prominent  than  it  is  repre- 
sented by  R.  W.  Smith  in  his  work ;  it  is  due  to  the  projection  forward  of 
the  edge  of  the  lower  fragment.  The  degree  of  mobility  is  not  great,  and  the 
crepitus  conveys  an  idea  of  smoothness  of  the  surfaces  in  contact  as  compared 
with  those  of  an  ordinary  fracture.  In  making  the  diagnosis,  the  age  of  the 
patient  is  an  important  point  to  be  considered. 

Fractures  of  the  surgical  neck  of  the  bone  are,  as  a  general  rule,  easily 
recoi>:nized ;  besides  total  loss  of  power  in  the  limb,  free  preternatural 
mobility,  and  distinct  crepitus,  the  exact  line  of  the  fracture  can  often  be 
made  out  by  feeling.  Sir  A.  Cooper  has  represented^  a  double  fracture  in 
this  region,  but  gives  no  history  of  the  case.  Such  an  injury,  probably  due 
to  great  direct  violence,  would  not  be  likely  to  offer  any  special  difficulty  in 
diagnosis,  unless  the  swelling  of  the  soft  parts  were  excessive. 

Fractures  of  the  upper  portion  of  the  humerus  for  the  most  part  unite 
readily,  with  the  exception  of  those  in  which  there  is  displacement  of  the 
head  of  the  bone  from  the  glenoid  cavity.  Even  when  the  change  of  rela- 
tion between  the  fragments  is  most  marked,  as  in  the  instances  before  quoted 
from  Gross  and  R.  W.  Smith,  consolidation  seems  to  have  occurred  in  every 
instance.  And,  as  a  rule,  the  usefulness  of  the  limb  is  in  great  measure 
regained,  although  the  mobility  of  the  shoulder-joint  is  of  necessity  impaired, 
either  as  a  result  of  inflammationc,  or  by  the  change  of  the  points  of  attach- 
ment of  the  muscles,  or  by  the  substitution  of  some  portion  of  one  or  other 
fragment  for  the  head  of  the  bone,  in  contact  with  the  glenoid  cavity. 

Xon-union  is,  however,  occasionally  met  w^ith,  as  in  a  case  recently  reported:^ 
A  girl,  aged  twenty,  had  the  surgical  neck  of  the  right  humerus  fractured 
three  times,  twice  by  direct  violence,  and  the  third  time  by  the  stress  put 
upon  it  in  drawing  on  a  tight  boot ;  the  fragments  remainiiig  ununited, 

Mr.  Croly  cut  down  on  the  fracture  under  the  spray,  drilled  the  ends  of  the 
bones,  and  wired  them.  The  case  was  not  a  favorable  one  for  the  operation, 
inasmuch  as  the  periosteum  Avas  separated  to  a  considei*able  extent,  and  the 
ends  of  the  bones  were  widely  apart.  Xecrosis  setthig  in,  and  extensive 
suppuration  and  hectic  threatening  the  patient's  life,  amputation  was  de- 
cided on."    The  patient  was  doing  well  at  the  time  of  the  report. 

'  Lancet,  Oct.  30,  1868. 

'  Treatise  on  Dislocations  and  Fractures  of  the  Joints,  p.  433.     London,  1842. 
8  British  Med.  Journal,  March  17,  1883. 


124 


INJURIES  OF  BONES. 


Compound  fractures  of  the  upper  third  of  the  humerus  are  extremely  rare, 
except  as  the  effect  of  gunshot  injury.  They  are  always  of  grave  import- 
ance, and  may  demand  excision,  or  even  amputation. 

Skey^  met  with  a  case  in  which  a  dislocation  of  the  humerus  was  reduced; 
eight  or  ten  days  afterwards,  a  large  traumatic  aneurism  was  developed  in  the 
axilla,  and  the  artery  was  tied  above  and  below.  After  the  patient's  death, 
it  was  found  that  he  had  had  "  a  fracture  of  the  neck  of  the  humerus,"  and 
that  the  artery  had  been  "  torn  across"  by  the  pointed  end  of  the  shaft. 

In  the  Museum  of  St.  Bartholomew's  Hospital ^  there  is  a  specimen  of  un- 
united fracture  of  the  neck  of  the  humerus,  with  obliteration  of  the  axillary 
artery  by  pressure  of  the  lower  fragment  of  the  bone  against  it.  The  subject, 
a  man  aged  75,  had  received  the  injury  ten  years  previous  to  his  death. 

"  The  fracture  extends  transversely  through  the  humerus,  immediately  below  its 
head  and  below  the  tuberosities  ;  and  it  communicates  with  the  cavity  of  the  shoulder- 
joint.  A  small  detached  piece  of"  the  bone  is  connected  with  the  synovial  membrane. 
The  synovial  membrane  is  thickened,  and  its  internal  surface  is  rough.  The  axillary 
artery  is  obliterated  to  the  extent  of  half  an  inch,  in  the  situation  in  which  the  end  of 
the  lower  portion  of  the  bone  pressed  against  it.  Immediately  above  the  obliterated 
part,  the  infra-scapular  artery  arises,  of  its  usual  size,  and  pervious.  Close  to  the 
infra-scapular  is  the  posterior  circumflex  artery,  obliterated  in  the  first  half  inch  from 
its  origin,  and  then  pervious  by  means  of  the  collateral  circulation.  About  two  inches 
above  the  origin  of  the  infra-scapular,  a  large  branch  arises  from  the  axillary  artery  ; 
this  branch,  extending  down  inside  of  the  arm,  was  continued  into  one  of  the  arteries 
of  the  forearm,  and  formed  a  principal  channel  for  transmitting  blood  to  the  lower  part 
of  the  limb." 

The  nerves  are  very  rarely  injured.  One  such  case  is  recorded  by  Berger,^ 
in  which  the  musculo-spiral  nerve  was  pressed  upoh,  and  paralysis  of  the 
parts  supplied  by  it  resulted,  with  some  superficial  sloughs.  The  patient,  a 
man,  died  of  malignant  scarlet  fever. 

Treatment  of  Fractures  of  the  Upper  Part  of  the  Humerus, — In  fractures  near 
the  upper  end  of  the  humerus,  the  proximity  of  the  shoulder-joint,  and 
the  danger  of  its  stiffening,  should  always  be  borne  in  mind.  When  there 
is  much  swelling  and  inflammation,  the  most  prompt  and  efficient  means 
should  be  employed  to  allay  it ;  the  patient  should  be  kept  at  rest  in  bed, 
with  the  arm  and  hand  on  a  pillow,  and  hot  fomentations  should  be  con- 
stantly used.  Where  the  injury  has  been  caused  by  great  direct  violence,  it 
may  be  well  even  to  apply  leeches  to  the  part.  On  the  subsidence  of  the 
inflammation,  the  condition  of  the  fragments  should  be  very  carefully  ascer- 
tained, and  measures  adopted  for  correcting  any  displacement  that  may  exist. 
If  this  be  very  slight,  as  may  happen-  in  feeble  persons,  or  when  the  perios- 
teum is  not  wholly  torn  through,  the  suspension  of  the  arm  in  a  sling,  with 
a  small  and  soft  axillary  pad,  may  suffice ;  or  the  arm  may  be  confined  to 
the  side  by  a  bandage  applied  around  it  and  the  body,  the  hand  merely  being 
placed  in  a  sling. 

Some  surgeons  employ  a  splint  along  the  inner  side  of  the  arm,  with  a 
leather  or  pasteboard  cap  fitted  on  the  shoulder,  the  whole  being  kept  in 
jjlace  by  a  bandage,  a  few  turns  of  which  are  carried  around  the  chest. 

But  in  very  many  instances,  in  which  the  upper  fragment  is  tilted  imvard 
by  the  scapular  muscles,  as  before  explained,  it  affords  so  little  purchase  that 
the  only  efficient  method  of  correcting  the  displacem.ent  is  to  carry  the  lower 
fragment  upward,  which  is  best  done  by  putting  an  angular  splint  in  the 


1  Lancet,  May  5,  1860.  2  Catalogue,  vol  i.  p.  32. 

*  Bulletin  de  la  Soc.  Anatomique,  Juillet,  1871. 


FRACTURES  OF  THE  HUMERUS. 


125 


axilla,  so  that  one  branch  of  it  fehall  be  applied  to  the  side  of  the  chest,  and 
the  other  along  the  inner  side  of  the  arm.  This  splint,  well  padded,  may  be 
secured  by  a  bandage,  which  in  the  case  of  very  restless  patients  may  be  im- 
bued with  plaster  of  Paris  or  some  other  solidifying  material.  Such  a  splint 
was  long  ago  recommended  by  Tyrrell,  and  has  been  more  recently  employed 
by  Middeldorpf,  Gely,  and  others.  It  is  not  needful  to  retain  the  arm  in  this 
position  during  the  whole  period  of  repair,  but  only  for  the  first  two  or  three 
weeks,  after  which  a  gradual  lowering  of  the  elbow  may  be  effected  without 
putting  too  much  stress  upon  the  newly-formed  uniting  material. 

When  this  splint  is  used,  the  binder's  board  shoulder-cap  may  be  dispensed 
with.  In  any  case,  the  cap  need  extend  no  further  over  the  shoulder  than 
just  to  cover  in  the  acromio-clavicular  junction.  I  recently  had  a  woman, 
aged  57,  in  my  ward  at  the  Episcopal  Hospital,  w^ho  had  sustained  a  fracture 
of  the  surgical  neck  of  the  left  humerus,  and  in  whom  the  upper  fragment 
projected  into  the  axilla,  while  the  lovver  was  drawn  up  so  as  to  overlap  it  at 
its  outer  side.  I  succeeded  in  overcoming  this  deformity  by  means  of  gentle 
pressure  with  a  small,  firm  compress,  held  in  place  by  a  wide  strip  of  adhesive 
l)laster  carried  around  the  arm  and  up  upon  the  shoulder 
(Fig.  827),  the  hand  being,  of  course,  supported  in  a  sling.  F^s-  ^27. 

The  ultimate  result  of  the  case  I  do  not  know. 

Fractures  of  the  tuberosities  admit  of  very  little  in  the 
way  of  treatment,  as  the  purchase  afforded  by  the  sepa- 
rated portions  is  so  slight.  The  elbow,  however,  should  be 
supported,  and  the  arm  placed  and  kept  in  such  a  position 
as  may  be  found  to  correct  the  deformity  most  completely. 

When,  along  with  fracture,  there  is  dislocation  of  the 
head  of  the  bone  from  the  glenoid  cavity,  it  becomes  a 
question  whether  the  dislocation  or  the  fracture  should  be 
first  treated.  Cases  might  be  cited  in  favor  of  either  course ; 
but  it  seems  to  me  that,  as  a  general  rule,  an  efibrt  at 
immediate  reduction  of  the  head  of  the  bone  ought  to  be 
made.    Such  a  procedure  is  certainly  difficult ;  but,  on  the 
other  hand,  the  fragments  can  scarcely  be  brought  into   p^t^Ind  Idheswe pLt 
proper  relation  as  long  as  the  head  of  the  bone  remains   ter  to  overcome  defor- 
out  of  the  glenoid  cavity,  and  the  reduction  cannot  be  easy    mity  in  fracture  of  the 
if  put  off  until  after  the  occurrence  of  union.  Indeed,  from  ^^^^ 

■L  .  humerus. 

the  cases  quoted  on  a  previous  page,  it  must  be  evident 
that  a  change  in  the  position  of  the  head  of  the  bone  is  very  apt  to  occur 
even  when  there  is  no  luxation.  Should  the  reduction  be  found  impos- 
sible, the  shaft  should  be  placed  in  the  best  attainable  position  for  union 
between  it  and  the  head,  in  hope  that  after  four  or  five  weeks  the  attempt 
may  be  renewed,  with  the  advantage  of  the  leverage  afforded  by  the  length 
of  the  bone ;  although  there  may  be  adhesions,  changes  in  the  capsule,  etc., 
as  in  other  cases  of  old  luxation,  which  may  foil  the  best  directed  efforts. 
Hence,  it  must  be  evident  that  the  prospect  in  cases  of  this  kind  is  anything 
but  encouraging. 

When,  reduction  being  impracticable,  the  displaced  head  gives  rise  to 
serious  trouble,  the  proper  course  is  to  excise  it. 

Fracture  of  the  shaft  of  the  humerus  is  of  very  frequent  occurrence,  and 
is  met  with  at  all  ages  and  in  both  sexes.  An  instance  is  reported  by  Lowen- 
hardt^  in  which  a  fracture  of  the  upper  third  of  the  left  humerus  took  place 

'  Am.  Journal  of  the  Med.  Sciences,  Jan.  1841  ;  originally  in  Medizinische  Zeitung,  6  Mai, 
1840. 


126 


INJURIES  OF  BONES. 


dnriog  the  expulsion  of  a  child  from  the  mother's  pelvis,  the  arm  lying  across 
the  chest ;  and  Hamilton  mentions  a  similar  case  as  having  been  seen  by  him, 
which  had  occurred  in  the  practice  of  a  Dr.  Lockwood,  as  well  as  another 
related  to  him  by  Dr.  Fanning,  of  Catskill,  [N".  Y.  The  latter  case  was  one 
of  head-presentation,  and,  as  the  right  shoulder  passed  under  the  arch  of  the 
pubis,  a  snap  was  heard,  the  humerus  giving  way  in  its  upper  third.  From 
Gurlt's  table,  before  quoted,  it  would  seem  that  females  are  very  much  more 
liable  to  this  injury  duriiig  the  tirst  decade  of  life  than  in  any  subsequent  one, 
whiie  it  is  most  common  in  males  between  the  twentieth  and  thirtieth  years. 
Under  ten  years,  the  cases  in  males  and  females  are  equally  numerous,  as  they 
are  also  after  the  seventieth  year ;  but  in  the  intermediate  period  the  cases 
in  males  are  largely  in  excess.  These  statements,  it  must  be  remembered,  are 
based  upon  a  comparatively  small  number  of  cases;  but  they  are  sufficiently 
in  accord  with  ordinary  experience  to  be  accepted,  although  further  observa- 
tion may  modify  them  to  some  extent. 

Under  the  term  "  shaft  of  the  humerus,"  is  comprised  all  of  the  bone  between 
the  lower  limit  of  the  surgical  neck  and  the  abrupt  widening  just  above  the 
condyles.  Every  variety  of  fracture  may  occur  in  the  region  thus  included, 
and  from  every  variety  of  cause — direct  or  indirect  violence,  or  muscular 
action.  Fractures  from  the  last-named  cause  are,  indeed,  more  frequently 
met  with  in  the  humerus  than  in  any  other  bone  in  the  body. 

A  thorough  knowledge  of  the  muscular  connections  of  the  humerus  is 
essential  to  a  proper  understanding  of  the  mechanism  of  the  production  of 
these  lesions,  afe  well  as  of  the  displacements  w^hich  ensue  upon  fractures  from 
whatever  cause. 

The  upper  extremity  constitutes  a  mechanical  system,  of  which  the  clavicle 
and  scapula  form  a  part,  and  in  which  the  humerus  is  an  intermediate  lever; 
the  ultimate  object  of  the  whole  being  the  discharge  of  the  functions  of  the 
hand.  The  muscles  operating  this  system  begin  at  the  spinal  column,  taking 
their  origin  from  its  whole  length,  and  from  this  point  to  the  fingers  each 
successive  member  of  the  system  is  in  a  rapidly  increasing  ratio  of  complexity 
of  structure  as  well  as  of  function,  and  in  a  diminishing  ratio  of  mere  strength. 
Perhaps  it  scarcely  needs  demonstration  that  on  the  humerus,  as  the  only 
single  lever  of  this  system,  and  the  member  upon  which  are  exerted  the  fix- 
ing muscles  from  the  trunk,  while  from  it  arise  the  greater  part  of  the  moving 
muscles  of  the  hand,  the  actions  are  all  concentrated.  The  exact  conditions 
of  the  leverage  must  vary  indefinitely  with  the  motions  executed  by  the 
limb,  as  well  as  with  the  postures  it  assumes ;  and  in  very  many  of  them  the 
muscles  passing  downward  from  the  humerus  combine  the  arm,  forearm,  and 
hand  into  one  continuous  lever,  in  which  case  the  stress  upon  the  humerus 
must  be  proportionately  increased.  Accordingly,  the  humerus  is  by  far  the 
strongest  of  the  bones  entering  into  the  system. 

Fractures  of  the  humerus  by  direct  violence  need  hardly  be  discussed,  as 
regards  the  conditions  of  their  production,  since  these  are  simple  enough. 
Those  produced  by  indirect  violence,  as  b}^  falls  on  the  hand  or  on  the  elbow, 
or  by  striking  a  blow  w^ith  the  fist,^  are  not  difficult  of  comprehension.  And 
the  cases  of  fracture  by  muscular  action,  which  is  generally  the  efl:brt  of  throw- 
ing, take  place  in  obvious  accordance  with  the  law^s  of  mechanics.  So  many 
instances  of  this  kind  are  on  record,  that  it  is  scarcely  necessary  to  refer  to 
them.  I  may,  however,  mention  one  reported  by  Lyon,^  in  which  a  man, 
aged  30, had  "a  comminuted  fracture  of  the  right  humerus,  caused  by  violent 
muscular  contraction  in  throwing  a  base-ball  by  the  '  underhand'  method. 
The  bone  was  broken  into  several  parts,  extending  from  the  lower  to  the 


'  Lonsdale,  op.  cit.,  p.  166. 


2  Trans,  of  Med.  Society  of  Pennsylvania,  1878. 


FRACTURES  OF  THE  HUMERUS.  127 

upper  third  ;  besides  this,  several  of  tlie  minor  bloodvessels  were  lacerated  to 
such  an  extent  as  to  threaten  gangrene."  I  know  of  no  other  case  in  which 
an  injury  of  this  kind  resulted  from  such  a  cause. 

Bellamy/  recording  the  case  of  a  boy  of  14,  whose  humerus  gave  way  just 
below  the  insertion  of  the  deltoid,  as  he  was  making  a  great  exertion  in 
throwing  a  cricket-ball,  speaks  of  the  twisting  motion  which  is  apt  to  be  the 
finale  of  this  act,  as  probably  the  real  cause  of  the  breakage ;  and  this  view 
certainly  seems  to  be  correct.  The  suddenness  of  the  stress  upon  the  bone  is 
also  to  be  taken  into  account. 

As  to  the  point  at  which  the  bone  yields,  whether  above  or  below  the 
insertion  of  the  deltoid,  this  would  appear  to  be  determined  by  slight  varia- 
tions in  the  character  of  the  movement  executed.  It  must  be  borne  in  mind 
that,  in  the  act  of  throwing,  the  humerus  is  steadied  by  its  upper  end  against 
the  scapula,  its  head  rolling  in  the  glenoid  cavity,  while  its  lower  end 
describes  a  somewhat  large  arc,  and  carries  the  weight  of  the  forearm  and 
hand,  the  latter  describing  the  largest  arc  possible  to  it.  Under  these  cir- 
cumstances the  bone  is  act^d  upon  by  the  deltoid,  pectoralis  major,  and  latis- 
simus  dorsi,  much  as  the  mast  of  a  vessel  is  by  its  stays  ;  and  it  yields  just  as 
the  latter  sometimes  does  when  overloaded  above. 

By  Malgaigne,  Lonsdale,  and  others,  cases  are  recorded  in  which  the 
humerus  has  been  broken  in  trials  of  strength ;  the  opponents  "  facing  one 
another,  their  elbows  resting  on  a  solid  plane,  their  forearms  touching  by 
their  ulnar  margins,  their  fingers  interlocked,  and  in  this  position  each  tries 
to  turn  outward  the  wrist  and  forearm  of  the  other."  Here  the  twisting 
mechanism  is  so  evident  that  it  need  hardly  be  demonstrated. 

In  one  case  reported  by  Mr.  Henry  Smith ,2  a  fracture  of  the  humerus  was 
caused  by  the  attempt  of  the  patient  to  lift  himself  by  grasping  the  top  of  a 
wall. 

Dr.  W.  B.  Hopkins,  in  a  recent  article,^  has  reported  three  instances  of 
fracture  of  the  humerus  by  muscular  action.  In  one,  the  patient  was  throw- 
ing a  base-ball  "  over-hand  ;"  in  a  second,  the  man  made  a  miss  in  striking  a 
hard  blow  at  another  with  whom  he  \vas  fighting  ;  and  in  the  third,  a  woman 
was  carrying  a  heavy  tub  of  clothes.'* 

1  Lancet,  May  11,  1878.  2  Med.  Times  and  Gazette,  July  25,  1857. 

8  Philadelphia  Medical  Times,  March  24,  1883. 

*  In  connection  with  these  cases  Dr.  Hopkins  says  : — 

"When  the  forearm  is  flexed  at  the  elbow-joint  by  the  contraction  of  the  muscles  of  the  arm, 
the  lower  end  of  the  humerus  acts  as  tlie  fulcrum,  the  biceps  and  brachial  muscles  as  the  power, 
and  the  hand,  with  whatever  it  may  grasp,  as  the  weight.  The  forearm  is,  in  other  words,  a 
lever  of  the  third  kind.  In  such  the  power  must  always  be  greater  than  the  weight,  technically 
expressed  by  the  phrase  'mechanical  disadvantage.'  The  amount  of  mechanical  disadvantage 
to  which  the  muscles  of  the  arm  are  put  to  raise  a  known  weight  placed  in  the  hand,  is  com- 
puted by  multiplying  the  weight  to  be  raised  by  its  distance  from  the  fulcrum,  and  dividing  the 
product  by  the  distance  of  the  power  from  the  fulcrum. 

"  The  following  measurements  were  taken  from  the  bones  of  a  well-developed  male  skeleton  : 
From  the  bottom  of  the  sigmoid  cavity  of  the  ulna  to  the  metacarpo-phalangeal  articulation  of 
the  middle  finger,  fourteen  inches,  and  from  the  same  point  to  the  tuberosity  of  the  radius,  two 
inches.  (For  convenience  in  computation,  the  attachment  of  the  biceps  alone  will  be  used,  as 
it  is  the  more  important  flexor  muscle,  and  as  it  presents  less  mechanical  disadvantage  tlian  the 
brachial.)  The  power,  then,  in  this  lever,  is  to  the  weight  as  seven  to  one.  If,  therefore,  a 
weight  of  one  hundred  and  fifty  pounds  is  raised  in  the  hand  by  flexing  the  forearm,  the  power 

exerted  by  the  muscles  in  executing  this  movement  is  represented  thus  :        ^  ^''^  =  1050 

2 

pounds — a  force  well  calculated  to  part  a  tendon  or  break  a  bone. 

"The  fact  that  the  forearm  cannot  be  extended  with  as  much  force  as  it  can  be  flexed,  though 
with  greater  velocity,  of  course  depends  upon  the  difference  in  distance  between  the  power  and 
the  fulcrum  in  the  two  cases.  For,  in  the  same  specimen,  the  distance  from  the  point  of  insertion 
of  the  tendon  of  the  triceps  in  the  olecranon  to  a  point  opposite  the  bottom  of  the  sigmoid  cavity 
of  the  ulna,  was  found  to  be  only  half  an  inch.   The  power,  then,  in  this  lever,  is  to  the  weight 


128 


INJURIES  OF  BONES. 


One  point  of  importance  in  the  mechanics  of  the  upper  arm  is  the  attach- 
nient  of  the  forearm  muscles,  especially  the  extensors  and  supinator  longus, 
the  action  of  which,  when  the  elbow  is  flexed,  is  to  draw  forward  the  lower 
part  of  the  humerus,  and  thus  to  increase  the  forward  angular  deformity 
when  this  bone  is  broken  anywhere  below  its  middle.  The  effect  of  the  con- 
traction of  these  muscles  is  even  more  marked,  as  might  be  supposed,  in  frac- 
tures near  the  lower  end  of  the  bone,  in  connection  with  which  it  will  be 
again  mentioned. 

In  fractures  of  the  humerus  in  children,  the  periosteum,  by  reason  of  its 
comparatively  great  thickness,  may  escape  complete  rupture,  and  there  may 
be  but  little  displacement.  The  same  is  generally  the  case  in  adults  when 
the  bone  is  broken  by  muscular  action,  or  by  slight  violence.  Sometimes, 
however,  the  fragments  may  be  very  widely  separated,  and  occasionally  the 
overlapping  is  so  marked  as  to  materially  shorten  the  arm.  In  fractures  by 
great  violence,  especially  if  compound,  this  condition^  of  things  may  give 
much  trouble.    Pierson^  gives  a  striking  instance  of  this  kind : — 

A  seaman  was  brought  under  my  care,  who,  forty-five  days  before,  while  at  sea, 
had  fallen  from  the  maintopsail-yard  upon  the  deck  of  the  vessel,  fracturing  the  hume- 
rus obhquely.  The  superior  fragment  penetrated  the  skin,  and,  after  ploughing  a  furrow 
in  the  plank  half  an  inch  deep  and  two  inches  long,  was  finally  broken  off  in  it.  Gn 
my  first  visit  this  fragment,  which  was  about  three  inches  long,  was  presented  to  me, 
which  the  captain  assured  me  he  had  had  much  difficulty  in  extracting,  two  days  after 
the  accident,  from  the  plank  in  which  it  had  embedded  itself." 

This  man  recovered  with  anchylosis,  partial  in  the  shoulder  and  complete 
in  the  elbow  ;  the  arm  was,  of  course,  shortened. 

Syme^  has  reported  a  case  of  fracture  at  or  about  the  middle  of  the  hume- 
rus, the  head  of  the  bone  being  at  the  same  time  luxated;  into  the  axilla.  The 
patient  had  fallen  through  a  trap-door  into  a  cellar,  entangling  the  arm  in  a 
ladder  as  he  fell.  Reduction  was  effected  by  firmly  splinting  the  bone,  and 
then  attaching  an  extending  band  above  the  seat  of  fracture.  The  subse- 
quent progress  of  the  case  was  satisfactory. 

The  symptoms  of  fracture  of  the  shaft  of  the  humerus  are  the  same  as  those 
of  the  long  bones  generally :  pain,  loss  of  power,  preternatural  mobility,  often 
deformity,  and  generally  crepitus.  Scarcely  any  fracture  is  less  likely  to  pre- 
sent difficulties  in  dias^nosis. 

As  to  the  course  of  these  cases,  in  most  of  them  union  takes  place  favorably 
in  from  four  to  six  weeks  ;  but  it  must  not  be  forgotten  that  the  humerus  has 
afibrded  more  instances  of  pseudarthrosis  than  any  other  bone  in  the  skeleton. 
In  Agnew's  tables,  containing  685  cases  of  non-union,  there  were  219,  or  a 
little  less  than  32  per  cent.,  in  which  the  humerus  was  the  bone  involved. 
Out  of  the  219,  the  exact  seat  of  the  lesion  is  not  stated  in  52,  leaving  167 ; 
and  of  these,  17  are  said  to  have  been  of  "  the  upper  third"  or  "  the  surgical 
neck,"  and  1  of  the  external  condyle.  Hence  the  shaft  of  this  bone  would 
seem  to  have  been  the  seat  of  non-union  in  149,  or  nearly  22  per  cent,  of  the 
whole  number. 

Fractures  of  the  humerus  in  children  sometimes  unite  with  great  readiness. 
Thus,  among  the  cases  reported  by  Berry ,3  there  were  three  in  which  this 
bone  was  aftected  ;  in  one  consolidation  had  occurred  on  the  11th  day,  and  in 
the  other  two  on  the  13th. 

as  twenty-eight  to  one.  Therefore,  when  a  sixty  pound  dumb-bell  is  put  up  from  the  shoulder, 
the  force  exerted  by  the  triceps  muscle  is  shown  thus  :  ]iA_^=  1680  pounds,  or  630  pounds 

2 

more  force  than  is  required  to  raise  150  pounds  by  flexion." 

•  Remarks  on  Fractures,  Boston,  1840.  ^  Edinburgh  Medical  Journal,  July,  1849. 

3  New  England  Med.  Monthly,  March  15,  1883. 


FRACTURES  OF  THE  HUMERUS. 


129 


It  very  often  happens  that  fractures  of  the  shaft  of  tlie  hunieriis  aiv  united 
with  scarcely  any  perceptihle  deformity;  and  in  the  Museum  of  St.  liar- 
tholomew's  Hospital^  there  is  a  "section  of  a  humerus,  in  which  a  fracture 
of  the  shaft  at  the  attachment  of  the  deltoid  muscle  has  heen  exactly  united, 
so  that  hoth  the  walls  and  the  cancellous  tissue  are  uninterruptedly  contiiui- 
ous  ;  and  except  by  a  slight  deviation  of  its  axis,  and  a  small  external  deposit 
of  new  bone,  the  situation  of  the  fracture  could  hardly  be  discerned."  Some- 
times, however,  the  deformity  is  very  great,  when  the  fragments  are  allowed 
to  overlap  one  another;  yet  even  in  these  cases  the  usefuhiess  of  the  limb  is 
not  necessarily  impaired. 

The  vessels  and  nerves,  as  a  general  rule,  escape  injury,  except  in  cases  of 
compound  fracture.  Laurent^  relates  one  case,  connnunicated  to  him  by  Ri- 
chet,  in  which  a  boy  ten  years  old  had  a  fracture  of  the  right  humerus,  one 
fragment  of  which  woimded  the  brachial  artery  and  gave  rise  to  an  aneurism, 
whtcb  was  cured  by  ligation  of  the  vessel  above  and  below.  Malgaigne 
quotes  two  cases  in  which  suppuration  ensued  ;  but  this  is  vory  rare.  In- 
stances of  the  almost  complete  absorption  of  this  bone  after  fracture  have 
been  referred  to  in  the  general  part  of  this  article.^ 

Occasionally  cases  are'met  with  in  which,  in  the  course  of  union  of  fractures 
of  the  humerus,  nerves  are  entangled  in  the  callus  or  pressed  upon  by  it,  with 
the  result  of  causing  pain  or  paralysis,  or  both,  of  the  limb.  Generally  it  is 
the  musculo-spiral  nerve  which  is  thus  interfered  with.  Trelat^  reports,  that 
a  young  man,  in  consequence  of  a  fracture  of  the  left  arm,  had  an  exuberant 
callus  which,  by  inclusion,  caused  paralysis  of  the  parts  supplied  by  the  above- 
mentioned  nerve.  An  operation  was  performed,  the  nerve  being  disengaged, 
and  the  projecting  part  of  the  callus  being  resected.  Two  months  afterward 
movements  began  to  be  possible,  and  the  functions  of  the  limb  were  gradually 
restored.    Tillaux  is  said  to  have  referred  to  a  similar  case  seen  by  him. 

G-ross^  speaks  of  having  seen  two  cases  of  wrist-drop  from  pressure  of  callus 
upon  the  musculo-spiral  nerve,  in  cases  of  fracture  of  the  humerus ;  he  says 
that  the  only  remedy  is  the  removal  of  the  callus,  but  does  not  state  whether 
by  operation  or  by  local  medication ;  nor  does  he  give  the  results  in  the  two 
cases  whicli  he  cites. 

Agnew^  mentions  such  a  condition,  in  a  boy  aged  ten  years,  and  says :  "As 
the  absorption  of  the  redundant  callus  took  place,  and  under  the  stimulus  of 
an  electro-galvanic  current,  his  improvement  was  quite  noticeable." 

The  treatment  of  fractures  of  the  shaft  of  the  humerus  is  simple  enough  in 
principle,  but  much  difference  of  opinion  has  existed  as  to  its  details.  Re- 
duction can  generally  be  effected  without  great  difficulty,  and  the  line  of 
breakage  is  not  often  so  oblique  as  to  prevent  the  fragments  from  being  kept 
in  good  position.  Yet,  as  has  been  already  stated,  no  other  bone  has  offered 
so  many  examples  of  non-union.  My  own  belief  is  that  the  true  explanation 
of  this  fact  is  to  be  found  in  the  leverage  upon  the  lower  fragment,  exerted 
by  the  forearm  and  hand,  which  can  only  be  counteracted  by  care  in  securing 
the  whole  arm — the  upper  fragment  as  well  as  the  lower,  ^^o  matter  how 
exactly  an  apparatus  is  applied,  if  it  does  not  extend  upward  sufficiently  to 
get  a  purchase  upon  the  portion  of  bone  above  the  seat  of  fracture,  there  is 
danger  of  deformity,  if  not  of  failure  of  union.  But  if  the  fragments  are 
controlled,  the  forearm  may  be  simply  supported  in  a  sling  across  the  front  of 
the  chest.    I  am  inclined  to  urge  this,  from  having  more  than  once  or  twice 

•  Catalogue,  vol.  i.  p.  139. 

2  Des  Anevrysmes  corapliquant  les  Fractures,  p.  42.    Paris,  1875. 

a  See  page  45.  *  Gazette  Medicale  de  Paris,  23  T>6c.  1882. 

»  Op.  cit.,  vol.  i.  p.  976.  ^  Op.  cit.,  vol.  i.  p,  887. 

VOL.  IV. — 9 


130 


INJURIES  OF  BONES. 


seen  cases  in  which  angular  splints  had  been  carefully  bandaged  on,  but  not  far 
enough  up  the  arm  ;  the  effect  being  simply  to  convert  the  whole  limb  below 
the  fracture  into  a  powerful  bent  lever,  by  which  the  lower  fragment  was 
moved  upon  the  upper,  and  the  amount  of  callus  augmented,  with  the  chance 
of  deformity,  more  or  less  permanent,  as  well  as  of  entanglement  of  nerve- 
fibres,  or  of  interference  with  the  bloodvessels. 

By  the  older  surgeons,  the  use  of  an  immediate  bandage — a  roller  applied 
next  to  the  skin — was  considered  indispensable  for  the  prevention  of  muscu- 
lar spasm.  Such  a  bandage,  although  less  objectionable  here  than  in  the  case 
of  the  forearm  or  leg,  can  do  no  good,  and  may  do  harm  by  hindering  the 
surgeon  from  accurately  judging  of  the  position  of  the  fragments.  It  is, 
however,  sometimes  well  to  apply  a  roller  to  the  hand  snd  forearm,  and  per- 
haps to  include  the  lower  part  of  the  arm  itself,  in  order  in  some  deo-ree  to 
prevent  swelling  of  the  distal  part  of  the  limb.  But  the  bandage  Should 
never  be  carried  up  as  far  as  the  fracture,  and  the  condition  of  the  fino;ers 
should  be  watched,  lest  trouble  arise  from  the  pressure. 

There  are  no  landmarks  by  which,  in  the  living  subject,  the  proper  line  of 
the  humerus  can  be  clearly  determined.  Perhaps  as  good  a  test  as  any  is, 
that  the  posterior  surface  of  the  upper  arm  being  even  and  vertical,  and  the 
thumb  held  upward,  the  whole  anterior  surface  of  the  forearm  is  in  apposi- 
tion with  the  side  of  the  chest.  Rotary  as  well  as  angular  displacement  is 
guarded  against  by  observing  this  position  in  cases  of  fracture. 

At  the  back  of  the  arm,  the  firm  and  even  mass  of  the  triceps  muscle,  and 
in  front  that  of  the  biceps  and  brachialis  anticus,  afibrd  an  opportunity  for 
making  very  accurate  and  eftective  pressure  on  these  surfaces  of  the  bone. 
On  the  inner  side,  except  in  very  muscular  subjects,  the  projection  of  the 
epicondyle  is  such  as  to  leave  quite  a  marked  hollow  above  it,  but  on  the 
outer  side  the  hollow,  which  is  much  less,  is  filled  up  by  the  deltoid  above 
and  by  the  outer  borders  of  the  triceps  and  brachialis  below\ 

Stromeyer's  cushion,*  a  sort  of  double  wedge-shaped  pad,  upon  which,  in- 
terposed between  the  body  and  the  limb,  the  latter  i^ests,  is  sometimes  of 
great  use  as  a  temporary  arrangement,  but  can  hardly  be  relied  upon  as  a 
permanent  dressing. 

By  some  surgeons,  it  has  been  thought  sufficient  to  confine  the  arm  to  the 
side  by  means  of  bandages,  with  an  axillary  pad  in  the  form  of  a  long,  fiat 
wedge.  In  very  quiet  and  submissive  patients  this  may  answer ;  but  it  is 
safer  to  apply  also  four  strips  of  wood,  lightly  padded,  one  on  each  aspect  of 
the  arm,  confined  either  by  adhesive  strips  or  by  a  roller,  and  then  to  fasten 
the  whole  limb  to  the  chest. 

My  own  preference  is  for  a  right-angled  splint  of  wood,  extending  from  the 
axilla  to  the  ends  of  the  fingers,  along  the  inner  side  of  the  limb ;  the  angle 
corresponding  to  the  elbow,  and  the  arm-part,  well  padded,  so  as  to  allow  for 
the  projection  of  the  inner  condyle.  In  the  case  of  a  very  lean  adult,  it  is 
better  to  cut  a  hole  with  bevelled  edges,  large  enough  to  permit  the  condyle  to 
sink  into  it  and  thus  escape  pressure.  Short  slips  of  wood,  binder's  board  or 
sole-leather,  properly  padded,  are  fitted  to  the  anterior,  posterior,  and  outer 
faces  of  the  arm  ;  the  edges  and  corners  of  these  small  splints  should  be  care- 
fully bevelled.  Adhesive  strips  an  inch  or  more  in  width  may  be  first  put  on 
near  the  ends  of  the  splints,  and  then  an  ordinary  roller ;  by  this  means  the 
occasional  removal  of  the  latter  for  the  purpose  of  examining  the  limb  may 
be  rendered  safer.  The  limb,  thus  bound  up,  should  be  suspended  in  a  sling 
passing  under  the  wrist ;  and  in  children  or  restless  adults,  a  few  turns  of  a 
wide  roller  may  be  applied  to  confine  the  elbow  to  the  side.    When  the  frac- 


1  See  Fig.  275,  Vol.  II.  p.  160. 


'      FRACTURES  OF  THE  HUMERUS. 


131 


ture  is  above  the  middle  of  the  shaft,  the  outer  short  splint  may  be  extended 
upward  into  a  shoulder-cap  such  as  has  already  been  described,  and  the  roller 
continued  upward,  and  made  to  form  what  is  known  as  the  "spica"  of  the 
shoulder,  a  few  turns  being  carried  around  the  upper  part  of  the  chest. 

Bandages  imbued  with  plaster  of  Paris,  or  other  solidifying  material,  have 
been  used  by  some  surgeons  in  fractures  of  the  shaft  of  the  humerus,  but  they 
aftbrd  no  special  advantage,  unless,  perhaps,  in  the  rare  instances  where  a 
patient  must  undergo  transportation,  or,  in  the  later  stages  of  the  treatment, 
if  the  dressings  cannot  be  often  examined.  If  applied  during  the  earlier 
period  they  need  to  be  carefully  watched,  lest  the  swelling  of  the  soft  parts 
should  subside,  and  the  requisite  control  of  the  limb  be  thus  lost. 

Let  me  again  repeat,  that  the  importance  of  so  arranging  the  dressings  as 
to  secure  the  upper  fragment  can  scarcely  be  overrated.  The  inside  splint 
should  extend  well  up  into  the  axilla,  onl}^  guarding  against  pressure  upon 
vessels  and  nerves  ;  and  the  outer  one  should  bear  upon  the  bone  in  its  whole 
length.  Sometimes  additional  security  may  be  given  by  placing  on  the 
exposed  surface  of  each  of  the  splints  a  strip  of  adhesive  plaster,  doubled,  so 
as  to  present  its  sticky  side  outward  to  the  roller,  as  well  as  inward  to  the 
splint. 

Sometimes  it  happens  that  extension  is  desirable  to  prevent  overlapping  of 
the  fragments  of  the  humerus.  According  to  Swinburne,^  this  is  the  only 
thing  needful  in  the  treatment  of  these  injuries;  and  he  recommends  the  em- 
ployment of  an  apparatus  which  certainly  has  the  merit  of  simplicity.  This 
consists  in  a  board-splint,  applied  either  on  the  outer,  inner,  or  posterior 
surface  of  the  arm,  and  attached  to  it  below  by  loops  of  adhesive  plaster  for 
extension.    Counter-extension  is  made  from  the  axilla. 

Ingenious  splints  on  the  same  principle,  but  provided  with  ratchets  for 
lengthening  them,  have  been  devised  and  used  by  Lonsdale,^  Vedder,^  and 
others.  The  objection  to  all  of  these  lies  in  the  fact  that  the  axilla  is  made 
the  resisting  point  for  the  counter-extension,  and  that  it  is  wholly  unreliable 
for  this  purpose. 

Harlan*  obtained  great  advantage  by  applying  the  counter-extending  ad- 
hesive strips  obliquely  over  the  chest  and  back.  He  used  in  one  case  a 
wooden  splint  for  the  outer  side  of  the  arm,  with  a  bracket  screwed  into  its 
upper  end  for  the  attachment  of  the  counter-extending  band ;  and  in  the  other, 
an  iron  bar  of  suitable  length,  bent  ati>oth  ends. 

Dr.  H.  A.  Martin^  has  employed  an  apparatus  in  wdiich,  while  the  counter- 
extension  is  obtained  by  strips  applied  to  the  front  and  back  of  t]ie  thorax, 
the  splint  itself  consists  essentially  of  a  double  iron  bar,  the  two  portions  of 
which  are  movable  upon  one  another  by  means  of  a  ratcliet  aAd  pinion, 
worked  by  a  key. 

1  have  myself  attained  the  same  object  by  employing  a  wooden  splint 
applied  to  the  outer  side  of  the  arm,  but  extending  several  inches  beyond  it 
upward  and  downward,  the  counter-extending  adhesive  strips  being  simply 
wound  around  the  arm  above  the  seat  of  fracture,  while  the  extension  was 
made  in  like  manner  from  below. 

*  Treatment  of  Fractures  of  the  Long  Bones  by  Simple  Extension.    Albany,  1861. 

2  Op.  cit.,  p.  174. 

'  Vedder's  splint  may  be  found  described  and  figvired  in  the  Medical  and  Surgical  History  of 
the  War  of  the  Rebellion,  Part  II.,  Surgical  Vol.,  pp.  812  and  822.  There  is  also  here  mentioned 
an  ingenious  expedient,  suggested  by  Dr.  Foster  Swift,  which  consists  in  fastening  together  two 
forked  branches  so  as  to  get  a  fork  above  and  another  below,  to  which  the  extending  and 
counter -extending  bands  may  be  attached.  Under  some  circumstances  this  idea  might  be  car- 
ried out  with  very  great  advantage. 

*  Med.  and  Surg.  History  of  the  War  of  the  Rebellion,  Part  II.,  Surg.  Vol.,  pp.  509,  562. 
6  Ibid.,  p.  822. 


132 


INJURIES  OF  BONES. 


Hamilton  mentions  that  a  plan,  first  suggested  and  tried  by  Clark  of  St. 
Louis,  has  been  found  satisfactory,  viz.,  the  attachment  of  a  weight  to  the 
lower  part  of  the  arm  by  means  of  adhesive  strips.  Without  questioning  the 
statements  in  favor  of  this  method,  I  must  say  that  ic  seems  to  me  to  present 
certain  practical  difiaculties  in  its  carrying  out,  which  are  not  easily  met. 
The  humerus  must,  of  course,  either  be  kept  vertical,  or  the  weight  must  pull 
it  out  of  shape,  and  when  the  patient  lies  down  the  weight  must  be  sus- 
pended over  a  pulley ;  but  a  slight  change  of  posture  would  interfere  with 
its  action,  or  cause  it  to  make  traction  out  of  the  proper  line. 

A  very  complicated  contrivance  has  recently  been  described^  by  Dr.  Hubbell, 
of  Colorado,  having  a  crutch-head  for  the  axilla,  a  screw  for  extension,  a  splint 
for  the  forearm,  and  a  hand-rest ;  short  splints  are  added  if  the  fracture  is 
not  compound.  It  serves  as  an  instance  of  the  revival  of  old  ideas  in  a 
slightly  modified  shape. 

Dr.  Hamilton  has  suggested  a  method  of  dressing  these  fractures,  with  a  view 
of  preventing  or  curing  non-union,  which  is  certainly  original,  and  which  can 
hardly  be  passed  over,  although  I  cannot  say  that  it  commends  itself  to  my 
judgment.  After  referring  to  the  peculiar  tilting  motion  apt  to  be  impressed 
upon  the  lower  fragment,  he  proposes  straightening  the  elbow,  and  applying 
a  firm,  straight  splint  from  the  top  of  the  shoulder  to  the  hand,  making  it 
fast  with  rollers.  'Not  only  would  such  a  posture  be  aw^kward  and  inconve- 
nient, but  the  tendency  would,  I  think,  be  to  tilt  the  i.pper  end  of  the  lower 
fragment  forward,  and  thus  to  give  rise  to  deformity. 

In  fractures  near  the  lower  part  of  the  shaft  of  the  humerus,  the  portion 
where  the  bone  begins  to  widen  out,  there  is  apt  to  be  a  displacement  of  very 
marked  character  from  muscular  action.  The  flexors,  2Dronators,  and  exten- 
sors all  tend  to  pull  the  lower  fragment  forw^ard,  and,  as  it  yields,  its  upper 
end  must,  of  course,  tilt  in  this  direction ;  the  triceps  draws  the  olecranon 
upward,  and  anteriorly  the  biceps  and  brachialis  anticus  do  the  same.  Hence 
the  combined  effect  of  all  these  forces  is  to  tilt  the  lower  fragment  at  an  angle 
with  the  upper,  as  in  Fig.  828.  If  union  takes  place  under  such  circum- 
stances, it  must  be  clear  that  when  flexion  of  the  forearm  upon  the  arm  is 


Fig.  828.  Fig.  829. 


Diagram  illustrating  tilting  of  lower  fragment  in  Splint  of  binder's  board  for  fracture  of  lower  part 

fracture  of  humerus  near  elbow.  of  humerus. 

attempted,  it  will  be  checked  as  soon  as  the  coronoid  process  of  the  ulna 
comes  in  contact  with  the  lesser  sigmoid  cavity  of  the  humerus,  and  that  in 
the  changed  position  of  the  lower  fragment  the  power  of  full  flexion  of  the 
elbow  must  be  lost.    In  order  to  obviate  the  tendency  to  this  condition  of 

»  Therapeutic  Gazette  (Detroit),  May,  1883. 


FRACTURES  OF  THE  HUMERUS. 


133 


things,  I  long  ago  devised  the  splint  shown  in  Fig.  829,  which  is  intended  to 
be  cut  out  of  the  exact  size  required  (ascertained  by  taking  an  outline  of  the 
sound  linih).  The  material  I  generally  use  is  binder's  board,  but  sole-leather 
or  patent  felt  w^ould  answer  the  same  purpose,  except  in  the  (,'ase  of  unusuall}'' 
large  limbs.  The  part  marked  a  is  bent  so  as  to  come  in  front  of  the  arm; 
b  is  bent  up  behind  the  elbow,  while  c,  c,  are  bent  so  as  to  give  the  forearm 
support  and  steadiness  on  the  ulnar  side.  Properly  proportioned  and  care- 
fully applied,  I  think  that  this  splint  gives  me  more  perfect  control  of  a  broken 
humerus,  especially  at  the  lower  part  of  the  bone,  than  I  have  succeeded  in 
getting  by  any  other.  As  consolidation  progresses,  it  is  my  practice  to  cut 
awav  more  and  more  of  the  splint  at  each  dressing,  so  that  the  patient  gains 
the  use  of  the  hand  before  the  arm  can  be  left  to  itself. 

Another  plan  which  w^ould  seem  to  promise  well,  in  fractures  of  the  lower 
part  of  the  humerus,  is  to  place  the  elbow  at  an  acute  angle,  and  keep  it 
so  for  perhaps  two  weeks,  when  union  may  be  supposed  to  have  begun,  and 
when  the  forearm  may  at  each  dressing  be  very  slightly  brought  down,  until 
at  last  the  bones  are  found  firm  enough  for  complete  passive  motion  to  be 
attempted.  By  this  method,  entire  relaxation  of  the  flexors  and  pronators 
v^ould  be  attained,  and  forward  angular  displacement  could  scarcely  occur. 
Should  it  be  found  that  the  lower  fragment  projected  backward,  the  angle  of 
the  elbow^  might  readily  be  made  more  obtuse,  and  a  short  splint  be  applied 
along  the  posterior  surface  of  the  arm. 

The  subject  of  pseudarthrosis  has  already  been  discussed  at  such  length  in 
the  general  part  of  this  article,  that  the  treatment  of  such  cases  in  this  region 
need  not  be  again  spoken  of  here. 

Fractures  of  the  lower  end  of  the  humerus,  as  has  been  already  stated, 
and  as  may  be  seen  from  Gurlt's  table  quoted'  on  page  118,  are  much  more 
frequently  met  with  than  those  of  either  the  shaft  or  the  upper  end.  In 
children  this  predominance  is  especially  marked,  since  up  to  the  tenth  year 
the  lower  portion  of  the  bone  is  broken  considerably  more  than  twice  as  often 
as  both  the  other  divisions  put  together.  Between  the  tenth  and  the  t\ventieth 
year  the  numbers  become,  in  the  set  of  cases  upon  which  this  table  is  based, 
exactly  equal.  Later  in  life  there  is  a  very  great  diminution  in  the  liability 
of  the  lower  part  of  the  bone  to  fracture  ;  but  the  fact  must  not  be  lost  sight 
of  that  the  shaft  also  shares  in  this  decrease,  so  that  the  difierence  of  propor- 
tion is  not  as  great  in  reality  as  it  would  at  first  sight  appear  to  be. 

The  boundary  between  the  shaft  of  the  humerus  and  what  we  call  the 
lower  end  is  not  exactly  defined  ;  even  less  so,  perhaps,  than  that  between  the 
neck  and  the  shaft.  It  is  a  surgical  and  not  an  anatomical  division  ;  and  a 
doubt  may  sometimes  arise  in  regard  to  certain  fractures,  as  to  whether  they 
should  more  properly  be  classed  among  those  of  the  shaft,  or  with  those  of 
the  lower  end.  But  in  general  the  cases  which  belong  to  the  latter  category 
present  features  which  render  them  plainly  distinguishable.  One  of  these  is 
the  eftect  of  muscular  action,  and  another  is  due  to  the  neighborhood  of  the 
elbow-joint ;  they  will  be  further  referred  to  directly. 

Under  the  present  head  are  included  a  variety  of  fractures,  the  j^rincipal 
lines  of  which  are  shown  in  the  annexed  diagrams  (Figs.  830  and  831).  Thus, 
there  are  cases  in  which  the  bone  is  separated  more  or  less  transversely,  just 
above  the  condyles,  the  line  of  division  sometimes  running  up  along  the 
outer  or  inner  side  of  the  bone  so  as  to  involve  in  the  lower  fragment  nearly  or 
quite  a  third  of  its  length.  Often,  along  wath  this,  one  or  more  lines  of 
breakage  pass  downward  into  the  joint.  Occasionally  the  outer  portion  of 
the  lower  end  only  is  involved,  the  condyle  only,  or  with  it  the  epicondyle, 
being  broken  ofi'.    Or  the  inner  part  of  the  lower  end  may  be  separated — the 


134 


INJURIES  OF  BONES. 


trochlea,  with  or  without  the  epitrochlea,  or  the  latter  process  by  itself. 
Finally,  there  are  disjunctions  of  the  lower  epiphysis,  or  of  its  articular 
portion  only. 

It  may,  perhaps,  be  as  well  to  say  here  that  although  these  various  forms 
of  fracture  can  be  thus  enumerated  theoretically,  they  are  not  in  practice  by 

Fig.  830.  Fig.  831. 


Diagram  showing  transverse  fracture  of  lower  Diagram  of  T-fracture  of  lower  end  of  humerus, 

end  of  humerus.    The  curved  line  shows  com-  with  lines  of  fracture  of  internal  condyle  or  trochlea, 

plete  epiphyseal  disjunction.  of  epitrochlea,  and  of  external  condyle. 

any  means  so  easily  distinguished.  The  lines  of  separation  may  run  very 
irregularly ;  occasionally  the  combination  of  two  or  more  fractures,  or  the 
existence  of  luxation  along  with  fracture,  may  present  a  condition  of  things 
in  the  highest  degree  perplexing.  But  this  matter  will  be  more  appropriately 
discussed  in  connection  with  the  diagnosis  of  these  injuries.  Fractures  of  the 
eirtcondyle  may,  I  think,  be  dismissed  without  further  mention,  since  there  is 
no  case  on  record  in  which  such  a  lesion  has  been  verified  beyond  a  doubt.  It 
is  true  that  ZuckerkandP  claims  to  have  seen  one,  and  that  Gurlt  figures  a 
specimen.  Sir  Astley  Cooper^  also  represents  one,  in  which,  however,  the 
bone  was  "  somewhat  thickened,"  and  the  original  lesion  may  have  been  more 
extensive.  Fresh  doubt  is  thrown  upon  these  specimens  by  the  statement  of 
McBurney3  that  "  he  had  found  in  the  dissecting-room  similar  isolated  pieces 
of  bone  resembling  detached  epicondyles,  and  existing  symmetrically  at  both 
elbows."  Fractures  detaching  the  epicondyle  along  with  the  condyle  are, 
however,  known  to  have  occurred  in  numerous  instances. 

A  careful  study  of  the  anatomy  of  the  lower  end  of  the  humerus,  and  of 
the  muscles  attached  to  it  as  well  as  to  the  adjoining  bones,  is  essential  to  the 
understanding  of  fractures  in  this  region.  Especial  attention  should  be  paid 
to  the  shape  and  extent  of  the  epiphysis,  in  view  of  the  fact  that  so  many  of 
the  subjects  of  these  injuries  are  at  an  age  when  it  has  not  yet  become  con- 
solidated with  the  shaft,  and  therefore  when  the  question  of  its  disjunction  is 
apt  to  arise.  The  fiattening  of  the  bone  antero-posteriorly  as  it  widens  out 
toward  the  condyles,  and  its  consequent  thinning,  have  already  been  mentioned, 
as  well  as  the  muscles  by  which  the  position,  bent  or  extended,  of  the  elbow- 
joint  is  controlled. 

The  epiphysis  consists  of  four  parts,  developed,  according  to  Gray,  in  the 
following  nianner:  "At  the  end  of  the  second  year,  ossification  commences 
in  the  radial  portion  of  the  articular  surface,  and  from  this  point  extends 
inwards,  so  as  to  form  the  chief  part  of  the  articular  end  of  the  bone,  the 
gentre  for  the  inner  part  of  the  articular  surface  not  appearing  until  about 
the  age  of  twelve.    Ossification  commences  in  the  internal  condyle  about  the 

'  London  Med.  Record,  May  15,  1878,  from  Allg.  Wie^ier  med.  Zeitung,  Feb  ]878. 

2  Dislocations  and  Fractures  of  Joints,  p.  467. 

'  Stimson,  Practical  Treatise  on  Fractures,  p.  395. 


FRACTURES  OF  THE  HUMERUS. 


135 


fifth  year,  and  in  the  external  one  not  until  between  the  tliirteenth  and  four- 
teenth year^?.  About  the  sixteenth  or  seventeenth  year,  the  outer  condyle  and 
both  portions  of  the  articulating  surface,  having  ah-eady  joined,  unite  with 
the  shaft;  at  eighteen  years,  the  inner  condyle  becomes  joined."  (The  reader 
will  note  that  ni  this  description  the  term  internal  condyle"  is  equivalent 
to  "epitrochlea,"  and  the  term  "external  condyle"  to  "epicondyle.")  The  im- 
portance of  these  facts  consists  in  their  bearing,  not  as  much  upon  the  separa- 
tion of  the  epiphysis  as  a  whole,  as  upon  disjunctions  of  portions  of  it,  which 
I  have  no  doubt  are  more  frequent  than  they  are  generally  sup[)ose(l  to  be. 

Another  matter  of  great  moment  in  this  connection  is  the  anatomy  of  the 
elbow-joint.  The  trochlea,  upon  which  the  ulna  moves  as  upon  a  hinge,  drops 
at  its  inner  margin  considerably  below  the  level  of  any  other  })art  of  the  joint, 
and  thus  locks  in  the  articulating  extremity  of  the  latter  bone.  Hence,  lever- 
age through  the  ulna  is  often  brought  to  bear  most  pov»'erfully  upon  the 
lower  endof  the  humerus,  tending  to  twist  it  off;  and  if  the  ei)iphysis  is  yet 
ununited  to  the  shaft  b}'  bone,  its  disjunction  may  ensue,  while  if  it  has  already 
become  consolidated,  a  fracture  may  be  produced  above.  The  radius, although 
it  shares  in  the  flexion  and  extension  of  the  forearm,  rotates  freely  upon  an 
axis  passing  through  the  centre  of  its  head,  and  hence  is  far  less  likely  either  to 
be  itself  broken,  or  to  be  the  means  of  breaking  the  corresponding  portion  of 
the  humerus. 

As  has  been  already  stated,  fractures  occurring  near  the  lower  end  of  the 
humerus  very  often  run  into  the  joint ;  but  even  when  this  is  not  the  case, 
the  near  neighborhood  of  the  joint  constitutes  a  complication  of  all  these 
injuries,  as  ifs  extensive  synovial  membrane  inflames  with  extreme  readiness, 
and  the  swelling  from  eflusion  into  its  cavity  not  only  greatly  increases  the 
difliculty  of  recognizing  the  exact  nature  of  the  lesion,  but  also  embarrasses 
its  treatment. 

In  front  of  the  joint,  the  median  and  the  musculo-spiral  or  radial  nerve, 
and  behind  it  the  ulnar,  are  in  very  close  relation  with  the  bone ;  so  that 
either  by  actual  pressure  upon  these  nerves  by  the  fragments,  or  by  their 
injury  or  displacement,  special  symptoms,  of  no  small  importance,  are  not 
utifrequently  induced. 

The  causes  of  fracture  of  the  lower  part  of  the  humerus  are  very  generally 
falls  on  the  hand  or  on  the  elbow  ;  they  are  in  the  former  case  due  to  indirect 
violence,  m  the  latter  to  direct.  Often,  however,  it  is  impossible,  to  arrive  at 
any  certainty  as  to  the  way  in  which  the  hurt  has  been  received,  from  the 
youth  of  the  subject,  or  from  the  confusion  and  terror  induced  by  the  accident. 
It  is  highly  probable  that  the  tension  of  the  muscles,  in  the  eftbrt  to  avoid  fall- 
ing, may  have  something  to  do  with  the  production  of  the  fracture,  or  at  least 
with  determining  its  seat  and  direction.  As  a  general  rule,  even  if  in  the  act 
of  falling  the  forearm  is  fully  extended  upon  the  arm,  it  becomes  flexed  to 
some  degree  when  the  hand  strikes  the  ground  ;  the  ulna  is  forced  against  the 
humerus,  and  held  there  by  the  muscles  before  mentioned,  so  that  there  is  a 
combination  of  leverage  and  muscular  action,  to  which  it  is  not  surprising 
that  the  bone  should  yield.  Still  another  condition  favoring  fracture  is  the 
irregular  way  in  which  the  force  is  suddenly  brought  to  bear,  so  that  the  stress 
comes,  not  in  the  axis  of  the  humerus,  but  at  an  angle  to  it,  as  a  "  cross- 
breaking  strain." 

The  symptoms  in  these  cases,  to  be  appreciated,  must  be  observed  at  a  very 
early  stage,  as  otherwise  the  swelling  which  rapidly  comes  on,  especially  if 
the  elbow-joint  be  directl}^  involved,  makes  everything  obscure,  except  the 
fact  of  fracture.  By  the  direction  of  the  fracturing  force,  as  well  as  by  the 
muscular  action  already  repeatedly  mentioned,  the  upper  fragment  generally 
presents  itself,  in  fractures  just  above  the  condyles  (to  use  Malgaigne's  term) 


136 


INJURIES  OF  BONES. 


in  front  of  the  lower.  Occasionally,  but  very  rarely,  the  lower  fragment  is 
found  in  front  of  the  upper ;  this  is  probably  due  to  the  direction  of  the  frac- 
turing force,  driving  the  wluole  elbow  forward.  Malgaigne  has  figured  a 
case  of  this  kind.  And  in  any  case,  unless  the  injury  has  been  the  result  of 
great  direct  violence,  there  is  a  tendency  to  the  tilting  forward  of  the  lower 
fragment,  and  thus  to  the  formation  of  an  angle,  salient  forward.  Thus  the 
antero-posterior  diameter  of  the  arm  just  above  the  elbow^  is  increased  in  a 
marked  degree.  Along  with  this  change  in  the  bone  there  must  be  more  or 
less  shortening  of  the  arm,  although  this  is  seldom  sufficient  to  attract  notice. 
I  think,  however,  that  I  have  observed  one  sign  of  this,  in  the  wrinkling  of 
the  skin  at  the  back  of  the  arm,  just  above  the  olecranon ;  but  this  disappears, 
or  at  least  becomes  less  distinct,  as  swelling  takes  place. 

Pain  is  nearly  always  present,  and  may  be  very  severe ;  it  is  aggravated 
by  the  least  motion  of  the  elbow,  so  that  the  patient  generally  supports  the 
arm  and  hand  very  carefully  with  the  sound  hand.  There  is,  of  course,  total 
loss  of  power,  involving  the  whole  limb. 

In  many  of  these  cases  the  abnormal  mobility  is  clearh'  perceptible,  and  it 
can  almost  always  be  detected  upon  careful  examination.  Sometimes,  indeed, 
it  is  so  free  ^is  to  be  in  itself  puzzling,  as  in  cases  where  from  a  transverse 
fracture  there  are  two  or  more  subordinate  lines  of  breakage  running  down- 
ward into  the  elbow-joint.  Here  the  sensation  imparted  to  the  touch,  when 
the  forearm  is  rotated  on  the  arm,  is  that  of  a  loose  rattling ;  and,  especially 
if  swelling  has  already  begun,  it  is  difficult  to  get  a  starting  point  from  which 
to  measure  the  relations  of  the  fragments. 

When,  however,  there  is  any  lateral  mobility  of  the  elbow,  the  fact  of  frac- 
ture may  be  regarded  as  established.  In  the  complexity  of  the  movements 
performed  by  the  hand,  we  are  apt  to  lose  sight  of  the  simplicity  of  the  parts 
of  the  system  upon  which  they  depend.  At  the  elbow,  in  the  normal  state, 
there  is  absolutely  no  motion  except  the  hinge-like  Hexion  and  "extension  of 
the  ulna  upon  the  humerus,  and  the  rotation  of  the  radius  upon  an  axis  pass- 
ing through  the  centre  of  its  head,  and  thence  downward  through  the  ulnar 
border  of  its  carpal  articulating  surface.  When  the  forearm  is  semi-fiexed  on 
the  arm,  and  the  hand  moved  outward  and  inward,  it  seems  as  if  there  must 
be  a  lateral  movement  at  the  elbow,  but  this  appearance  will  be  found  to  be 
wholly  due  to  rotation  of  the  humerus  around  its  long  axis ;  the  real  motion 
is  altogether  confined  to  the  shoulder.  If  the  hand  can  be  thus  moved  when 
the  arm  is  grasped  and  held  still,  it  is  proof  positive  of  the  existence  of  frac- 
ture.   Luxation  does  not  free  the  elbow  in  any  way. 

When  the  upper  extremity  hangs  by  the  side,  with  the  elbow  extended 
and  the  hand  in  supination,  it  will  be  seen  at  once  that  the  eJbow  forms  a 
very  obtuse  angle,  salient  inward,  and  that  the  hand  hangs  out  from  the  side. 
Now,  if  without  any  rotation  of  the  humerus  at  all,  the  forearm  be  fully 
flexed,  it  will  be  found  that  the  hand  comes  up  at  the  outer  side  of  the 
shoulder,  and  that  not  even  by  the  utmost  pronation,  with  flexion  of  the 
wrist,  can  the  end  of  the  middle  finger  be  brought  opposite  to  the  mouth. 
These  facts  are  all  accounted  for  by  the  outward  slant  of  the  trochlear  por- 
tion of  the  lower  articular  end  of  the  humerus,  and  are  of  great  importance  in 
the  recognition,  and  especially  in  the  treatment,  of  fractures  in  this  region. 

I  have  already  referred  to  the  muscles  by  which  deformity  is  produced  or 
kept  up  in  fractures  of  the  lower  half  of  the  humerus,  and  need  hardly  urge 
that  the  shorter  the  lever  upon  which  they  act,  or,  in  other  words,  the  lower 
the  seat  of  fracture,  the  more  direct  and  decided  will  be  their  influence.  But 
it  must  be  remembered  that  the  line  of  separation  of  the  bone  is  very  seldom 
directly  transverse ;  even  wdien  it  runs  almost  directly  across  in  front,  as  I 
have  seen  in  a  few  specimens,  there  is  apt  to  be  irregularity  somewhere  in 


FRACTURES  OF  THE  HUMERUS. 


137 


the  thickness  of  the  bone,  and  this  gives  rise  to  a  lateral  tilting,  by  a  me- 
chanism too  obvious  to  need  more  than  mention. 

Hamilton^  has  detailed  a  ninnl)er  of  instances  in  which  the  ultimate  effect 
of  this  displacement  was  clearly  shown  ;  and  it  has  occurred  to  me  to  see  it 
repeatedly.  When  union  takes  place  without  the  correction  of  this  angle 
forward,  the  articulating  surface  of  the  humerus  is  directed  downward  and 
backward,  and  the  result  is  that  flexion  of  the  forearm  is  limited,  while  its 
extension  may  be  abnormally  increased.  The  reason  why  extension  is  not 
always  thus  increased,  is  sometimes  the  tension  of  the  anterior  muscles,  the 
biceps  and  brachialis  anticus,  and  sometimes  the  irregularity  of  the  fracture 
at  the  posterior  part  of  the  bone,  just  above  the  joint. 

Another  efl:ect  of  the  abnormal  mobility  in  question,  which  has  been 
already  hinted  at,  is  the  bringing  up  of  the  transverse  line  of  the  elbows-joint 
to  a  horizontal  direction  instead  of  the  obliquity  natural  to  it.  This  change 
is  often  favored  by  the  treatment  resorted  to — as  w^as  long  ago  pointed  out  by 
Dorsey,^  and  more  recently  by  Allis^ — the  result  being  to  do  away  with  the 
obtuse  angle,  salient  inward,  wdiich  the  limb  should  present  at  the  elbow,  and 
to  substitute  for  it  a  bending  in  the  opposite  direction.  Such  a  condition, 
when  existing  in  a  marked  degree,  produces  a  very  noticeable  awkwardness 
at  all  times,  and  interferes  with  the  strength  and  usefulness  of  the  member  in 
lifting  and  carrying,  as  well  as  in  some  other  of  its  functions. 

Solar,  I  have  been  speaking  only  of  fractures  traversing  the  humerus  just 
above  its  lower  articulating  extremity,  whether  accompanied  or  not  by  fis- 
sures running  downi  into  the  joint.  With  regard  to  separations  of  the  outer 
or  inner  angles  of  this  extremity,  of  the  epicondyle  or  epitrochlea,  or  of  the 
epiphysis,  it  is  impossible  to  lay  down  any  distinct  and  definite  statements, 
partly  because  of  the  small  number  of  recorded  cases,  and  partly  because  of 
the  obscurity  of  the  conditions  attending  these  lesions. 

As  regards  the  epitrochlea^  there  can  be  no  doubt  of  its  occasional  separa- 
tion from  the  rest  of  the  bone,  the  elbow-joint  remaining  intact.  First 
described  by  Granger,^  this  lesion  has  been  recognized  by  Sir  A.  Cooper, 
Malgaigne,  Grurlt,  and  others.  But,  as  Gurlt  remarks,  the  line  cannot  be 
sharply  drawn  between  cases  of  this  kind  and  those  in  which  the  fracture 
involves  also  the  trochlea,  wholly  or  in  part.  Cooper^  represents  a  specimen 
of  the  latter  form  of  injury ;  he  does  not  refer  to  any  other,  and  the  only 
case  he  records  is  that  of  a  girl  "  who,  by  a  fall  upon  her  elbow,  had  fractured 
the  olecranon,  and  also  broken  the  internal  condyle  of  the  os  humeri,  the 
point  of  the  broken  bone  having  almost  penetrated  the  skin."  Hamilton® 
gives  an  account  of  eleven  cases,  examined  by  him  at  various  periods  after 
the  occurrence  of  the  injuries.  In  one  only  does  he  state  positively  that  the 
fracture  did  not  pass  into  the  joint. 

Six  of  these  cases  of  Hamilton's  have  a  special  interest  in  reference  to  the 
permanent  displacement  of  the  fragment. 

1.  Case  45.  Examined  seven  years  after  the  accident.  "  The  apopliysis  is  carried 
backward  about  two  lines,  and  upward  toward  the  shoulder  about  three  lines." 

2.  Case  49.  Examined  after  sixteen  years.  "  The  internal  condyle  was  displaced 
forward. " 

3.  Case  51.  Examined  after  three  months.  "I  find  a  fragment — the  apophysis  of 
the  internal  condyle — broken  off,  and  removed  downward  toward  the  wrist  one  inch 
and  a  quarter,  where  it  is  immovably  fixed." 

1  Report  on  Deformities  after  Fractures.    Trans,  of  Amer.  Med.  Association,  vol.  ix.  1856,  p.  106. 

2  Elements  of  Surgery,  vol.  i.  p.  145  ;  also  Plate  V. 

*  Annals  of  the  Brooklyn  Anatomical  and  Surgical  Society,  August,  1880. 

*  Edinburgh  Med.  and  Surg.  Journal,  April,  1818.  ^  Op.  cit.,  p.  466. 
^  Report,  etc.,  before  quoted,  pp.  110  et  seq. 


138 


INJURIES  OF  BONES. 


4.  Case  52.  Examined  after  five  weeks.  "  The  inner  condyle  is  displaced  upward 
three-quarters  of  an  inch.  The  olecranon  process  has  followed  this  fragment.  Large 
amount  of  callus  in  front  at  seat  of  fracture.  The  elbow  is  nearly  anchylosed  at  an 
obtuse  angle." 

5.  Case  53.  Examined  after  six  years.  "  The  internal  condyle  is  displaced  down- 
ward toward  the  wrist  half  an  inch."  Extension,  flexion,  pronation,  and  supination 
are  stated  to  have  been  all  impaired  in  this  case. 

6.  Case  55.  Examined  after  five  years.  "  The  inner  condyle  displaced  downward 
and  forward  half  an  inch." 

The  reader  will  perceive  from  the  above  quotations,  I  think,  more  distinctly 
than  from  a  mere  general  statement,  the  influence  of  the  muscles  in  produc- 
ing and  keeping  up  displacement  of  the  fragment,  when  the  epitrochlea, 
with  or  without  part  of  the  joint  surface,  is  broken  off.  It  will  be  noted 
that  the  separated  portion  had  been  moved  in  various  directions — backward 
and  upward,  forward,  downward  (in  two  instances),  upward,  and  downward 
and  forward.  When  the  fragment  is  drawn  upward  along  the  arm,  it  seems 
to  me  that  it  must  be  by  portions  of  the  triceps  and  brachialis  anticus,  the 
fibres  below  the  fragment  being  probably  torn  across.  Other  displacements 
may  be  due  to  traction  by  the-^  pronator  radii  teres,  or  by  the  superficial 
flexors.  Very  possibly  the  action  is  a  gradual  one,  the  separated  portion  of 
bone  being  drawn  into  its  new  position  during  the  period  preceding  the 
organization  of  the  callus.  Certainly,  in  some  cases  there  is  at  first  distinct 
crepitus,  showing  that  no  such  gap  exists  between  the  fractured  surfaces  as 
is  brought  about  afterwards. 

When  a  fracture  runs  obliquely  into  the  elbow-joint,  separating  the  outer 
or  inner  portion  of  the  articulating  surface  of  the  humerus,  it  is  not  diflScult 
to  see  how  in  the  former  case  the  radius,  and  in  the  latter  the  ulna,  loses  its 
support,  and,  under  the  influence  merely  of  the  muscles,  pushes  the  fragment 
before  it.  Sometimes  the  fracturing  force  itself  may  cause  the  displacement, 
and  in  that  case  the  muscular  action  would  surely  tend  to  keep  up  the  de- 
rangement of  the  parts.  An  obvious  result  of  either  disturbance  of  relation 
must  be  to  twist  the  forearm  into  an  abnormal  direction,  and,  by  changing 
the  position  of  the  points  of  origin  of  muscles,  to  interfere  with  some  actions, 
while  others  are  made  more  free,  although  less  powerful.  Pick^  has  recorded 
a  curious  case  of  fracture  of  the  external  condyle^  the  fragment  having  been 
carried  up  and  attached  to  the  outer  side  of  the  bone.  Hunter  ^  met  with  a 
case  in  which  the  external  condyle  was  broken  oft',  the  radius  and  ulna  being 
at  the  same  time  luxated  outward.  The  fragment  "  had  apparently  becoixie 
wedged  in  between  the  bones  forming  the  elbow-joint,"  and  reduction  was 
impossible.    Strength  was  regained  in  the  joint,  but  not  much  motion. 

In  1856,  I  saw  a  washerwoman  in  whom  a  fracture  of  the  inner  condyle 
had  resulted  from  muscular  eftbrt  in  lifting  a  heavy  tub.  The  accident  had 
occurred  some  two  months  previously ;  there  was  much  eftusion  into  the 
cavity  of  the  joint,  and  the  head  of  the  radius  was  widely  separated  from 
the  ulna,  but  some  use  of  the  arm  remained.  The  nature  of  the  lesion  was 
quite  clear,  and  the  patient's  account  of  the  matter  plain  and  straightforward. 
I  do  not  know  any  further  history  of  the  case. 

Disjunction  of  the  lower  epiphysis  of  the  humerus  is  an  accident  which  can 
of  course  happen  only  in  childhood  or  youth.  It  is  probable  that  here,  as  else- 
where, the  line  of  separation  may  not  always  be  exactly  confined  to  the  carti- 
lage, but  that  a  portion  of  the  bone  may  be  torn  oft".  On  the  other  hand,  I 
think  the  fracture  may  concern  a  portion  only  of  the  epiphysis,  and  thus  be 
entirely  within  the  joint.    The  cases  of  this  kind  which  have  come  under 

1  Trans,  of  London  Pathological  Society,  1870.         2  Philadelphia  Med.  Times,  April  1,  1871. 


FRACTURES  OF  THE  HUMERUS. 


139 


my  notice  have  been  in  children,  and  the  mechanism  of  their  production  was 
not  known.  On  passive  motion  of  the  elbow,  distinct  crepitus  was  elicited, 
and  no  other  sign  of  fracture  existed  except  loss  of  power  in  the  limb,  and 
pain,  aggravated  by  handling;  there  was  no  i)erceptible  deformity.  The 
limb  was  in  each  case  kept  at  perfect  rest  by  means  of  an  angular  splint,  and 
in  the  two  cases  of  which  I  have  kept  notes,  complete  recovery  ensued  in 
about  six  weeks. 

When  the  epiphysis  is  separated  as  a  whole,  the  epitrochlea  and  epicondyle 
are  of  course  included  in  the  lower  fragment,  and  the  line  of  division  curves 
downward  above  each  of  them,  to  run  almost  transversely  above  the  edge  of 
the  articular  surface.  In  the  cases  of  this  kind  which  I  have  seen,  the  lower 
fragment  has  always  been  carried  backward,  the  radius  and  ulna  following 
it,  and  the  lower  end  of  the  up})er  fragment  projecting  somewhat  strongly  in 
front  of  the  elbow.  I  think  that  the  anterior  edge  of  this  fragment  corre- 
sponds pretty  nearly  with  the  fold  of  skin  at  this  point.  All  motion  of  the 
part  is  painful,  and  there  is  especial  difficulty  in  flexion  ;  crepitus  is  easily 
detected.  Tlie  antero-posterior  diameter  of  the  joint  is  increased,  and  swell- 
ing comes  on  with  great  rapidity,  augmenting  the  deformity  and  in  great 
measure  obscuring  the  condition  of  the  parts.  ' 

The  course  and  ultimate  result  of  fractures  of  the  lower  part  of  the  humerus 
is  apt  to  be  very  unsatisfactory.  Inf.amrnation  of  the  elboiv-Joint  is  commonly 
set  up,  and  although  it  may  be  actively  combated,  and  may  not  run  high,  a 
certain  amount  of  stiffening  is  almost  always  induced  ;  this,  as  a  general  rule, 
is  in  time  overcome,  but  there  is  often  left  a  tendency  to  occasional  attacks 
of  pain  and  tenderness. 

A  curious  point  may  here  be  noted,  namely,  that  in  some  cases  the  stiffen- 
ing of  the  elbow  may  be  limited  to  the  uhiar  portion  of  the  joint.  Thus 
Lallemand  ^  had  a  patient  aged  thirty-two  years,  who,  in  consequence  of  a 
crush  of  the  elbow,  opening  the  joint  extensively,  had  the  humero-cubital 
articulation  anchylosed,  but  the  radius  was  still  capable  of  motion  on  the 
ulna,  and  with  some  supplemental  aid  from  the  shoulder-joint  all  the  motions 
of  pronation  and  supination  were  accomplished. 
In  one  of  Hamilton's  cases,^  a  fracture  of  the  inner 
condyle,  he  found  that  "  the  arm  was  nearly  anchy- 
losed in  a  rectangular  position  ;  pronation  and  supi- 
nation were  perfect." 

The  inflammation  of  the  elbow  occasionally  leads 
to  more  serious  results.  In  one  case  recorded  by 
Wright,^  a  strumous  boy,  aged  twelve,  had  a  frac- 
ture detaching  the  capitellum  of  the  humerus,  which 
gave  rise  to  pulpy  degeneration,  for  which  excision 
of  the  elbow  was  performed. 

Perhaps  it  may  be  regarded  as  strange  that  the 
vessels  so  seldom  suffer  in  these  fractures,  but  in 
fact  they  are  not  only  separated  from  the  bone  by  a 
thick  layer  of  soft  parts,  but  are  by  their  flexure 
in  a  position  to  yield  readily,  and  thus  to  escape 
tearing.  When  the  fracture  is  a  compound  one, 
however,  the  course  of  things  may  be  different. 
Fig.  832  represents  a  fracture  of  the  humerus  in  a  boy,  aged  about  twelve, 
who  fell  from  a  low  fence;  the  upper  fragment  was  forced  out  through  a 

1  Am.  Journal  of  the  Med.  Sciences,  Jan.  1841 ;  from  Lancette  Fran9aise,  Mai,  1840. 

2  Report,  etc.,  p.  Ill  ;  Case  48. 

'  Guy's  Hospital  Reports,  3d  ser.,  vol.  xxiv.,  1879. 


Fracture  of  lower  end  of  humerus. 


140 


INJURIES  OF  BONES. 


wound  in  front  of  the  arm,  and  the  artery  was  torn  completely  across,  render- 
ing amputation  necessary. 

Sometimes,  but  more  rarely  than  might  perhaps  be  supposed,  the  circulation 
is  interfered  with  by  ill-applied  apparatus,  as  in  a  case  recorded  by  Wright,^ 
m  which  by  the  pressure  of  an  anterior  angular  splint,  in  a  case  of  separation 
of  the  lower  epiphysis  of  the  humerus,  the  artery  was  occluded  for  twenty- 
two  days  ;  no  permanent  harm,  however,  resulted. 

Occasionally,  serious  damage  is  done  to  nerves  in  connection  with  the 
fractures  in  question.  The  close  relation  of  the  ulnar  nerve  to  the  bone 
would  seem  to  involve  it  in  constant  danger ;  yet  the  usual  character  of  the 
displacement,  the  lower  end  of  the  upper  fragment  going  forward,  is  ob- 
viously such  as  to  diminish  the  risk.  Callender^  gives  a  number  of  cases 
in  which  this  or  the  median  nerve  suffered,  and  suggests  that  they  may 
l)ecome  adherent,  and  be  stretched  by  sudden  movements.  Lange^  has  re- 
corded the  case  of  a  girl,  aged  eight,  who,  after  a  supra-condyloid  frac- 
ture of  the  humerus,  had  pain  at  the  seat  of  injury,  the  wrist  and  fingers 
being  flexed,  with  a  very  limited  degree  of  motion.  A  sharp  edge  of  bone 
could  be  felt.  Electricity,  massage,  and  systematic  movements  were  tried 
for  six  weeks,  at  first  with  some  apparent  success.  An  operation  was  per- 
formed, and  the  median  nerve  found  flattened  against  the  edge  of  bone ; 
above  this  point  it  was  thickened  and  swollen.  The  nerve  was  loosened,  and 
the  edge  of  bone  excised,  with  decided  relief  to  the  symptoms.  "  There  was 
one  interesting  point,  namely,  that  since  the  operation  an  entirely  diflerent 
and  more  normal  form  of  nail  was  growing,  and  there  were  ridges  on  all  of 
the  nails  alike,  marking  the  parts  before  the  operation  from  those  afterward. 
The  color  and  temperature  of  the  skin  had  also  markedly  improved." 

Another  danger  in  these  cases  is  from  the  abnormal  or  excessive  development 
of  callus^  which  however  happens  more  rarely  here  than  in  some  other  regions. 
In  the  Museum  of  the  [N'ew  York  Hospital^  is  a  specimen  of  T -fracture  at' 
the  lower  end  of  the  humerus,  in  which  the  ulna  and  radius  are  anchylosed 
to  each  other  and  to  the  external  condyle  by  bone  effused  between  their  con- 
tiguous surfaces.  A  case  is  recorded^  in  which  Mr.  Croly  excised  the  elbow- 
joint  of  a  man  about  thirty  years  of  age,  who  had  about  fifteen  months  pre- 
viously sustained  a  fracture  of  the  joint.  A  large  amount  of  callus  prevented 
flexion  of  the  joint  or  use  of  the  fingers.  The  olecranon,  the  head  of  the 
radius,  and  the  end  of  the  humerus  were  removed ;  the  coronoid  process  was 
left  in  order  to  keep  the  brachialis  anticus  muscle  intact.  The  ultimate 
result  is  not  stated. 

Malgaigne  refers  to  a  case,  seen  by  Monteggia,  in  which  tetanus  ensued 
upon  a  simple  fracture  near  the  lower  end  of  the  humerus,  and  proved  fatal, 
although  amputation  was  performed. 

As  to  the  diagnosis  of  these  fractures,  it  presents  in  some  cases  little  or  no 
difiaculty,  while  in  others  it  is  more  or  less  obscure,  and  occasionally  ex- 
tremely so.  Much  depends  upon  the  time  which  has  elapsed  between  the 
receipt  of  the  injury  and  the  examination,  since  often  a  very  few  hours  suffice 
for  the  occurrence  of  such  swelling  as  to  completely  mask  the  parts.  Under 
such  circumstances  the  patient  should  be  placed  under  the  influence  of  an 
anaesthetic,  and  the  utmost  care  used  in  determining  whether  or  not  there  is 
luxation  of  the  bones  of  the  forearm — a  point  which  can  generally  be  de- 
cided, if  in  no  other  way,  by  the  degree  to  which  passive  motion  can  be 
made.    This  is  a  matter  of  the  utmost  importance,  as  the  reduction  can  be 


'  Ibid.  2  St.  Bartholomew's  Hospital  Reports,  1870. 

»  New  York  Medical  Journal,  April  28,  1883. 

4  Catalogue,  p.  68.  5  Lancet,  Feb.  17,  1883. 


FRACTURES  OF  THE  HUMERUS. 


141 


tar  more  easily  effected  at  once  than  at  any  later  period  ;  but  its  discussion 
belongs  more  appropriately  elsewhere. 

As  a  general  rule,  fractures  in  this  region  resemble  luxations  in  the  abnor- 
mal projection  backward  of  the  olecranon  ;  in  fact,  the  two  lesions  are  often 
undistinguishable  from  one  another  by  the  mere  api)earance  of  the  parts. 
(In  both,  the  elbow  is  sligbtly  Hexed;  although  some  authors  have  represented 
it  as  iixed,  or  nearly  so,  at  a  right  angle,  when  luxated.  The  former  has 
been  the  position  in  the  eight  cases  of  children  and  boys  which  have  come 
under  my  own  observation,  and  this  experience  is  confirmed  by  that  of  Mal- 
gaigne*  and  Hamilton.  In  adults  I  have  seen  the  elbow  quite  rigid,  and 
semi-Hexed  ;  but  the  other  condition  obtains  sometimes  in  them  also.)  But 
in  case  of  fracture,  if  the  surgeon  places  his  thumbs  in  front  of  the  projection 
of  the  humerus,  he  can  with  his  hngers  press  the  olecranon  forward  into  its 
normal  place,  and  keep  it  so  until  he  relaxes  its  hold.  Dislocations,  I  need 
hardly  say,  are  often  very  difficult  to  reduce,  and  are  very  unapt  to  recur. 

Dislocation  having  been  set  aside,  the  surgeon's  attention  should  be  directed 
to  the  allaying  of  the  inflammation  by  the  usual  means,  the  limb  being  kept 
in  the  most  comfortable  posture ;  and  as  soon  as  possible  the  attempt  to  esta- 
blish an  accurate  diagnosis  should  be  renewed. 

Either  before  the  occurrence  of  inflammatory  swelling,  or  after  it  has  sub- 
sided, the  eye  may  detect  certain  abnormities  in  the  shape  of  the  limb.  One 
of  the  most  important  of  these  is  the  increase  of  its  antero-posterior  diameter 
either  at  or  just  above  the  elbow.  Another  is  the  change  in  the  relative 
directions  of  the  axes  of  the  arm  and  forearm.  Still  another  is  a  widening 
of  the  arm  transversely  at  the  elbow.  But  when  either  or  all  of  these  signs 
are  present,  they  need  to  be  interpreted  by  means  of  further  investigation. 

If,  upon  applying  the  fingers  to  the  bend  of  the  elbow,  or  perhaps  a  little 
above  it,  the  more  or  less  sharp  and  ragged  edge  of  the  upper  fragment  is 
felt,  the  fact  of  fracture  is  established ;  in  case  of  luxation,  the  rovmded 
articular  surface  of  the  lower  end  of  the  bone  w^ould  pi'esent  itself.  The 
processes  commonly  known  as  the  condyles,  but  more  correctly  as  the  epi- 
condyle  and  epitrochlea,  should  now  be  found — as  they  often  can  be  even 
where  the  parts  are  swollen — and  pressure  made  through  them  across  the 
bone.  If  pain  be  thus  caused,  a  fracture  running  into  the  joint  may  be  sus- 
pected ;  if  crepitus,  it  may  be  regarded  as  certain.  Unless  sw^elling  have 
occurred,  it  may  be  possible  to  grasp  the  epicondyle  or  the  epitrochlea  be- 
tween the  thumb  and  finger,  and  determine  its  mobility  or  fixedness  upon 
the  rest  of  the  bone.  The  attempt  may  be  made  also  to  sway  the  forearm 
from  side  to  side,  which  ought  not  to  be  possible.  In  so  doing,  crepitus  may 
be  elicited. 

Upon  making  passive  motion,  flexing  and  extending  the  elbow,  and  pro- 
nating  and  supinating  the  hand,  it  will  be  found,  if  there  be  fracture,  that  in 
one  or  -more  of  these  movements  there  is  crepitation.  If  this  occur  in  flexion 
only,  or  in  flexion  and  extension,  it  may  be  that  the  humerus  is  simply  broken 
across;  but  if  every- motion  develop  it,  the  probability  is  that  the  joint  itself 
is  involved. 

Measurement  may  now  be  made  of  the  breadth  of  the  joint,  from  the  epi- 
condyle to  the  epitrochlea,  and  it  may  be  compared  with  that  of  the  sound 
limb.  The  best  means  of  doing  this  is  of  course  a  pair  of  callipers  ;  but  as 
these  are  not  likely  to  be  at  hand,  resort  may  be  had  to  other  methods,  the 
simplest  being  to  apply  the  back  of  the  elbow  to  a  plane  surface,  on  which 
a  sheet  of  paper  has  been  placed,  and  then  to  put  a  book  on  either  side  of  it, 
standing  edgewise  on  the  paper.    The  distance  betw^een  the  lower  edges  of 


1  Op.  cit.,  tome  ii.  p.  576. 


142 


INJURIES  OF  BONES. 


the  books  being  marked  on  the  paper,  the  same  may  be  done  for  the  sound 
elbow,  and  the  two  measurements  compared.  An  increase  in  the  width  may 
be  regarded  as  probably  due  to  fracture  involving  the  joint. 

Wright^  gives  two  test-lines  which  may  be  useful  in  the  diagnosis  of  inju- 
ries about  the  elbow.  He  says  that  it  will  be  found  "  that  a  line  can  be 
drawn  in-  all  positions  of  the  joint,  from  the  most  prominent  point  of  the 
internal  condyle,  through  the  upper  border  of  the  olecranon,  obliquely  down- 
ward and  outward  to  the  head  of  the  radius,  and  that  such  line  is  bisected  at 
a  point  corresponding  to  the  superior  and  external  angle  of  the  olecranon." 
The  relation  of  these  points  to  the  line  would  obviously  be  altererl  in  case  of 
fracture  of  the  olecranon  or  of  the  inner  CQudyle.  Wright  says  further :  If 
also  a  line  be  drawn  across  the  back  of  the  joint  in  full  extension,  from  the 
external  to  the  internal  condyle,  or  vice  versa,  that  line  will  lie  above  the 
upper  border  of  the  olecranon,  or,  in  other  words,  the  angle  it  forms  with 
the  first  test-line  will  be  on  the  distal  side  of  the  inter-condyloid  line.  This 
line  is  most  conveniently  taken  by  extending  the  arm  horizontally,  with  the 
humerus  rotated  so  that  the  bicipital  or  anterior  aspect  looks  toward  the 
middle  line  of  the  body,  and  dropping  a  j)erpendicular  through  the  condyles." 

There  is  one  condition  in  wdiich  the  test  afi:brded  by  these  lines  wx)uld  fail, 
that,  namely,  of  a  separation  of  the  articulating  portion  only  of  the  humerus. 
Here  the  relation  of  the  condyles  (epicondyle  and  epitrochlea)  to  the  olecra- 
non would  be  changed,  perhaps  indeed  in  a  very  slight  degree,  but  still  per- 
ceptibly ;  yet  the  inference  that  the  case  was  one  of  luxation  and  not  of  frac- 
ture w^ould  be  incorrect.  Here,  however,  the  application  of  the  other  means 
of  diagnosis,  the  development  of  crepitus,  and  the  fact  of  the  ready  correc- 
tion of  the  slight  displacement,  together  wdth  that  of  its  equally  ready  recur- 
rence, should  sufiice  to  prevent  any  mistake. 

The  significance  of  a  change  in  the  relative  direction  of  the  axes  of  the 
arm  and  forearm  must  depend  upon  the  other  features  of  the  deformity.  H, 
for  instance,  the  obtuse  angle  before  noted  as  existing  at  the  normal  elbow  is 
done  away  with,  it  may  be  either  by  a  fracture  across  the  humerus  just  above 
the  joint,  or  by  the  separation  of  the  trochlea,  or  b}^  luxation  backward  of 
the  ulna  and  forward  of  the  radius.  If  it  is  rendered  more  acute,  there  may 
be  fracture  of  the  outer  angle  of  the  lower  end  of  the  humerus,  allowing  the 
head  of  the  radius  to  slip  somewhat  backward  ;  or,  the  humerus  being  broken 
very  low  down,  there  may  be  a  slight  twist  of  the  short  lower  fragment  upon 
the  upper. 

The  foregoing  statement  embraces  the  leading  facts  in  regard  to  the  diag^ 
nosis  of  these  injuries ;  but  in  practice  there  are  shades  of  difierence  in  the 
phenomena  presented,  which  it  would  be  in  vain  to  attempt  to  set  forth.  1 
do  not  hesitate  to  say  that  no  class  of  cases  demand  more  care,  tact,  and 
judgment  for  their  detection  and  discrimination,  than  those  involving  the 
elbow. 

As  to  prognosis,  the  surgeon  should  always  bear  in  mind  the  fact  that  the 
elbow-joint  is  apt  to  be  at  least  temporarily  stiftened  after  injuries  in  its 
neighborhood ;  and  that  a  slight  displacement  of  the  fragments,  when  the 
lower  part  of  the  humerus  has  been  broken,  may  give  rise  to  a  permanent 
limitation  of  mobility.  Hence  he  should  be  very  guarded  in  his  promises  of 
complete  restoration  of  the  functions  of  the  limb ;  and  it  is  much  better  to 
warn  the  patient,  or  the  friends  in  the  case  of  a  child,  that  stiftening  of  greater 
or  less  duration  is  likely  to  occur.  If  the  fracture  can  be  clearly  made  out  to 
be  entirely  above  the  joint  and  above  the  line  of  the  epiphysis,  the  prospect 
for  complete  recovery  is  more  promising  than  if  the  joint  be  involved ;  yet 


'  Log.  cit.,  3d  ser.,  vol.  xxiv.  1879,  p.  54. 


FRACTURES  OF  THE  HUMERUS. 


143 


(iven  here,  unless  the  tilting  of  the  lower  fragment,  hefore  spoken  of,  can  he 
])revented,  there  will  be  some  limitation  of  movement.  Moreover,  this  limi- 
tation is  permanent,  and  not  to  be  diminished  by  any  treatment ;  which  is 
not  usually  the  case  with  mere  stiffening  of  the  joint. 

I  have  occasionally  seen  in  adults,  after  injuries  of  this  kind,  the  stiffening 
recur  from  time  to  time,  unless  guarded  against  by  continual  exercise  ;  and  it 
is,  of  course,  well  to  mention  the  possibility  of  such  a  result  beforehand. 

The  treatment  of  fractui-es  of  the  lower  portion  of  the  humerus  presents 
difficulties  of  a  very  serious  nature.  Su imposing  the  diagnosis  to  have  been 
clearly  made  out,  the  object  of  the  surgeon  must  of  course  be,  in  accordance 
with  general  principles,  to  correct  any  existing  deformity,  and  to  maintain 
the  fragments  in  their  normal  relation  until  union  shall  have  occurred.  But 
plain  as  the  indications  are,  the  fultilling  of  them  is  by  no  means  easy,  nor,  as 
before  stated,  are  the  results  apt  to  satisfy  either  the  surgeon  or  the  patient. 

The  difficulties  referred  to  are  four :  to  keep  the  fragments  in  contact  and 
at  rest ;  to  prevent  the  formation  of  an  angle,  salient  anteriorly  ;  to  maintain 
the  oblique  line  of  the  articulation  by  avoiding  upward  pressure  on  the  inner 
portion  of  the  joint-surface  of  the  low^ei-  fragment ;  and  to  obviate  stiffening 
of  the  elbow. 

As  to  the  first  of  these  difficulties,  it  is  due  to  the  extreme  shortness  of  the 
lower  fragment,  which  gives  very  little  purchase  to  any  confining  apparatus ; 
in  the  case  of  T-fractures,  or  separations  of  the  trochlea,  the  tendency  is  to  a 
forcing  apart  of  the  articulating  surfaces,  or,  what  is  equally  bad,  a  gaping  of 
the  fractured  portions  above,  and,  perhaps,  the  insertion  between  them  of 
part  of  the  upper  fragment.  In  epiphyseal  disjunctions,  the  correct  posi- 
tion of  the  detached  portion  is  almost  wholly  a  matter  of  conjecture,  and 
must  of  necessity  be  so,  until  a  favorable  result  affords  proof  of  it.  I^'ow,  if 
an  anterior  angular  splint,  or  two  lateral  ones,  be  carefully  applied  to  a  sound 
arm,  it  will  be  found  that  a  certain  amount  of  rocking  motion  can  be  given, 
with  the  effect  of  loosening  somewhat  the  upper  portion  of  the  bandage ; 
should  the  same  thing  be  done  in  a  case  of  fracture,  it  may  readily  be  seen 
that  the  part  of  the  limb  below  the  breakage  is  converted  into  a  bent  lever, 
the  short  arm  of  which  is  the  lower  fragment ;  and  upon  this  a  very  slight 
amount  of  force  applied  to  the  hand  will  act  most  powerfully.  Hence, 
scarcely  any  good  can  be  expected  from  means  of  fixation  of  this  kind,  un- 
less bound  on  so  tightly  as  to  endanger  interference  with  the  vascular  supply, 
or  with  the  innerv^ation  of  the  limb. 

^  The  force  of  this  statement  is  still  greater,  if  the  fact  is  considered  that 
the  parts  about  the  elbow  are  apt  to  be  largely  swollen  at  the  time  of  the 
first  dressing,  and  that  a  daily  subsidence  of  the  swelling  must  be  looked  for, 
so  that  the  controlling  power  of  any  apparatus  is  continually  becoming  less 
and  less,  until  the  inflammation  has  gone  down  and  its  products  have  been 
absorbed. 

Of  the  second  difficulty  I  have  already  spoken  at  some  length,  so  that  it 
need  not  be  further  discussed  at  present  until  the  details  of  "treatment  are 
tak-en  up. 

The  third  difficulty  is  one  which  has  been  more  fully  appreciated  of  late 
years  than  formerly.  Dorsey,  as  already  said,  pointed  out  the  frequent  occui^ 
rence  of  deformity  from  the  substitution  of  an  angle,  salient  outward,  for  the 
normal  one,  salient  inward;  and  Allis  has  recently,  wath  much  force,  called 
attention  to  the  same  point.  Yet  it  seems  to  me  that  the  real  source  of  the 
trouble  is  the  want  of  recognition  of  the  obliquity  of  the  line  of  the  articu- 
lation, and  the  application  of  dressings,  no  matter  in  what  position — flexed 
or  extended — which  press  straight  across  the  front  of  the  joint,  and  tlius 
by  their  posterior  bearings  push  the  trochlea  upward,  and  force  the  upper 


INJURIES  OF  BONES. 


and  inner  angle  of  the  lower  fragment  past  the  corresponding  portion  of  the 
npper  fragment,  whether  behind  it  or  in  front  of  it.  Allis's  method,  putting 
the  forearm  in  extension,  with  the  normal  angle  maintained,  and  keeping  the 
limb  in  this  posture  by  means  of  the  plaster-of-Paris  or  starched  bandage,  or 
other  form  of  immovable  apparatus,  is  a  very  sound  one  in  theory,  and  no 
doubt  has  given  good  results.  But  I  believe  that  the  same  advantage  may 
be  gained  by  other  means,  and  perhaps  with  more  comfort  to  the  patient,  if 
only  the  normal  shape  of  the  joint  be  borne  in  mind.  Any  one  may  readily 
satisfy  himself,  by  inspection  of  a  sound  arm,  of  the  obliquity  of  the  anterior 
fold  of  the  elbow ;  and  a  glance  at  the  skeleton  of  the  limb  will  show  that 
the  line  between  the  bones  corresponds  with  the  furrow  in  the  skin. 

The  means  of  preventing  stiffening  of  the  elbow  will  be  spoken  of  here- 
after. 

Now,  as  to  the  special  plans  of  treatment  of  these  fractures,  they  may  be 
classed  as  those  without  apparatus,  those  with  apparatus  for  maintaining 
flexion,  and  those  with  apparatus  for  keeping  the  limb  extended. 

The  principle  of  treatment  without  apparatus  is  merely  to  suspend  the 
limb  in  a  sling,  the  elbow  being  flexed,  and  to  favor  a  certain  amount  of 
change  of  angle  of  the  joint,  in  order  to  obviate  stiflening.  I  have  heard  the 
opinion  expressed  by  a  surgeon  of  large  experience  and  high  reputation,  that 
the  formation  of  a  false-joint  near  the  elbow  was  by  no  means  a  misfortune ; 
he  had  seen  a  number  of  cases  of  permanent  disability  from  anchylosis  of  the 
joint,  the  fractures  having  united.  But  I  do  not  believe  that  it  is  necessary 
to  run  the  risk  of  deformity  by  leaving  the  joint  uncontrolled,  lest  it  should 
stiften ;  nor  does  it  seem  to  me  that  the  favoring  of  a  pseudarthrosis  to  take 
the  place  of  such  a  joint  as  the  elbow,  is  a  good  surgical  procedure.  The  only 
proper  aim,  in  dealing  with  the  cases  in  question,  must  be  to  obtain  union  of 
the  fracture,  and  to  preserve  the  mobility  of  the  elbow;  and  my  conviction 
is,  not  only  that  these  ends  can  in  the  majority  of  instances,  by  due  care  and 
attention,  be  accomplished,  but  that  any  other  course  would  justly  fail  to 
receive  the  approval  of  the  profession. 

Various  plans  have  been  proposed  and  adopted  for  treating  these  fractures 
in  the  flexed  position.  By  some  surgeons,  a  rectangular  splint  has  been 
employed,  extending  along  the  whole  posterior  surface  of  the  limb ;  and  to 
this  Sir  Astley  Cooper  added  an  anterior  arm-splint  to  correct  the  angle 
forward.  Physick's  splints,  also  rectangular,  and  applied  along  the  lateral 
surfaces  of  .  the  arm  and  forearm,  had  for  many  years  a  popularity  in  this 
country,  due  more  to  the  name  of  their  advocate  than  to  the  excellence  of  the 
results  obtained  with  them.  To  these  succeeded  the  anterior  angular  splint, 
somewhat  hollowed  to  fit  along  the  front  of  the  arm  and  upper  surface  of  the 
supinated  forearm. 

Physick's  splints,  as  used  by  him,  and  I  believe  by  all  of  his  followers, 
were  made  of  wood:  for  the  others,  wood,  tin,  binders'  board,  gutta-percha, 
and  felt,  have  been  employed.  My  own  practice  has  been  to  use  binders' 
board,  shaped  as  shown  in  Fig.  829,  giving  the  lower  edge  of  the  part  applied 
to  the  front  of  the  arm  an  obliquity  corresponding  to  that  of  the  crease  at  the 
bend  of  the  elbow,  and  bevelling  it  oft'  so  as  to  avoid  painful  pressure  on  th*e 
skin.  The  advantage  obtained  in  the  pressure  of  the  upper  part  of  the  lower 
fragment  backward,  while  the  olecranon  is  pushed  forward  by  the  projection 
at  the  angle  of  the  splint,  bent  around  against  it,  has  seemed  to  me  to  be  very 
great. 

Another  plan,  which  I  think  would  answer  well,  although  it  has  never  to  my 
knowledge  been  employed,  would  be  to  place  the  forearm  in  a  state  of  flexion 
at  a  somewhat  acute  angle,  keeping  the  hand  semiprone,  and  directed  a  little 
outward,  so  as  to  maintain  the  normal  angle  before  referred  to.    In  this  way 


FRACTURES  OF  THE  HUMERUS.  145 

the  projection  forward  of  the  upper  end  of  the  lower  fragment  would  be  in 
great  measure,  if  not  altogether,  obviated,  since  the  nniscles  which  cause  it 
w^ould  thus  be  relaxed.  The  posture,  although  not  as  comfortable  for  a  length 
of  time  as  the  rectangular,  would  still  not  be  unendurable,  and  w^ould  not 
need  to  be  maintained  after  the  process  of  union  had  begun. 

The  method  by  extension,  advocated  by  A 11  is,  has  already  been  described. 
It  is  recommended  also  by  Ingalk.' 

A  most  important  matter,  in  the  treatment  of  all  these  cases,  is  the  making 
of  passive  motion.  This  ought,  in  my  opinion,  always  to  be  begun  as  early  as 
possible;  but  the  proper  time  varies  with  circumstances.  When  the  line  of 
fracture  is  wholly  outside  of  the  joint,  and  the  latter  does  not  become  swollen 
by  effusion  within  its  cavity,  I  think  it  well  at  the  very  first  dressing  to 
grasp  the  lower  part  of  the  arm  firmly,  but  gently,  and  to  slowly  and  (j^uietly 
make  flexion,  extension,  pronation  and  supination,  not  to  extreme  degrees, 
but  freely  enough  to  exercise  the  wdiole  joint.  Properly  done,  this  process 
involves  no  risk  of  disturbing  the  fragments,  nor  is  it  followed  by  any  pain, 
tenderness,  swelling,  or  other  evidence  of  inflammation.  Even  if  the  joint  is 
involved  in  the  breakage,  I  think  that  as  soon  as  the  inevitable  inflammation 
has  subsided,  passive  motion  may  be  very  gently  made,  and  with  advantage; 
perhaps,  at  first,  the  movements  may  be  limited  to  pronation  and  supination, 
and  flexion  may  be  added  subsequently,  extension  being  postponed  on  account 
of  the  risk  of  tilting  the  lower  fragment  forw^ard.  Should  marked  irritation 
ensue,  it  may  be  allayed  by  hot  fomentations,  by  poulticing,  or  by  the  local 
use  of  lead-w^ater  and  laudanum,  and  no  further  attempt  should  be  made  for 
a  few^  days,  perhaps  for  a  week. 

When  stiffening  of  the  elbow  has  already  occurred,  whether  early  or  late 
in  the  progress  of  the  case,  it  is  very  desirable  to  overcome  it ;  and  the  means 
to  be  adopted  with  this  view  must  vary  according  to  circumstances.    If  it  is 
early,  an  attempt  should  be  made  to  change  the  angle  from  day  to  day,  or 
oftener.    This  may  be  done  either  by  employing 
difterent  splints,  with  slightly  varying  angles,  sub- 
stituting  at  each  dressing  a  fresh  one,  or  by  the 
use  of  a  single  splint  with  a  hinge  corresponding  to 
the  elbow,  and  with  the  two  portions  movable  by 
means  of  Stromeyer's  screw  (Fig.  833).    A  modi- 
fication of  this  appliance  has  lately  been  proposed 
by  Keen,  consisting  simply  in  attaching  the  screw 
by  curved  arms,  so  as  to  place  it  well  over  at  one 
side,  and  avoid  interference  with  the  bandaging  of       ^'"^strom'"*  ^'"^ 
the  arm  to  the  splint.   I  think  advantage  is  some-  romeyer  s  screw, 

times  gained  by  poulticing  the  joint  for  a  day  or  two  previous  to  attempting 
to  change  the  angle.    Violence  should  never  be  used  in  these  cases. 

An  important  point  to  be  noted  is  the  degree  to  which  flexion  can  be  made, 
and  the  character  of  its  limitation.  If  the  forearm  is  checked  at  an  angle  of  say 
30°,  there  is  reason  to  believe  that  the  lower  fragment  is  tilted  forward ;  and 
this  is  the  more  likely  if  extension  can  be  carried  beyond  its  natural  limit. 
In  such  a  case,  it  becomes  a  question  whether  an  attempt  should  be  made, 
under  anaesthesia,  to  correct  the  abnormal  position  of  the  lower  fragment,  or 
to  do  the  same  thing  by  gradual  means — changing  the  posture  of  the  limb  by 
dressing  it  in  a  state  of  flexion;  or  it  may  be,  especiallj^  if  the  previous  history 
of  the  case  shows  the  joint  to  be  readily  inflamed,  that  the  more  prudent 
course  will  be  to  let  things  remain  as  they  are,  notifying  the  patient  or  his 
friends  that  there  will,  probably,  be  a  permanent  limitation  of  movement. 


1  Medical  News,  Jan.  7,  1882. 

VOL.  IV. — 10 


146 


INJURIES  OF  BONES. 


As  extension  is  made,  the  degree  to  which  the  normal  angle  between  the 
axes  of  the  arm  and  forearm  has  been  preserved,  should  be  noticed,  and  if  it 
has  been  lost,  the  propriety  of  an  effort  to  restore  it  must  be  obvious. 

Compound  fracture  of  the  lower  extremity  of  the  humerus^  not  involving  the 
joint,  is  of  rare  occurrence.  It  differs  from  simple  fracture  of  the  same  part 
mainly  in  the  difficulty  of  treatment,  and  in  the  risk  of  inflammation  of  the 
joint,  w^ith  consequent  stiffening.  Almost  always  due  to  great  direct  violence, 
it  may  present  any  of  the  forms  before  spoken  of,  wdth  like  displacements. 

When  the  elbo^v-joint  is  involved,  the  lesion  is  a  very  serious  one,  and  is 
extremely  apt  to  be  followed  by  anchylosis,  in  spite  of  all  the  eftbrts  of  the 
surgeon.  The  fact  that  the  joint  is  opened  is  generally  revealed  by  the  escape 
of  svnovia ;  but  the  absence  of  this  symptom  does  not  prove  that  the  joint  is 
intact. 

When  the  external  wound  is  large  enough,  an  exploration  may  be  properly 
made  with  the  finger  ;  but  if  otherwise,  the  ordinary  rule  should  be  followed, 
to  close  the  orifice  at  once  as  completely  as  possible,  in  the  hope  that  it  may 
heal,  and  thus  render  the  fracture  a  simple  one.  Occasionally,  if  the  bone 
seem  to  be  extensively  smashed,  with  only  a  small  skin-wound,  the  latter 
may  be  enlarged  by  incision.  The  injury  to  the  soft  parts  is  very  generally 
on  the  posterior  face  of  the  limb,  unless  it  be  due  to  the  projection  forward 
of  the  upper  fragment,  in  w^hich  case,  as  in  one  instance  before  mentioned,  the 
vessels  or  nerves,  or  both,  may  have  sustained  damage.  Amputation  is  some- 
times unavoidable. 

The  advocates  of  Listerism  advise  that,  if  the  joint  has  been  entered,  it 
should  be  washed  out  with  carbolized  water,  with  the  view  of  destroying 
germs,  and  thus  preventing  suppuration.  I  believe  that  the  practice  is  followed 
by  good  results,  but  not  on  the  theory  just  mentioned.  It  is  a  matter  of  obser- 
vation that,  when  any  serous  membrane  is  laid  open,  pure  water  applied  to  it 
acts  as  an  irritant ;  and  the  anaesthetic  property  of  carbolic  acid  is  also  a  known 
fact.  By  virtue  of  this,  a  weak  solution  of  the  acid  may,  it  seems  to  me, 
prevent  the  inflammatory  action  which  would  naturally  follow  the  admission 
of  air  to  the  joint-surface.  Dirt  or  other  foreign  matter  forced  in  at  the  time 
of  the  receipt  of  the  injury  must  be  carefully  washed  out,  and  for  this  pur- 
pose the  carbolized  water  answers  as  well,  if  not  better,  than  anything  else.^ 

When  the  fracture,  besides  being  exposed  to  the  air,  is  comminuted,  it  is 
important  for  the  surgeon  to  see  that  any  loose  fragments  are  removed,  and 
that  those  that  remain  are  in  proper  place.  Otherwise,  even  if  the  joint  con- 
tinue free  from  adhesions,  its  motions  may  be  interfered  with,  and  the 
usefulness  of  the  member  be  proportionally  lessened. 

A  small  wound  may  be  closed  with  lint  and  collodion,  or  with  any  good, 
non-irritant  adhesive  plaster.  Another  excellent  plan  is  to  apply  lint  satu- 
rated with  Peruvian  balsam.  Good  results  have  also  been  attained  by  the  old 
plan  of  saturating  lint  with  the  blood,  and  allowing  it  to  dry  over  the  wound. 
For  the  first  few  days,  until  the  subsidence  of  the  acute  inflammatory  con- 
dition which  must  attend  an  injury  of  this  kind,  the  application  of  a  splint  is 
needless,  unless  it  be  merely  a  wide  rectangular  one,  well  padded,  upon  w^hich 
the  limb  can  be  laid  for  the  purpose  of  keeping  it  steady.  Irrigation  may, 
in  these  cases,  be  sometimes  employed  with  advantage.  When  the  wound 
has  healed  or  has  begun  to  suppurate,  and  the  swelling  has  gone  down,  atten- 
tion must  be  paid  to"  the  position  of  the  fragments,  as  w^ell  as  of  the  forearm 
and  hand.  Anchylosis  is  so  likely  to  occur,  that  it  is  important  to  arrange 
the  limb  in  such  a  way  as  to  make  it  most  useful  even  with  a  stiftened  elbow; 
the  proper  plan  is  therefore  to  flex  the  forearm  at  an  angle  of  about  90°,  and 
to  keep  the  hand  semi-prone. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


147 


When  the  services  of  a  skilled  mechanic  can  he  liad,  some  form  of  hracketed 
splint,  one  portion  to  fit  the  front  of  the  arm,  and  the  other  that  of  the  fore- 
arm, may  be  employed.  Or,  by  a  little  ingenuity,  the  surgeon  may  adapt  a 
strip  of  tin,  of  sheet-zinc,  or  of  hoop-iron,  so  as  by  means  of  a  plaster-of- 
Paris  bandage  to  control  the  limb  properly.  In  either  case,  a  sufficient  space 
should  be  left  opposite  the  wound  for  the  application  of  suitable  dressings. 
When  there  is  much  discharge,  cleanliness  requires  that  the  renewal  of  the 
dressings  should  be  frequent;  and  it  is  well  to  protect  the  adjacent  edges  of  a 
plaster-of-Paris  bandage,  either  by  a  strip  of  oiled  silk  folded  over  them,  or 
by  a  coating  of  varnish. 

As  to  the  character  of  the  dressings  to  be  employed,  nothing  need  be  said 
here,  the  subject  having  been  fully  d'lscussed  in  previous  portions  of  the  En- 
cyclopaedia. 

Before  dismissing  the  subject  of  fractures  of  the  humerus,  I  wish  to  add  a 
case  which  came  under  my  notice  too  late  to  be  mentioned  in  its  proper  place. 
It  is  recorded  by  Mr.  R.  Jones,*  and  was  that  of  a  man,  age  not  given,  who 
fell  from  a  height,  and  in  falling  grasped  at  a  door.  He  thus  sustained  a 
subclavicular  dislocation  of  the  right  humerus,  which  bone  was  broken  at  the 
middle,  and  a  dislocation  backward  of  the  elbow.  The  fracture  was  secured 
in  splints,  and  the  dislocation  reduced.  Some  eftusion  occurred  in  the  elbow- 
joint  on  the  third  day,  but  was  rapidly  absorbed ;  and  the  movements  of  both 
elbow  and  shoulder  were  free  and  painless  in  six  weeks.  He  had  previously 
dislocated  both  hips,  and  on  three  occasions  the  left  shoulder. 

Fractures  of  the  elhow^  properly  so  called,  in  which  not  only  the  low^er  por- 
tion of  the  humerus,  but  the  upper  portions  of  the  bones  of  the  forearm,  are 
involved,  present  certain  special  features  which  entitle  them  to  separate  con- 
sideration. They  can,  however,  be  more  suitably  spoken  of  after  the  discussion 
of  fractures  of  the  last-mentioned  parts. 


Fractures  of  the  Bones  of  the  Forearm. 

Taken  collectively,  the  fractures  of  this  part  of  the  skeleton  constitute  a 
very  large  proportion  of  the  whole  number  of  these  inj nicies.  Wide  difi:er- 
ences  exist,  however,  between  the  two  bones  of  the  forearm,  as  well  as  between 
the  difi:erent  portions  of  each,  in  regard  to  their  liability  to  fracture.  Thus, 
the  ulna  by  itself  is  rarely  broken,  especially  at  its  lower  part;  the  radius  by 
itself  is  almost  exempt  above,  but  fractures  near  its  lower  extremity  are  among 
the  most  common  of  accidents.  Both  bones  may  give  way  at  once,  to  a  crush- 
ing force,  in  any  part  of  their  length ;  but  more  frequently  they  are  broken 
by  indirect  violence,  somewhere  near  the  middle,  or  below  it. 

The  order  of  frequency  of  these  accidents  .may  therefore  be  stated  as  follows: 
The  radius  alone  near  its  lower  end ;  both  bones  about  their  middle  third,  or 
in  the  upper  part  of  the  lower  third  ;  the  olecranon ;  the  coronoid  process ; 
the  radius  alone  near  its  upper  end ;  the  ulna  alone  in  its  lower  part. 

]^ow  these  ditterences,  far  from  being  unaccountable  and  as  it  were  capri- 
cious, find  a  clear  explanation  in  the  anatomy  and  mechanical  conditions  of 
the  forearm  and  of  the  bones  themselves ;  as  does  also  the  fact,  at  first  sight 
strange,  that  the  thickest  and  seemingly  the  strongest  portion  of  each  bone  is 
the  one  which  most  frequently  gives  way. 


1  Lancet,  April  28,  1883. 


148 


INJURIES  OF  BONES. 


Fracture  of  the  olecranon  is  very  rare  in  children,  although  it  is  men* 
tioned  three  times  among  the  316  cases  in  the  records  of  the  Children's  Hos- 
pital, before  quoted,  while  Malgaigne  quotes  three  cases  recorded  at  the 
Hotel  Dieu  between  the  ages  of  eleven  and  fifteen.  Holmes^  figures  a  speci- 
men of  "fracture  of  the  cartilaginous  epiphysis  of  the  olecranon,"  but  does 
not  mention  the  age  of  the  patient ;  the  head  of  the  radius  was  dislocated  for- 
ward. 

By  far  the  most  common  cause  of  this  injury  would  seem  to  be  falling 
upon  the  elbow,  the  joint  being  strongly  flexed  at  the  moment.  A  blow,  or 
any  other  direct  violence,  may  cause  it  in  like  manner.  An  old  woman  once 
came  under  my  care,  who  had  fallen  down  in  ascending  a  staircase,  striking 
her  elbow  on  a  pebble  which  lay  on  one  of  the  steps,  and  breaking  the  ole- 
cranon. Muscular  action  has  been  thought  to  produce  this  fracture  in  a 
number  of  cases,  although  Malgaigne,  while  admitting  four,  says  that  "  in- 
stances of  this  kind  call  for  careful  scrutiny."  Dupuytren^  says:  "A  sud- 
den and  very  violent  extension  of  the  forearm,  by  the  action  of  the  triceps, 
may  also  produce  fracture  of  the  olecranon,  which  happened  whilst  I  was 
a  student,  to  a  person  who,  whilst  playing  at  tennis,  gave  the  ball  a  violent 
back-stroke  with  the  racket,  and  immediatel}^  felt  a  sharp  pain  at  the  elbow, 
I  examined  the  arm,  and  found  that  the  olecranon  was  fractured." 

It  must  be  remembered  that  the  triceps  is  not  inserted  into  the  tip  of  the 
olecranon,  but  "  into  the  back  part  of  its  upper  surface,  a  small  bursa,  occa- 
sionally multilocular,  being  interposed  between  the  tendon  and  the  front  of 
this  surface."^  Moreover,  the  tendon  of  the  triceps,  expanding  over  the 
upper  and  back  part  of  the  ulna,  gets  a  much  larger  attachment  than  merely 
to  the  upper  surface  of  the  olecranon,  and  the  "  tearing  off"  of  this  process, 
described  by  some  surgical  writers,  is  actually  impossible.  In  one  case, 
quoted  Dy  Malgaigne  from  Yeyne  and  Robert,  it  is  said  that  these  surgeons 
"  made  out  a  detachment  of  the  apex  of  the  olecranon ;"  and  this  is  the  only 
one  of  the  instances  mentioned  by  Malgaigne  in  which  the  exact  seat  of  the 
fracture  is  stated. 

Lonsdale^  suggests  that  fracture  of  the  olecranon  may  sometimes  be  ex- 
plained "  by  the  ulna  being  thrown  back  against  the  humerus  with  great 
violence,  which  motion  produces  extreme  extension,  and  throws  the  olecranon 
process  forcibly  against  the  humerus,  which  may  be  sufiicient  to  break  it  off 
from  the  rest  of  the  bone ;"  I  may  say  that  this  idea  had  crossed  my  own 
mind,  but  that  it  had  seemed  to  me  that  the  anterior  attachments  of  the  fore- 
arm, both  muscular  and  ligamentous,  would  prevent  such  extreme  extension. 

The  olecranon  may  give  way  at  either  of  several  points.  Sometimes  the 
line  of  fracture  runs  through  the  slightly  constricted  part  which  corresponds 
to  the  middle  of  the  sigmoid  cavity,  as  looked  at  from  the  side.  Sometimes 
it  passes  across  the  middle  of  the  process,  and  occasionally  it  is  much  closer 
to  the  apex.  In  one  specimen  in  the  Warren  Museum,^  in  Boston,  there  is  a 
double  fracture,  with  close  fibrous  union.  "  The  lines  of  fracture  are,  respec- 
tively, J  inch  and  1^  inches  from  the  extremity  of  the  bone ;  and  at  this  last 
the  union  was  so  close  that  it  only  appeared  when  the  pieces  were  separated 
by  maceration."  Very  probably  there  is  often  a  certain  amount  of  crushing 
of  the  edges  of  a  fracture  produced  by  direct  violence,  but  the  above  is  the 
only  instance  known  to  me  of  double  fracture. 

The  direction  of  the  line  of  fracture  varies,  although  it  would  seem  to  be 
mainly  transverse. 

'  Surgical  Treatment  of  Children's  Diseases,  p.  265,  Fig.  45. 
2  Diseases  and  Injuries  of  the  Bones,  Syd.  Soc.  Transl.,  p.  37. 
'  Gray's  Anatomy,  Descriptive  and  Surgical,  p.  305. 
4  Op.  cit.,  p.  154.  6  Catalogue,  p.  171. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


149 


Both  olecranon  processes  are  reported  to  have  heen  hroken  in  one  case 
observed  by  Mr.  Fletcher  the  patient  was  a  youth  of  sixteen,  and  it  seems 
likely  that  the  lesions  might  have  been  more  correctly  called  epiphyseal  sepa- 
rations. They  were  due  to  direct  violence.  Hamilton  mentions  liaving  had 
occasion  to  reduce  a  backward  dislocation  (of  nine  weeks'  standing)  of  the 
radius  and  ulna  in  a  boy  aged  seven,  in  whom  the  olecranon,  still,  of  course, 
an  epiphysis,  was  separated  by  forcible  Hexion  during  the  operation.  He 
says  further:  "I  have  twice  since  broken  the  olecranon  in  attempts  to  reduce 
old  dislocations  of  the  radius  and  ulna  backward,  and  I  have  not  regretted 
the  occurrence,  since  it  enabled  me  to  reduce  the  dislocations  without  cutting 
the  triceps." 

In  most  cases  there  is  a  perceptible  gap  between  the  detached  portion  and 
the  rest  of  the  bone,  due  in  some  measure  at  least  to  traction  on  the  fragment 
by  the  triceps  muscle  ;  but  there  may  be  so  much  of  the  periosteum  left 
intact  as  to  prevent  any  separation.  Cases  do  occur  in  which  the  fragment 
is  drawn  up  along  the  back  of  the  arm,  but  they  are  more  rare  than  might 
be  supposed.    Flexion  of  the  elbow  increases  the  gap  when  one  exivsts. 

Tillaux^  expresses  the  opinion  that  when  there  is  separation  of  the  frag- 
ments, it  is  due  not  to  the  drawing  up  of  the  upper  one,  but  to  the  flexion  of 
the  elbow,  removing  the  lower  one ;  and  cites  in  proof  of  this  view^  the  fact 
that  the  gap  disappears  when  the  elbow  is  again  extended. 

As  soon  as  there  is  any  separation  at  the  point  of  juncture,  the  elbow-joint 
is  of  course  opened,  and,  although  the  injury  is  subcutaneous,  effusion  takes 
place  from  the  torn  and  irritated  synovial  membrane ;  a  circumstance  which, 
although  it  would  not  in  itself  suffice  to  push  the  fragments  apart,  certainly 
does  not  tend  to  diminish  the  gap.^ 

The  symptoms  of  this  injury  are:  immediate  loss  of  the  power  of  extend- 
ing the  forearm,  and  pain  in  the  elbow  on  attempting  to  do  so  ;  some  pain 
and  soreness  in  the  part,  although  this  has  not  been  marked  in  the  cases  I 
have  seen ;  a  cleft  or  gap  between  the  fragments,  filled  up  when  wide  by  a 
soft,  almost  or  quite  painless,  fluctuating  swelling ;  generally  there  is  also 
some  bulging  of  the  triceps  muscle  at  its  lower  part,  just  above  the  seat  of 
injury.  Lonsdale'^  quotes  from  Earle  the  case  "  of  a  gentleman  who  fractured 
the  olecranon,  and  where  the  separation  did  not  take  place  till  the  sixth  day 
after  the  injury,  at  which  period  it  was  caused  by  the  patient  attempting  to  tie 
his  neck-cloth."  The  detached  portion  can  be  grasped  between  the  surgeon's 
thumb  and  finger,  and  moved  by  itself  with  more  or  less  freedom.  Crepitus  is, 
of  course,  wanting  unless  the  fragments  are  in  contact ;  and  the  smaller  the 
portion  broken  off,  or,  in  other  words,  the  nearer  the  fracture  is  to  the  sum- 
mit of  the  process,  the  less  likely  is  it  that  the  surfaces  can  be  rubbed  upon 
one  another.  Ecchymosis  is  very  commonly  present,  and  may  gradually 
extend  along  the  ulnar  margin  of  the  forearm  for  several  days. 

These  symptoms  may  vary  considerably  in  distinctness,  but  they  are,  as  a 
general  rule,  well  enough  marked  to  make  the  diagnosis  clear.  Bransby 
Coopei-^saw  a  case  in  which  the  power  of  extension  of  the  forearm  was  so  far 
retained  as  to  give  rise  to  much  doubt. 

'  Med.  Times  and  Gazette,  Aug.  16,  1851.  2  Anatomie  Topographiqne,  p.  578. 

In  this  respect  the  olecranon  differs  from  the  patella,  which  is  of  less  size  as  compared  with 
the  knee-joint.  In  fractures  of  the  latter  bone,  it  is  held  by  some  high  authorities,  that  the  sepa- 
ration of  the  fragments  depends  largely  upon  the  free  effusion  of  liquid  into  the  articular  cavity. 
But  the  patella  clearly  belongs  among  the  "  sesamoid"  bones,  while,  according  to  Owen  (Gray's 
Anatomy,  p.  135,  note),  the  olecranon  is  homologous  with  an  extension  of  the  upper  end  of  tho 
fibula  above  the  knee-joint,  which  is  met  with  in  the  Oruithorhynchus,  Echidna,  and  some  other 
animals. 

*  Op.  cit.,  p.  156. 

A  Treatise  on  Dislocations  and  Fractures  of  the  Joiuta,  by  Sir  Astlev  Cooper.  Edition  of  1842, 
p.  471.  )  .7  .  r 


150 


INJURIES  OF  BONES. 


Fractures  of  the  olecranon  are,  for  the  most  part,  united  by  fibrous  tissue 
only,  the  length  of  the  band,  as  well  as  its  thickness,  varying  in  different 
cases.  Yet  there  are  many  instances  on  record  of  true  bony  union ;  and  this 
might  be  much  oftener  obtained,  but  for  the  difficulty  of  keeping  the  frag- 
ments in  complete  apposition.  In  Fletcher's  case  of  fracture  of  both  olecra- 
nons, before  quoted,  this  result  took  place  on  each  side,  as  proved  by  dissec- 
tion after  the  patient's  death  nearly  a  year  subsequently. 

When  osseous  union  occurs,  there  is  on  the  outer  aspect  of  the  bone  a 
deposit  of  callus,  which  gradually  becomes  absorbed  ;  on  the  articular  surface 
there  is,  as  in  other  cases  of  fracture  running  into  joints,  a  depression  or 
groove  marking  the  line  of  the  fracture.  In  the  case  of  ligamentous  union, 
there  are  sometimes  numerous  bands  passing  from  one  fragment  to  the  other, 
sometimes  two  or  more  at  either  side,  and  occasionally  a  thin  membrane-like 
sheet,  apparently  derived  from  the  periosteum. 

A  curious  specimen  exists  in  the  Warren  Museum,^  of  "  a  piece  of  bone 
broken  from  the  olecranon,  and  fifteen  years  afterwards  removed  from  the 
elbow-joint."  It  seems  probable  that  this  was  a  fragment  from  a  comminuted 
fracture,  torn  away  entirely  from  its  fibrous  connections,  the  remainder  of 
the  bone  having  become  solidly  united ;  but  the  account  is  not  as  full  as  it 
might  be. 

The  difiiculty  often  met  with  in  maintaining  the  contact  of  the  fragments, 
is  due  to  several  circumstances.  One  of  these  is  the  contraction  of  the  tri- 
ceps muscle,  which,  when  the  fibrous  tissues  surrounding  the  bone  are  torn 
through,  must  tend  to  draw  the  fragment  up  along  the  back  of  the  arm,  tilt- 
ing itiat  the  same  time  so  as  to  widen  the  gap  posteriorly.  Another  is  the 
efiusion  which  takes  place  in  the  joint,  and  which  may  be  very  copious. 
Still  another  is  the  upward  traction  not  only  of  the  triceps,  but  of  the  biceps 
and  brachialis  anticus  (the  latter  especially),  tending  to  crowd  the  end  of  the 
humerus  between  the  fragments.  All  these  belong  especially  to  the  early 
period,  and  vary  in  their  degree  in  difterent  cases.  Sometimes  the  smaller 
fragment,  drawn  upwards,  contracts  adhesions  in  its  new  position,  and  thus, 
when  swelling  has  subsided  and  muscular  contraction  has  been  quieted,  may 
resist  all  efforts  at  bringing  it  down. 

The  result  of  experience  is  that  the  usefulness  of  the  limb  after  a  fracture 
of  the  olecranon  is  not  dependent  altogether  upon  the  shortness  of  the  band 
uniting  the  fragments.  Even  if  union  is  effected  by  bone,  there  may  be  adhe- 
sions within  the  joint,  about  it,  limiting  the  movements  of  the  forearm 
upon  the  arm.  And,  on  the  other  hand,  it  sometimes  happens  that,  although 
the  separation  of  the  fragments  is  considerable,  the  freedom  and  strength  of 
the  limb  are  but  little  impaired.  In  most  of  the  ordinary  functions  of  the 
hand,  act  we  extension  of  the  elbow  is  less  indispensable  than  flexion. 

The  analogy  between  fractures  of  the  olecranon  and  those  of  the  patella,  in 
reo-ard  to  the  recovery  of  function  even  with  a  fibrous  connection  of  some 
length,  will  be  pointed  out  in  connection  with  the  account  which  will  be 
given  of  the  fractal  res  of  the  latter  bone. 

Absorption  of  ligamentous  union  is  recorded  in  one  case  by  Mr.  E.  Cooper.^ 
He  says : — 

"The  patient  should  be  cautioned  against  using  his  arm  too  freely,  till  the  uniting 
Jigament  has  acquired  strength  and  firmness.  A  patient  of  Mr.  Mayo's,  whose  olecra- 
non had  been  fractured,  and  liad  united  in  six  weeks  by  a  ligament  of  the  ordinary  firm- 
ness, suffered  severely  from  neglecting  this  precaution  ;  for  after  using  the  arm  as  much 
as  possible  for  some  time,  he  found  that  it  became  weaker  and  weaker ;  the  uniting  liga- 


1  Catalogue,  p.  171. 


*  Op.  cit.,  p.  475,  note. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


151 


ment  was  entirely  absorbed,  so  that  the  fractured  olecranon  was  drawn  up  by  the  tri- 
ceps, the  power  of  extending  the  elbow  was  almost  lost,  and  the  limb  became  wasted 
and  useless." 

The  time  required  for  the  union,  whether  fibrous  or  bony,  of  a  fractured 
olecranon,  must  vary  somewhat,  especially  in  the  former  case.  About  six 
weeks  may  be  stated  as  the  average  period.  AVlien  the  fragments  are  united 
by  bone,  the  strength  of  the  limb  is  soon  regained,  and  less  caution  is  needed 
than  if  they  are  joined  by  fibrous  tissue  only.  Such  cases  as  that  of  Mr. 
Ma^^o,  just  quoted,  are  extremely  rare ;  yet  the  stretching  of  newly-formed 
li2:ament  may  impair  greatly  a  result  which,  if  the  tissue  had  time  to  gain 
strength,  would  be  satisfactory. 

Anchylosis  of  the  elbow-joint  sometimes  follows  fracture  of  the  olecranon, 
and  the  chance  of  its  occurrence,  although  remote,  is  one  which  ought  always 
to  be  borne  in  mind.  Some  degree  of  stittening  is  very  common,  but  usually 
disappears  without  special  treatment ;  it  depends  upon  the  thickening  and 
contraction  of  the  fibrous  tissues  about  the  joint,  as  well  as  upon  loss  of  tone 
in  the  muscles  from  want  of  exercise.  When  adhesions  occur  within  the 
joint,  they  may  be  the  result  of  inflammation  due  to  the  severity  of  the 
original  injury ;  but  there  can  be  no  doubt  that  they  may  be  also  occasioned 
by  injudicious  treatment,  and  that  they  are  very  apt  to  end  in  fixation  of 
the  parts.  The  means  of  avoiding  this  very  unpleasant  issue  will  be  presently 
discussed. 

The  treatraeMt  of  fracture  of  the  olecranon  consists  in  placing  the  arm  in 
such  a  position  as  to  facilitate  bringing  the  fractured  surfaces  in  contact,  and 
contining  it  so  until  union  shall  have  taken  place.  When  there  is  veiy  little 
separation  the  surgeon's  task  is  simplified,  as  it  is  also  by  the  absence  of  high 
infiammatory  action  in  the  jcint.  Yet  it  must  be  remembered  that  without 
the  further  advantage  of  proper  care,  stretching  of  the  fibrous  tissues  connect- 
ing the  fragments  may  take  place,  and  the  ultimate  result  be  unsatisfactory. 

For  the  first  few  days  the  arm  should  be  laid  in  an  easy  position,  with  the 
elbow  well  extended,  and  means  taken  to  allay  any  inflammation  that  may 
arise.  I  do  not  think  that  anything  is  gained  by  bringing  the  upper  fragment 
down  until  all  effusion  into  the  joint  has  subsided  ;  but,  after  this,  the  earlier 
and  the  more  completely  it  is  done  the  better.  Of  course,  if  no  inflammation 
is  set  up,  and  the  joint  does  not  swell,  there  is  no  reason  for  w^aiting. 

Modern  surgeons  are  agreed  that  the  best  results  are  obtained  by  placing 
the  foreai-m  at  a  very  obtuse  angle  with  the  arm,  and  keeping  it  so  by  means 
of  an  anterior  splint.  The  splint  should  extend  well  up  towards  the  shoulder, 
»,nd  far  enough  down  to  thoroughly  control  the  forearm  ;  I  think  it  should 
go  down  into  the  palm  of  the  hand,  so  as  just  to  allow  of  flexion  of  the  fingers. 
An  ordinary  roller,  snugly  applied,  suffices  to  keep  it  in  place.  As  to  the 
material  for  the  splint,  it  may  be  of  wood,  binders'  board,  or  felt ;  tin,  which 
answers  very  well  when  properly  shaped  and  fitted,  has  the  great  advantage 
of  not  adding  miich  to  the  bulk  of  the  limb,  and  thus  of  allowing  a  loose 
sleeve  to  be  slipped  over  it. 

Some  surgeons  employ  the  plaster-of-Paris  or  starched  bandage,  but  I  can- 
not see  that  it  is  of  any  especial  use  in  these  cases.  A  skilfully  applied  roller 
will  remain  in  perfect  efficiency  for  three  or  four  days,  and  the  whole  appar- 
atus should  be  removed  at  least  as  often  as  this,  for  the  purpose  of  ascertaining 
the  condition  of  the  parts. 

Various  devices  have  been  employed  or  recommended  for  the  purpose  of 
preventing  the  retraction  upward  of  the  upper  fragment  in  these  cases. 
Figure-of-8  turns  of  a  bandage,  with  or  without  the  previous  application  of  a 
compress,  have  often  been  used.    Hervez  de  Chegoin^  employed  with  success 

1  Am.  Journal  of  the  Med.  Sciences,  July,  1848  ;  originally  in  the  Gaz.  des  Hopitaux. 


152 


INJURIES  OF  BONES 


an  elastic  compress,  drawn  downward  bv  tapes  attached  to  tlie  lower  end  of  a 
hollow,  jointed  splint. 

Sir  A.  Cooper,^  who  advocated  the  straight  position,  advised  that  after 
bringing  the  fragment  into  apposition  with  the  ulna,  a  piece  of  linen  should 
be  laid  longitudinally  on  each  side  of  the  joint,  and  wetted  rollers  applied 
above  and  below  the  elbow ;  the  extremities  of  the  linen  were  then  to  be 
doubled  down  over  the  rollers,  and  tightly  tied,  so  as  to  cause  approxima- 
tion. It  is  not  distinctly  said  that  he  ever  used  this  plan,  which  would 
seem  to  involve  great  discomfort  at  least  to  the  patient,  as  well  as  risk  of 
interference  with  the  nutrition  and  innervation  of  the  distal  portion  of  the 
limb.  This  objection,  indeed,  holds  good  with  regard  to  all  the  ligure-of-8 
and  other  bandages  which  encircle  the  limb ;  if  tightly  enough  applied  to  be 
efficient,  they  may  do  harm. 

AYith  the  excellent  adhesive  plaster  now  procurable,  it  is  easy  to  keep  the 
fragment  in  place  without  any  such  binding ;  a  strip  of  suitable  length  and 
width  being  put  on  so  that  its  middle  shall  press  just  above  the  fragment, 
while  its  ends  are  carried  down  along  the  ulnar  side  of  the  forearm,  one  in 
front  and  the  other  at  the  back,  far  enough  to  take  a  firm  hold.  The  splint 
and  bandage  are  then  applied  as  before  directed.  A  compress  is  needless, 
and  might  indeed  do  harm  by  tilting  the  fragment,  so  as  to  produce  a  con- 
dition such  as  Malgaigne  quotes  as  seen  byPasquier:  "the  fragments,  far- 
ther separated  posteriorly  than  anteriorly,  were  only  in  contact  by  their  ante- 
rior edge.'' 

It  has  been  suggested  b}^  my  self ,2  as  well  as  b}'  others,  that  in  cases  of  much 
difliculty  an  instrument  analogous  to  Malgaigne's  patella-hooks  might  be  used 
— ^a  small  metallic  plate  or  wire  frame,  with  either  one  or  two  short  recurved 
hooks,  to  be  inserted  into  the  posterior  and  upj^ei'  part  of  the  olecranon,  drawn 
down,  and  fastened  in  place  by  means  of  a  strip  of  adhesive  plaster  carried 
along  the  forearm,  as  before  described.  Such  a  contrivance  could  be  readily 
made,  and  probably  could  be  used  without  danger  ;  3'et  I  think  that  the  ma- 
jority of  surgeons  would  be  content  with  the  results  procurable  by  less  for- 
midable appliances. 

Dieftenbach,^  many  years  ago,  proposed  and  practised  the  division  of  the 
tendon  of  the  triceps,  bringing  the  upper  fragment  down  into  place,  and 
occasionally  rubbing  the  two  fragments  forcibly  together ;  he  claimed  to 
have  obtained  firm  union  in  this  way. 

Suturing  the  fragments  has  been  proposed,  and  the  operation  has  been  per- 
formed in  a  number  of  instances.  Mac  Cormac^and  others  have  thus  obtained 
bony  union  in  cases  attended  with  marked  separation.  Sheldon  had  already, 
in  1789,  proposed  the  laying  bare  of  the  bone  and  rasping  of  the  fractured 
surfaces,  but  says,  in  his  work,^  that  he  never  had  attempted  the  operation. 
The  introduction  of  the  wire  suture  made  the  procedure  far  more  eflective, 
and  the  advocates  of  the  so-called  antiseptic  sj^stem  claim  that  their  precau- 
tions make  it  safe.  I  must  confess  that  no  case  has  ever  come  under  my 
own  observation,  in  which  it  has  seemed  to  me  that  the  amount  of  advantage 
likely  to  be  derived  from  such  severe  measures  w^ould  warrant  their  substitu- 
tion for  the  less  brilliant  methods  above  described.  By  care  and  accuracy 
in  the  adaptation  and  use  of  simple  apparatus,  satisfactory  results  can,  as  a 
general  rule,  be  obtained. 

>  Op.  cit.,  p.  474.  2  New  York  Medical  Journal,  Dec.  1866. 

8  Casper's  Wochenschrift,  2  Oct.,  1841. 
Trans,  of  Clinical  Society  of  London,  vol.  xiv.,  1881. 

*  An  Essay  on  the  Fracture  of  the  Patella,  or  Knee-pan  ;  containing  anew  and  efficacious  method 
of  treating  that  accident:  With  Observations  on  the  Fracture  of  the  Olecranon.  By  John  Shel- 
don.   London,  1789. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


153 


Compound  fracture  of  the  olecranon  is  occasionally  met  with.  Its  gravity 
must  depend,  in  a  measure,  upon  the  possible  admission  of  air  into  the  joint, 
(.r  the  effusion  of  blood  into  that  cavity,  either  of  which  occurrences  would 
be  of  serious  import  as  to  the  prognosis  and  treatment  of  the  case,  by  reason 
of  the  inflammation  likely  to  ensue.  W^hen  the  synovial  membrane  remains 
intact,  the  wound  must  be  closed,  and  the  fracture  dealt  with  as  in  ordinary 
cases ;  wdien  the  joint  is  laid  op'en,  it  ought  to  be  carefully  cleansed  with 
carbolized  water,  and  all  inflammation  allayed  by  appropriate  means  before 
splints  are  applied.  Anchylosis  is  very  apt  to  ensue  under  such  circumstances. 

Fracture  of  the  coronoid  process  ot  the  ulna  is  a  lesion  usually  described 
as  very  rare,  and  it  has  certainly  been  very  seldom  recognized  as  occurring 
by  itself.  It  may,  however,  be  questioned  wliether  it  does  not  sometimes 
attend  backward  luxations  of  the  forearm,  as  in  a  case  reported  by  Say  re.  ^ 

The  flrst  published  observation  of  this  lesion,  according  to  Malgaigne, 
was  that  of  Brassard,  in  1811.  The  patient  had  fallen,  three  months  pre- 
viously, on  his  outstretched  hand  ;  the  motions  of  the  forearm  were  all  free 
and  painless,  except  flexion,  which  was  limited.  "In  front  of  the  uhia, 
between  it  and  the  end  of  the  humerus,  was  found  a  hard  body,  somewhat 
movable,  against  which  the  ulna  was  arrested  when  the  attempt  to  flex  the 
forearm  was  made."    Dorsey,^  in  1813,  says : — 

"  The  coronoid  process  of  the  uhia,  Dr.  Physick  has  once  seen  broken.  The  symp- 
toms resembled  a  dislocation  of  tlie  humerus  forward,  or  rather  of  the  forearm  back- 
ward, except  that  when  the  reduction  was  effected  the  dislocation  was  repeated,  and 
by  careful  examination  the  crepitation  was  discovered." 

Hulke^  mentions  the  case  "  of  a  man  killed  by  a  fall  from  the  roof  of  St. 
George's  Hospital,  in  whom  the  coronoid  processes  were  found  to  be  frac- 
tured, and  the  two  bones  of  the  forearm  dislocated  backward,  on  both  sides." 
Bradford^  has  reported  the  case  of  a  man,  aged  twenty-four,  who  fell  a  dis- 
tance of  forty  feet,  and  died  of  his  injuries,  among  which  was  a  fracture  of 
the  coronoid  process  of  the  ulna,  part  of  the  trochlea  of  the  humerus  being 
also  chipped  oft'.  The  main  symptom  is  stated  to  have  been  constantly  recur- 
rino;  dislocation  backward.  Sir  Astley  Cooper's  two  cases,^  one  of  which  was 
verified  by  dissection,  are  well  known.  In  the  account  of  the  latter,  it  is 
stated  that  the  coronoid  process  had  been  broken  oft"  within  the  joint," 
which  is  obviously  an  anatomical  impossibility,  although  the  fracture  must 
of  course  have  entered  the  joint.  Another  very  often  quoted  case  is  that  of 
Liston,  in  which  a  boy  aged  eight  sustained  the  injury  by  hanging  by  his 
hand  from  the  top  of  a  high  wall,  afraid  to  drop  down. 

Fahnestock®  reported  the  case  of  a  boy  who  "  fell  from  the  haymow,  and 
received  the  whole  w^eight  of  his  body  on  the  back  part  of  the  palm  of  the 
left  hand,  whilst  the  arm  was  extended  forward,  by  which  impulse  the  coro- 
noid process  of  the  ulna  was  displaced  ;"  the  limb  presented  the  appearance  of 
one  in  which  the  forearm  was  dislocated  backward,  but  on  being  reduced 
the  deformity  recurred,  and  the  recurrence  was  attended  by  an  evident  crepi- 
tation. It  is  stated  that  the  boy  "  recovered  very  speedily,"  but  the  degree  to 
which  the  power  of  flexion  was  restored  is  not  noted.  Duer^  saw  a  boy,  aged 
six,  who,  seven  weeks  before,  had  fallen  from  a  haymow  and  dislocated  the 
forearm  iDackw^ard.  The  displacement  still  existed,  "  and  the  arm  being  some- 
what flexed,  the  detached  portion  of  the  coronoid  process  lying  in  front  of  the 

>  Transactions  of  Med.  Soc.  of  State  of  New  York,  1871.  2  Op.  cit.,  vol.  i.  p.  152. 
3  Holmes's  System  of  Surgery,  3d  edit.  vol.  i.  p.  162. 

*  Boston  Med.  and  Surg.  Journal,  July  17,  1883.  ^  Op.  cit.,  p.  469. 

«  Am..  Journal  of  the  Med.  Sciences,  May,  1830.  '  Ibid.,  Oct.  1863. 


154 


INJURIES  OF  BONES. 


joint  could  be  distinctly  felt,  and  freely  moved  in  any  direction  over  a  small 
space."  Every  effort  at  reduction  failed,  and  the  case  was  dismissed,  prona- 
tion, supination,  and  extension  being  unimpaired.  Gross^  mentions  a  case 
reported  to  him  by  Dr.  Scott,  of  Missouri,  in  which  "the  coronoid  process 
formed  a  distinct  prominence  upon  the  anterior  and  inferior  surface  of  the 
humerus,  a  short  distance  above  the  joint,  movable  from  side  to  side,  the  ole- 
cranon being  at  the  same  time  displaced  slightly  backward,  and  the  forearm 
somewhat  flexed.  The  accident  was  caused  by  a  fall  upon  the  hand  while 
the  forearm  was  forci])ly  extended."  In  Sayre's^  case  the  fragment  was 
adherent  to  the  anterior  surface  of  the  (inner  ?)  condyle  of  the  humerus.  He 
refers  to  a  specimen  of  Dr.  Darling's,  shoAving  this  condition  of  things,  and 
to  another  in  which  ligamentous  union  had  occurred.  The  latter  was  ob- 
tained in  the  dissecting  room,  and  was  without  history.  Bryant  mentions 
and  figures  a  specimen  in  which  the  coronoid  process  and  the  anterior  margin 
of  the  head  of  the  radius  were  detached  in  an  old  woman  by  a  fall ;  the  frac- 
tures were  compound,  and  amputation  was  performed. 

From  the  foregoing  quotations  it  sxill  be  at  once  perceived  that  the  frac- 
ture in  question  may  occur  at  almost  any  age,  and  has  been  ascribed  to  veiy 
various  causes.  I  do  not  think  it  needful  to  discuss  the  correctness  of  the 
diagnosis  in  each  case,  as  Hamilton  has  done,  because  the  fact  that  the  lesion 
occurs  has  been  placed  beyond  doubt ;  and  for  practical  purposes  this  is  sufi- 
cient.  Equally  useless  is  the  enumeration  by  Lotzbeck^  of  twenty-four  varie- 
ties of  the  injury.  There  can  be  no  difficulty  in  understanding  how,  if  the 
ulna  is  forcibly  driven  upward  against  the  humerus,  in  any  position,  but 
especially  in  extension  of  the  forearm,  the  coronoid  process  as  a  whole,  or 
its  tip  only,  may  be  split  ofi".  In  the  case  of  muscular  action,  as  in  the  boy 
seen  by  Liston,  the  muscles  arising  from  the  inner  side  of  the  lower  part  of 
the  humerus  would  pull  the  coronoid  process  backward  against  that  bone, 
while  the  brachialis  anticus  would  tend  to  drag  it  away  from  the  body  of 
the  ulna.  And  a  glance  at  a  longitudinal  section  of  the  upper  part  of  the 
nhia  will  show  at  what  a  disadvantage  the  cancellous  structure  of  the  base  of 
the  coronoid  process  would  thus  be  placed,  and  how  readily  its  separation 
might  be  brought  about. 

The  cases  of  this  fracture  may  be  practically  divided  into  two  classes, 
according  to  the  extent  of  the  portion  detached.  If  the  tip  only  of  the  pro^ 
cess  is  broken  off,  the  fragment  will  be  very  small,  and  there  will  be  no 
marked  separation,  except  by  the  slipping  backward  of  the  ulna,  and  the 
consequent  relative  forward  displacement  of  the  humerus,  limited  by  conta^-t 
with  the  head  of  the  radius.  But  when  the  whole  of  the  coronoid  process 
is  split  off  from  the  ulna,  the  action  of  the  brachialis  anticus  will  serve  to 
draw  it  upward,  and  the  gap  between  the  fractured  surfaces  will  of  necessity 
be  more  considerable. 

Perhaps  yet  another  division  might  be  made,  of  those  cases  which  aie 
complicated*^  by  fractures  of  other  bones  in  the  neighborhood,  as  when  the 
olecranon  also  is  broken,  or  when,  as  in  one  of  Sir  A.  Cooper's  cases,  the 
external  condyle  has  been  likewise  separated.  But  here  the  fracture  of  the 
coronoid  would  as  a  general  rule  be  the  less  important  injury,  and  hence  it 
would  be  more  properly  assigned  the  secondary  place,  as  being  itself  a  mere 
complication  of  the  graver  lesion. 

The  symptoms  of  fracture  of  the  coronoid  process  have  already  been  given 
incidentally.  The  power  of  flexing  the  elbow  must  be  more  or  less  seriously 
impaired ;  pain  in  attempting  this  motion,  and  tenderness  in  front  of  the 


1  Op.  cit.,  p.  697. 

*  Noticed  in  Schmidt's  Jahrbiicher,  1866. 


2  Loc.  cit.,  p.  108. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


155 


joint,  with  occasionally  the  perceptible  presence  of  the  fragment,  are  to  be 
looked  for.  Crepitus,  if  it  exist  at  all,  can  be  but  slight.  A  tendency  to 
luxation  backward  of  the  ulna  may  exist,  but  can  hardly  be  marked  unless 
some  loosening  of  the  attachments  of  the  head  of  the  radius  has  also  occurred. 

The  diagnosis  may  sometimes  be  very  obscure,  and  only  to  be  arrived  at 
by  exclusion.  Separation  of  the  articulating  portion  of  the  lower  epiphysis 
of  the  humerus  might  induce  symptoms  almost  identical  with  those  of  this 
lesion,  although  inlhe  former  case  it  is  probable  that  the  interference  with 
flexion  alone  would  be  less  distinct. 

The  treatment  of  fracture  of  the  coronoid  process  consists  simply  in  flexing 
the  forearm  upon  the  arm,  at  an  angle  of  about  90°  or  less,  and  securing  it  in 
this  position  by  means  of  an  anterior  angular  splint.  Pressure  should  also  be 
made  upon  the'^olecranon  by  applying  the  middle  of  a  strip  of  adhesive  plaster 
around  it,  and  carrying  the  ends  forward  to  be  secured  to  the  splint  over  the 
forearm ;  in  this  way  the  tendency  to  displacement  of  the  forearm  backward 
may  be  overcome  with  more  certainty  than  by  the  turns  of  the  bandage, 
which  may  slip  and  become  loosened. 

Especial  care  is  to  be  taken  in  the  treatment  of  cases  in  which  the  whole 
process  is  separated,  as  the  action  of  the  brachialis  anticus  will  tend  to  draw 
the  frao;ment  up  along  the  front  of  the  arm,  and  permanent  impairment  of 
flexion'must  be  expected.  If  the  tip  only  is  broken  ofl:*,  it  will  be  subject  to  no 
such  traction,  and  the  fragment  can  only  give  trouble  either  by  being  entan- 
gled in  the  joint,  or  by  adhering  to  the  anterior  face  of  the  humerus  just  at 
fts  lower  end.  When  the  process  is  drawn  up,  it  may  be  carefully  coaxed 
down  by  the  surgeon's  fingers,  and  perhaps  the  pressure  of  the  splint  may 
keep  it  in  place  :  ""or  the  forearm  may  be  flexed  at  an  acute  angle  so  as  to  let 
the  lower  fragment  follow  the  upper.  Doubt  must  always  exist,  however, 
as  to  the  eflficiency  of  any  treatment  adopted,  until  the  patient  attempts  to 
resume  the  use  of  the  limb ;  and  the  prudent  surgeon  will  be  chary  of  giving 
assurances  which  the  l-esult  may  not  justify. 

Fractures  of  the  head  of  the  radius  are  very  rare,  unless  along  with  other 
severe  inj  uries  of  neighboring  bones.  Bryant's  case  has  already  been  mentioned, 
in  which  the  coronoid  process  of  the  ulna  was  also  broken  ofl'.  Malgaigne  could 
only  cite  two  cases,  in  both  .of  which  there  was  also  fracture  of  the  coronoid, 
and  backward  luxation  of  the  elbow.  The  head  of  each  radius  was  split  lon- 
gitudinally in  Hulke's  case  of  fracture  of  both  coronoid  processes,  referred  to 
on  a  previous  page. 

In  the  Warren  Museum^  there  is  a  specimen  (No.  1026)  of  "  one-third  of 
the  head  of  the  radius  broken  oft',  with  a  comminuted  fracture  of  the  upper 
extremity  of  the  ulna,"  taken  from  a  man  who  had  fallen  from  the  roof  of  a 
house.  Another  (No.  1031)  is  described  as  "  longitudinal  fracture  of  the  head 
of  the  radius,  with  fracture  of  the  ulna  from  the  coronoid  process  downward ;" 
and  further  as  "  a  clear  and  regular  split,  involving  very  nearly  one-half  of 
the  head  of  the  radius,  and  cleaving  outward  so  as  to  extend  no  further  than 
the  neck  of  the  bone."  Stimson^"  saw  a  fracture  of  the  outer  half  of  the 
head  of  the  radius,  produced  by  direct  violence  and  followed  by  suppurative 
arthritis,  in  a  boy  aged  thirteen ;  the  excision  of  the  joint  enabled  him  to 
establish  the  diagnosis.  Adams  exhibited  to  the  Pathological  Society  of 
London^  a  specimen  in  which  several  fissures  radiated  from  a  point  just 
below  the  head  of  the  radius  upward  to  the  articulating  surface ;  the  injury 
was  the  result  of  a  fall  from  a  height. 


1  Catalogue,  p.  172. 
8  Op.  cit.,  p.  433. 


'  Transactions,  vol.  xxii.  1871. 


156 


INJURIES  OF  BONES. 


Other  cases,  followed  by  recovery,  and  hence  open  to  some  doubt,  have  been 
reported. 

The  causes  of  fracture  of  the  head  of  the  radius  are  those  of  similar  injuries 
in  the  other  bones  of  the  same  region ;  cases  resulting  from  blows,  falls,  in 
which  there  is  sometimes  a  doubt  whether  the  violence  has  been  direct  or 
indirect,  and  railroad  crushes,  have  thus  been  observed.  In  Hulke's  case, 
affecting  both  arms,  it  can  scarcely  be  doubted  that  there  was  indirect  vio- 
lence ;  in  Bryant's,  it  is  distinctly  stated  that  the  woman  had  a  fall,  striking 
on  the  elbow.  But  in  either  class  of  cases,  the  mechanism  is  readily  enough 
explained. 

As  to  the  symptoms^  they  are  by  no  means  as  clear  as  might  be  supposed, 
in  view^  of  the  ease  with  which  the  head  of  the  radius  may  be  felt  in  the 
normal  state.  Pain,  loss  of  power  of  rotating  the  hand,  as  well  as  of  flexing  the 
elbow,  crepitus  on  passive  motion,  very  rapid  swelling,  and  synovitis  of  the 
elbow,  are  quite  sure  to  occur ;  but  the  determination  of  the  exact  nature  of 
the  injury  is  not  so  simple  a  matter,  especially  in  view  of  the  fact  that  in  so 
many  of  the  recorded  instances  other  lesions  have  also  been  present. 

The  prognosis  of  these  cases  must,  of  course,  depend,  in  some  measure,  upon 
the  amount  of  damage  done  to  the  joint,  and  to  neighboring  parts,  as  well  as 
upon  the  success  of  efforts  directed  tow^ard  allaying  inflammation.  A  con- 
siderable degree  of  stiffening  may  always  be  looked  for,  and  this,  in  some 
cases,  will  be  permanent. 

As  to  the  treatment,  the  first  object  must  be  to  keep  down  inflammation  in 
the  joint,  by  the  usual  means,  the  forearm  being  semi-flexed.  Nothing  can  be 
done  in  the  way  of  correcting  displacement,  should  such  exist,  which  does 
not  seem  to  have  been  the  case  in  any  of  the  recorded  instances.  The  limb 
should  be  placed  in  the  posture  which  affords  the  greatest  ease,  and  lightly 
bound  to  a  well-padded,  angular  splint.  Passive  motion  should  be  attempted 
at.  about  the  tenth  day,  and  repeated  every  twenty-four  or  forty-eight  hours ; 
the  movements  should  be  made  with  the  utmost  gentleness,  but  very  thor- 
oughly, and  any  irritation  caused  by  them  must  be  allowed  to  subside  com- 
pletely before  the  joint  is  again  disturbed.  If  the  irritation  run  very  high, 
and  last  long,  and  if,  on  each  successive  occasion,  it  become  more  decided, 
the  forearm  must  be  bent  at  a  right  angle  with  the  arm,  in  semipronation, 
in  order  to  give  the  greatest  use  of  the  hand  in  >case  the  stiffening  becomes 
permanent. 

Fractures  of  the  Elbow. — A  few  words  may  be  said  here  in  regard  to 
these  injuries,  which  comprise  all  those  in  which  not  only  the  lower  end  of 
the  hume]»us,  but  one  or  both  of  the  other  bones  entering  into  the  joint  are 
involved.  They  may  be  either  simple  or  compound,  and  the  extent  of  the 
lesion,  whether  of  the  bones  or  of  the  soft  parts,  may  vary  greatly.  Some- 
times the  fragments  are  very  much  displaced,  while,  in  other  cases,  they  may 
remain  almost  undisturbed.  Generally  the  cause  is  great  direct  violence,  such 
as  the  passage  of  a  wheel  over  the  arm,  or  other  crushing  force. 

When  these  fractures  are  compound,  the  position  and  extent  of  the  wound 
of  the  skin  will  be  influenced  in  some  degree  by  the  character  of  the  cause. 
If  the  latter  be  direct  violence,  the  wound  may  be  at  the  back  of  the  elbow  ; 
but  if  indirect,  the  skin  being,  as  it  were,  burst  open  by  the  projection  of  the 
bone,  the  anterior  surface  of  the  arm  just  above  the  flexure  is  most  frequently 
involved.  In  the  former  case,  also,  the  wound  is  apt  to  be  smaller  than  in 
the  latter ;  although  this,  of  course,  is  by  no  means  a  constant  rule.  Some- 
times, although  the  fracture  is  compound,  the  joint  is  not  laid  open  to  the  air, 
and  this  fact  lessens  the  gravity  of  the  injury. 

Fractures  of  the  elbow  may  occur  to  either  sex,  at  any  time  of  life ;  but. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM.  157 

for  obvious  reasons,  adult  males  are  most  exposed  to  the  causes  of  such 
injury. 

The  diagnosis  is  sometimes  quite  clear  as  to  the  nature  of  the  hurt,  but  it 
may  not  be  easy  to  determine  exactly  which  bones  are  involved,  and  to  what 
extent.  Malgaigne  mentions  a  case,  as  follows :  "  In  the  only  example  of 
comminuted  fracture  of  the  elbow  which  I  have  seen,  the  humerus  was  intact, 
except  that  its  articular  cartilage  was  stripped  otf ;  the  patient  had  fallen 
from  a  second  story  upon  the  elbow,  and  the  wound  answered  merely  to  a 
transverse  fracture  of  the  olecranon,  leading  me  to  think  that  this  process 
alone  was  involved.  The  patient  dying  on  the  fifty-eighth  day,  the  autopsy 
revealed  a  comminuted  fracture  of  the  coronoid  process  of  the  ulna,  as  well 
as  of  the  head  and  neck  of  the  radius." 

When  the  external  wound  is  large,  exploration  with  the  finger  may  aftbrd 
much  more  exact  information  as  to  the  precise  nature  of  the  damage  to  the 
bones. 

There  are  very  few  injuries  in  which  the  prognosis  is  more  doubtful  than 
in  those  now  under  consideration.  Every  pathological  cabinet  contains  speci- 
mens illustrating  most  extensive  fractures  involving  the  elbow,  from  which 
recovery  has  taken  place,  with  deformity  indeed,  yet  apparently  with  a  fair 
degree  of  usefulness  of  the  limb.  In  Malgaigne's  case,  just  mentioned,  there 
was  an  incessant  oozing  of  blood  from  the  fractured  surfaces,  which  filled  the 
joint,  and  doubtless  had  to  do  with  the  unfavorable  result ;  such  a  complica- 
tion might  occur  in  any  case,  and  disappoint  hopes  otherwise  well  founded. 
On  the  other  hand.  Sir  A.  Cooper^  relates  the  case  of  a  brewer's  servant,  in 
wdiom  the  elbow  w^as  crushed  by  the  wheel  of  a  dray,  so  that  the  finger  ccmld 
be  passed  through  the  joint,  and  the  artery  thus  felt.  He  refused  to  subnjit 
to  amputation,  and  recovered,  with  suflB.cient  motion  in  the  elbow  to  allow 
him  to  resume  his  former  occupation.  Another  case  is  given  by  the  same 
author,  in  which  a  man,  aged  seventy-four  years,  with  very  extensive  frac- 
ture, made  a  complete  recovery  ;  "  although  the  form  of  the  joint  was  irregu- 
lar, yet  a  considerable  degree  of  motion  was  preserved." 

I  think  it  may  be  assumed  that,  in  the  latter  case,  the  joint  was  not  laid 
open — a  circumstance  which,  as  a  general  rule,  renders  the  chance  of  a  good 
result  much  greater.  When  this  can  be  ascertained,  the  surgeon  may,  there- 
fore, venture  to  give  the  patient  much  more  encouragement  than  if  the  latter 
is  likely  to  undergo  the  risk  of  a  suppurative  arthritis. 

When  the  joint  does  not  show  any  sign  of  stifliening,  and  especially  if 
passive  motion  neither  gives  pain  nor  excites  inflammation,  the  prospect  is 
favorable,  even  if  the  outward  shape  of  the  part  is  disfigured — the  result  of 
several  displacements  being  to  give  something  like  the  natural  mechanism. 
Much,  however,  depends  upon  the  judgment  with  which  passive  motion  is 
employed. 

For  the  treatment  of  cases  varying  so  widely  in  the  degree  and  character  of 
the  lesions  presented,  it  can  scarcely  be  expected  that  definite  rules  should  be 
laid  down.  When  the  fracture  is  a  simple  one,  the  course  to  be  pursued  is 
identical  with  that  recommended  when  only  one  of  the  bones  entering  into 
the  joint  is  concerned. 

In  compound  fractures,  if  the  joint  be  not  laid  open,  the  fragments  must  be 
adjusted,  and  any  that  are  entirely  loose  removed ;  the  wound  is  next  to  be 
closed  as  securely  as  possible,  and  the  limb  placed  upon  a  rectangular  splint ; 
inflammation  is  to  be  expected,  and  must  be  met  by  fomentations,  evaporating 
and  anodyne  lotions,  or  irrigation.  Upon  its  subsidence,  the  same  treatment 
should  be  instituted  as  for  simple  fractures,  provision  being  made  for  the 
dressing  of  the  wound  until  it  has  completely  healed. 


1  Op.  cit.,  p.  477. 


158 


INJURIES  OF  BONES. 


When  the  joint  is  extensively  laid  open,  or  if  the  bones  are  very  badly 
crushed,  it  may  be  good  practice  to  excise  the  whole  joint ;  a  procedure 
which,  although  not  mentioned  by  Malgaigne,  has  been  resorted  to  with  suc- 
cess in  many  instances,  and  is  at-  present  of  recognized  value.  Sir  A.  Cooper 
cites  two  cases  in  which  it  was  employed  with  excellent  results  by  Mclntyre, 
in  one  as  early  as  1829.  I  myself  had  at  the  Episcopal  Hospital,  a  few  years 
ago,  a  young  man,  who,  by  a  fall  from  a  roof,  had  sustained  a  very  extensive 
compound  fracture  of  the  elbow  ;  I  freely  excised  the  joint,  and  he  recovered 
with  so  good  an  arm  that  he  was  able  to  resume  his  business  as  a  tin-roofer. 

When  excision  is  decided  upon,  it  is  important  to  remember  that  much 
depends  upon  the  removal  of  a  sufficient  amount  of  bone  to  leave  the  forearm 
freely  movable ;  upon  sparing  muscular  attachments  as  much  as  possible ; 
and  upon  avoiding  interference  with  vessels  and  nerve-trunks.  Partial  ex- 
cisions have,  in  some  instances,  been  done  with  success;  but  I  think  that  the 
general  result  of  expei'ience  is,  that  it  is  better  to  remove  all  the  articulating 
surfaces,  that  healing  thus  takes  place  more  quickly,  and  that  to  leave  any 
portion  of  the  joint  adds  nothing  either  to  the  safety  of  the  procedure  or  to 
the  subsequent  usefulness  of  the  limb. 

Occasionally,  besides  the  damage  to  the  bones,  the  vessels  are  torn  across, 
or  such  extreme  injury  has  been  inflicted  on  the  soft  parts  as  to  be  irrepara- 
ble, and  amputation  must  then  be  performed. 

The  question  may  be  raised  with  regard  to  either  amputation  or  excision, 
whether  the  better  plan  is  to  operate  at  once,  or  to  wait  until  suppuration 
has  been  established  ;  in  other  words,  whether  a  primary  or  a  secondary  ope- 
ration affords  the  best  chance  of  a  good  result.  I  think  it  should  be  decided, 
not  abstractly,  but  according  to  the  circumstances  of  each  case.  If  it  is  clear 
that  operative  interference  must  be  resorted  to,  and  the  patient's  condition 
does  not  forbid,  there  would  seem  to  be  no  valid  reason  for  postponing  it. 
But  if  there  is  a  doubt  in  the  surgeon's  mind,  either  as  to  the  necessity  of  any 
operation,  or  as  to  which  he  should  adopt,  or  if  grave  constitutional  symp- 
toms are  present,  a  few  days'  delay  may  be  of  momentous  advantage.  Such 
questions,  however,  belong  rather  to  general  surgery  than  to  the  special 
branch  now  under  consideration. 

Fractures  of  the  shaft  of  the  ulna  are  rare  as  the  result  of  indirect  vio- 
lence, although  Bellamy!  has  reported  one  in  the  upper  third  of  the  bone  from 
a  fall  on  the  hand,  in  a  child  six  years  of  age.  Yoisin  is  quoted  by  Malgaigne 
as  having  seen  "  a  detachment  of  a  longitudinal  splinter  from  the  articular 
facet"  at  the  lower  end,  produced  in  the'same  way.  Macleod  has  reported* 
a  case  seen  by  him  in  which  the  patient,  in  striking  a  blow,  sustained  a  frac- 
ture of  the  styloid  process  of  the  ulna,  with  separation  of  the  triangular  car- 
tilage. A  more  frequent  cause  is  direct  violence,  as  when  a  pugilist  wards 
off  a  blow^,  and  receives  it  on  the  edge  of  the  forearm  ;  or  from  a  fall,  striking 
the  same  part  against  a  step  or  other  resisting  body.  The  ulna  is  subcuta- 
neous in  its  whole  length,  and  hence  is  specially  exposed  to  injuries  of  the 
kind  just  referred  to. 

Labatt^  saw  a  healthy  girl  w^ho  had  sustained  a  fracture  of  the  lower  third 
of  the  ulna  by  muscular  action,  as  she  was  engaged  in  wringing  clothes.  A 
previous  injury  had  impaired  the  power  of  supination. 

In  the  statistics  from  the  Children's  Hospital,  already  quoted,  in  tlie  316 
cases,  the  ulna  by  itself  is  said  to  have  been  fractured  11  times,  or  in  very 
nearly  ^  per  cent.    Yet  the  causes  are  much  more  prevalent  among  grown 

1  British  Medical  Journal,  Sept.  16,  1876. 
«  Edinburgh  Medical  Journal,  Nov.  1874. 
3  Dublin  Med.  Press,  April  8,  1840. 


rKACTUKES  OF  THE  BONES  OF  THE  FOREARM. 


159 


persons,  and  particularly  in  men,  who,  according  to  MaJgaignc,  contribute 
)bur-tifths  of  the  subjects  of  this  injury.  Of  the  different  portions  of  the  bone, 
it  would  seem  from  the  statistics  given  by  Hamilton,  as  well  as  from  those  of 
Agnew,  that  the  middle  third  is  somewhat  more  frequently  affected  than  either 
the  upper  or  the  lower ;  and  the  reason  of  this  may  be  readily  perceived. 

In  the  Museum  of  the  Pennsylvania  Hospital  there  is  a  specimen^  of  double 
fracture  of  the  ulna,  the  forearm  having  been  bent  around  a  revolving  shaft. 
"  The  upper  fracture  is  near  the  junction  of  the  upper  and  middle  thirds,  and 
is  somewhat  oblique.  The  lower  fracture  is  in  the  lower  third,  and  is  trans- 
verse. At  the  time  of  removal  the  fractures  were  not  complete,  the  fibres  of 
the  bone  which  remained  unbroken  being  much  bent."  The  patient  was  a 
boy  aged  fifteen. 

Wlien  the  ulna  is  broken  by  direct  violence,  the  fracturing  force  M^ill 
obviously  tend  almost  invariably  to  drive  one  or  both  of  the  fragments 
toward  the  radius,  and  thus  to  diminish  the  interosseous  space.  The  upper 
fragment,  from  the  nature  of  its  connection  with  the  humerus,  is  not  as 
movable,  laterally,  as  the  lower,  which  is  moreover  acted  upon,  in  some 
degree  at  least,  by  the  pronator  quadratus  muscle.  But  the  upper  fragment 
may  be  tilted  either  forward  or  backward,  as  indeed  the  lower  may  be  also; 
and  thus  will  result  a  deformity  and  change  of  relation  between  the  bones,  by 
w^hich,  if  uncorrected,  the  pronation  and  supination  of  the  hand  would  be 
almost  altogether  prevented.  For  the  production  of  this  unfortunate  effect, 
it  is  not  necessary  that  either  fragment  should  be  very  markedly  displaced ; 
a  very  slight  change  of  angle  is  sufficient  to  destroy  the  parallelism  of  the 
two  bones,  and  thus  to  impair  the  efficiency  of  their  mechanism. 

Hamilton  says  that  there  is  no  other  long  bone  the  fractures  of  which  are  so 
often  complicated  as  are  those  of  the  ulna;  and  Agnew  makes  nearly  the  same 
statement.  The  former  author  saw,  in  12  cases  out  of  36,  the  radius  dislocated 
forward,  or  forward  and  outward,  and  in  one  a  backward  luxation  of  both 
radius  and  ulna,  while  in  four  cases  the  fracture  was  compound.  The  rationale 
of  the  displacement  of  the  head  of  the  radius,  after  the  support  of  the  sound 
ulna  is  lost,  is  not  difficult  to  comprehend. 

A  curious  specimen  exists  in  the  Warren  Museum,^  which  has  been  already 
noticed  on  account  of  the  lesion  of  the  radius ;  that  of  the  ulna  is  thus 
described :  "  The  fracture  of  the  shaft  of  the  ulna  is  very  oblique,  commenc- 
ing at  the  depression  of  the  articular  surface,  marking  the  separation  of  the 
coronoid  proces,s  and  the  olecranon,  extending  almo&t  longitudinally  3 J  inches 
downward,  and  detaching  from  the  shaft  that  portion  of  the  bone  to  w^hich 
the  olecranon  was  attached."  A  somewhat  similar  case,  but  extending  down- 
ward only  two  inches,  and  followed  by  non-union,  was  reported  by  Brainard.^ 
Very  generally  the  fractures  of  the  ulna  present  but  a  slight  degree  of 
obliquity. 

The  symptoms  are  pain  and  loss  of  power  in  the  forearm  and  hand,  swelling, 
ecchymosis,  and  tenderness  at  the  seat  of  fracture.  Sometimes  the  fingers  of 
the  surgeon,  passed  along  the  edge  of  the  forearm,  perceive  a  depression  or 
angle,  and  crepitus  is  elicited  on  pressure.  Occasionally,  in  order  to  develop 
this  latter  sign,  it  is  necessary  to  grasp  the  upper  and  lower  portions,  of  the 
forearm,  and  make  a  slight  effort  as  if  to  rotate  the  low^er  upon  the  upper. 
Care  must  be  taken,  however,  to  avoid  any  manipulation  which  might  cause 
displacement,  or  increase  it  if  it  already  exists. 

^  The  diagnosis  is  not  often  difficult,  the  subcutaneous  position  of  the  bone 
giving  a  fair  opportunity  for  its  thorough  examination.    The  possibility  of 


»  Catalogue,  p.  23,  No.  1095.  2  Catalogue,  p.  173,  No.  1031. 

•  Transactions  of  the  Am.  Med.  Association,  vol.  vii.  1854. 


160 


INJURIES  OF  BONES. 


complications  should  not  be  lost  sight  of  ;  the  slirgeon  should  see,  for  example, 
that  the  head  of  the  radius  is  in  its  proper  place. 

Union  generally  takes  place  readily,  but  a  number  of  cases  of  false  joint 
have  been  observed  in  this  bone,  perhaps  on  account  of  rotary  motion  com- 
municated to  the  lower  fragment  through  too  great  liberty  allowed  to  the 
hand,  or  it  may  be  by  the  entanglement  of  a  torn  edge  of  the  interosseous 
membrane  between  the  fragments. 

Callenderi  has  recorded  a  case  in  which  the  styloid  process  of  tlie  uhia, 
carrying  with  it  the  triangular  ligament  (?),  was  torn  off,  and  in  which,  when 
the  parts  were  examined, '"the  ulnar  nerve  was  found  wedged  between  the  two 
portions  ot  bone. 

The  treatment  may  be  a  very  simple  matter,  or  may  present  considerable 
difficulties.  The  first  point  is  to  correct  any  displacement  that  may  exist ; 
and  the  only  direction  that  can  be  given  for  this  is,  that  such  manipulation 
is  to  be  employed  as  may  in  each  case  be  found  most  effectual.  Sometimes 
the  bone  is  brought  into  perfect  line  by  merely  pressing  the  soft  parts  into 
the  interosseous  spaces,  anteriorly  and  posteriorly;  and  this  should  always  be 
done,  although  it  may  also  be  requisite  to  correct  an  angle  forward  or  back- 
ward, as  well  as  to  make  some  extension  in  order  to  disengage  the  fragments 
from  one  another,  or  from  the  torn  interosseous  ligament. 

As  a  general  rule,  the  semi-prone  position  (with  the  thumb  upward),  is  the 
best ;  and  if  the  patient  is  either  a  child  or  a  restless  or  unruly  adult,  a  splir.t 
extending  from  the  middle  of  the  upper  arm  to  the  ends  of  the  fingers,  with 
a  right  angle  correspondins:  with  the  elbow,  will  serve  to  secure  it.  My  own 
preterence  is  for  two  smalhslips  of  wood,  well-padded,  and  applied  along  the 
dorsal  and  palmar  surfaces  of  the  forearm,  with  very  careful  bandaging  from 
the  tips  of  the  fino:ers  to  the  elbow ;  a  piece  of  binder's  board,  cut  so  as  to 
form  an  internal,  angular  splint,  reaching  down  to  the  ends  of  the  fingers, 
and  with  the  forearm  part  broad,  so  that  its  lower  edge  can  be  turned  up  to 
support  the  whole  ulnar  side  of  the  limb,  may  then  be  softened  in  hot  water, 
moulded  to  the  arm,  and  secured  by  a  roller.  For  the  first  few  days  the  con- 
dition of  the  fingers  should  be  carefully  watched,  lest  the  circulation  be 
interfered  with  by  the  compression  ;  a  number  of  cases  are  on  record  in  which 
HB-glect  in  this  respect  has  cost  the  patients  the  loss  of  their  arms,  and  even 
of  their  lives. 

Some  surgeons  are  content  with  a  mere  trough,  in  which  the  semi-prore 
forearm  is  laid,  and  confined  by  means  of  a  bandage ;  but  there  can  be  do 
question  that  more  efficient  confinement  is  needed  in  many  cases,  and  is  safer 

in  all.  1  X-  n  xT„ 

In  compound  fractures  of  the  ulna  the  treatment  must  be  essentially  the 
same,  although  a  gap  should  be  left  opposite  the  wound  to  allow  of  its  being 
dressed. 

When  the  trough  or  angular  splint  is  properly  applied,  the  sling  can  hardly 
do  anv  harm  by  pressing  one  or  both  fragments  toward  the  radius ;  but  it  7,8 
better  to  have  it  of  ample  width.  The  hand  should  never  be  allowed  to  hang 
free,  but  should  be  well  supported  by  the  angular  splint.  When  the  appa- 
ratus is  removed  for  the  purpose  of  examining  the  limb,  the  utmost  care 
should  be  taken  to  guard  against  any  sudden  displacement.  I  think  it  may 
even  be  better  to  leave  the  small  splints  in  place  for  a  week  or  two,  and 
merely  to  ascertain  by  passing  the  fingers  along  the  bone  that  the  fragments 
are  in  their  proper  relation. 

Passive  motion  is  in  these  cases  wholly  unnecessary,  and  would  be  very 
likely  to  do  harm.   At  the  end  of  about  four  weeks,  the  arm-part  of  the  sup- 

»  St.  Bartholomew's  Hospital  Reports,  1870. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


161 


porting  splint  may  l)e  left  oft",  and  in  a  week  more  the  hand  may  be  set  at 
liberty ;  next  the  small  splints  may  be  removed,  and  then  the  api)aratus  may 
be  permitted  to  become  loose,  and  so  worn  for  a  few  days,  when  it  may  be 
finally  dispensed  with. 

Pseudarthrosis,  when  it  occurs  in  the  ulna,  is  not  easy  to  deal  with  on 
account  of  the  presence  of  the  radius.  Of  sixteen  cases  collected  by  Muhlen- 
berg,^ live  were  treated  successfully  by  drilling,  and  in  one  the  plan  failed  ; 
four  by  resection,  with  one  success,  two  failures,  and  the  result  in  one  not 
stated;  three  by  frictions,  with  two  successes  and  one  failure;  one  successfully 
by  tincture  of  iodine  applied  to  the  skin  ;  another  by  scraping  the  periosteum 
subcutaneously  ;  and  another  by  mere  mechanical  pressure.  From  this  it 
would  appear  that  the  methods  which  do  not  involve  much  disturbance  of 
the  parts  are,  in  the  case  of  this  bone,  the  most  effective. 

I  may  add  that  Le  Fort^  has  recently  recorded  a  case  in  which  he  succeeded 
in  obtaining  union  by  means  of  electricity. 

Malgaigne  quotes  from  Berard  a  case  of  comminuted  fracture  of  the  lower 
lourth  of  the  ulna,  with  division,  not  only  of  the  muscles,  but  of  the  ulnar 
artery  and  nerve ;  he  tied  both  ends  of  the  artery,  dressed  the  wound,  placed 
the  forearm  first  upon  cushions  and  afterward  in  the  ordinary  apparatus  for 
fracture  of  both  bones,  and  succeeded  in  obtaining,  at  the  end  of  sixty-eio-ht 
days,  complete  consolidation  and  cicatrization.  ^ 

Fractures  of  the  radius  alone  constitute  a  very  large  proportion  of  the 
whole  number  of  fractures,  not  only  of  the  upper  extremity,  but  of  the  skele- 
ton m  general.  But  this  is  due  to  the  frequency  with  which  the  bone  o-ives 
way  at  its  lower  part,  close  to  the  wrist ;  the  other  portions  of  it  are  much 
more  rarely  broken.  In  illustration  of  this  statement,  I  may  quote  the  fio-ares 
^iven  by  Agnew,3  derived  from  the  registers  of  the  Pennsylvania  IIospitaL 
Out  ot  648  lully  recorded  cases,  24,  nearly  4  per  cent.,  were  in  the  upper  third 
ot  the  bone;  d3,  a  little  over  8  per  cent,  in  the  middle  third;  and  571 
about  88  per  cent.,  in  the  lower.  Hamilton's  observations  present  a  curious 
agreement  with  these ;  out  of  101  cases,  3  were  in  the  upper  third  of  the 
bone,  6  in  the  middle  third,  and  92  in  the  lower. 

Fractures  in  the  upper  third  of  the  bone  are  generally,  I  think,  the  result 
ot  direct  violence.    But  in  1856  I  saw  a  case  under  the  care  of  Dr.  Milton- 
berger,  m  Baltimore,  in  which  the  radius  had  given  way  very  hio-h  up  as  the 
patient  was  pulling  very  hard  in  driving  a  pair  of  horses.    I  do  not  know  of 
any  other  recorded  case  of  the  kind,  but  the  history  of  this  one  was  clear,  and 
the  mechanism  may  be  easily  perceived ;  the  twist  impressed  upon  the  bone 
Dy  the  action  ot  the  biceps  was  such  as  to  overcome  the  strength  of  the  tissue 
J^ractui^e  of  the  neck  of  the  radius,  properly  so  called,  may  take  place  from 
direct  violence,  as  in  some  cases  of  crushino;  of  the  elbow ;  althouo-h  I  think 
this  bone  IS  more  apt  to  escape  by  reason  of  its  mobility  and  small  size.  But 
no  instance  is  known  to  me  in  which  it  has  been  ascertained  to  be  broken  by 
itse  .    The  specimen  in  the  Mutter  Museum,  which  has  been  sometimes  said 
to  illustrate  this  lesion,  is,  m  fact,  one  of  fracture  through  the  tubercle  and 
the  displacement  is  such  as  to  show  the  action  of  the  biceps  upon  the  upper 
as  well  as  upon  the  lower  fragment ;  it  is  without  history,  which  is  much  to 
be  regretted    Moore^  has  reported  a  case  in  which  the  separation  was  clearly 

obferviJi  Z  v   t     '        'IZ^  itself;  and  he  refers  to  another. 

Observed  by  Parker,  where  there  was  luxation  of  the  head  of  the  bone,  which 

*  Agnew,  op.  cit.,  vol.  i.  pp.  768,  769,  770,  806. 

»  Bull,  et  Mem.  de  la  Society  de  Cliirurgie  de  Paris,  1882 

Op.  cit.  vol  i.  p.  901.  4  London  Med.  Gazette,  Oct.  17,  1845. 

V  OL.  W, — 11 


162 


INJURIES  OF  BONES. 


"was  drawn  considerably  above  the  elbow-joint,  by  the  cor.traction  of  the 
biceps  muscle ;"  reduction  was  accomplished,  and  the  case  is  said  to  have 

*^°In  ^-leakino-  of  the  relative  frequency  of  fractures  in  difterent  portions  of 
the  radius  if  will  be  remembered  that  I  quoted  statistics  from  Agnew  and 
Hamiiton  in  which  the  bone  was  considered  as  divided  into  an  upper,  middle, 
and  lower' third.  I  venture  to  su^a;est  that  it  would  be  better  tor  practical  pur- 
BO'.es  to  stady  these  injuries  accoi-ding  as  they  aftect  the  shaft  of  the  bone  above 
or^below  the  insertion  of  the  pronator  teres,  leaving  fractures  at  or  close  to 
its  lower  extremity  in  a  separate  class.  For  there  is  no  portion  ot  the  skele- 
ton in  the  fractures  of  which  the  influence  of  muscular  action  i^pon  the  pro- 
duction or  maintenance  of  displacement  is  more  distinctly  traceable  than  it  is 
in  those  of  the  shaft  of  the  radius.  v 

Th-  o-reat  function  of  this  bone  is  pronation  and  supination,  as  may  be 
elearlv  seen  by  a  glance  at  the  muscles  which  act  upon  it.  One  of  these,  the 
biceps,  is  indeed  a  flexor,  but  it  is  a  supinator  also  The  supmator  brevis 
acts  upon  the  upper  portion-almost,  if  not  quite,  halt  ot  the  bone--the  supi- 
nator longus  upon  its  lower  end.  The  pronator  teres  is  inserted  into  about 
an  inch  of  its  outer  edge  at  its  mid-length,  while  the  pronator  quadratus  act-, 
in  a  supplementary  way  on  the  lower  portion  of  the  sha,ft  _ 

If  now  the  shaft  gives  way  between  the  tubercle  and  the  insertion  of  the 
pronator  teres,  it  must  be  obvious  that  while  this  muscle  wdl  tend  to  rotate 
the  lower  fragment  into  pronation,  and  to  drag  it  toward  the  ulna,  the  upper 
frao-ment  wilt  be  rolled  outward  by  the  supinator  brevis  and  biceps,  the  latter 
alsS  tiltino-  it  up  forward.  The  action  of  the  supinator  longus  in  opposition 
to  the  pronator  teres  will  amount  to  nothing  as  soon  as  the  continuity  of  the 
bone  is  lost;  and  the  pronator  quadratus  will  simply,  by  the  contraction  of 
its  upper  fibres,  pull  the  lower  fragment  toward  the  ulna. 

If  on  the  other  hand,  the  shaft  is  broken  below  the  insertion  of  the  pro- 
nator teres,  this  muscle  will  draw  the  upper  fragment  toward  the  ulna,  but 
its  rotating  action  will  be  opposed  by  the  supinator  brevis  and  biceps;  the 
pronator  q°iadratus  will  act  in  the  same  manner  as  before,  but  more  strongly, 
as  the  fragment  will  be  shorter.  Here  the  displacement  produced  will  be  an 
angle  saliSnt  toward  the  ulna,  while  in  the  former  case  there  will  be  added  a 
Son  outward,  as  well  as  a  tilting  up  forward,  of  the  upper  fragnient 
Clinical  observation,  as  well  as  the  testimony  ot  museum  specimens,  will  be 
found  to  support  these  statements,  the  practical  bearing  ot  which  will  pres- 

*"5[af"aSe  S  some  curious  facts  as  to  the  distribution  of  these  fractures 
between  the  sexes.  He  found  the  radius  broken  in  mnety-flve  m£iles,_and  in 
sixty-five  females ;'  but  this  proportion,  three  to  two,  was  not  maintained  at 
all  ages. 

The  number  of  male  cases  to  females  is  ten  to  one  in  infancy  ;  between  fifteen  and 
twenty  it  is  fifteen  to  one.  Thus  up  to  twenty  years  of  age  this  fracture  is  almost  ex- 
clus  vely  masculine.  From  twenty  to  forty-five,  it  afl^ects  women  m  pretty  large  num- 
bers twery'two,  in  a  total  of  seventy-two.  But,  after  forty-five,  another  change 
occurs,  and  the  fr;cture  displays  a  marked  preference  for  the  female  sex  ;  there  be.ng 
but  twenty  men  to  forty-one  women." 

As  to  the  causes  of  these  fractures,  they  would  seem  to  be  sometimes  direct 
violence,  sometimes  tails  on  the  hand.  Malgaigne  quotes  from  \  an  Nierop 
the  case  of  a  woman,  aged  thirty,  who,  after  wringing  out  two  large  sheets, 
felt  sharp  pain  in  the  I'orearm,  when  a  fracture  m  the  lower  third  of  the 

>  These  figures  include  all  fractures  of  the  radius-not  those  of  the  shaft  of  the  bone  only,  but 
those  of  its  lower  extremity  also. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


163 


radius  was  detected.  O'Brien^  rei)orts  that  lie  saw  an  oblique  fracture  of  the 
bone,  about  three  inches  above  the  wrist,  produced  by  muscular  effort  in 
aiding  to  lift  a  large  cask.  It  is  not  improbable  that  cases  of  this  kind  are 
more  frequent  than  would  be  supposed  from  the  scantiness  of  the  records. 

l*rominent  among  the  symptoms  of  fracture  of  the  shaft  of  the  radius  is 
always  loss  of  power  in  the  hand ;  although  the  patient  may  still  be  able  to 
flex  the  lingers,  and  perhaps  to  pull  or  lift  in  some  degree.  But  from  what  was 
before  said  as  to  the  function  of  the  radius,  and  the  action  of  muscles  uiion  it, 
it  nmst  be  clear  that  the  breaking  of  this  bone  cannot  fail  to  render  the  hand 
useless,  for  want  of  pronation  and  supination.  Deformity  is  usually  present, 
the  forearm  having  a  curiously  twisted,  look  ;  and  if  the  hand  is  grasped  and 
rotated,  there  is  an  odd  sense  of  looseness  in  the  limb,  the  patient'experiences 
pain,  and,  unless  the  fragments  are  separated  altogether,  there  is  crepitus.  I 
have,  never  myself  seen  a  case  in  which  the  latter  symptom  was  wanting.  The 
injured  part  quickly  swells,  and  the  other  phenomena  become  much  obscured. 

In  examining  a  forearm  for  the  detection  of  this  or  any  other  fracture,  the 
best  procedure  is  for  the  surgeon,  after  noting  the  position  in  which  the  limb 
lies,  to  grasp  the  hand  with  his  corresponding  hand,  and  bring  it  into  semi- 
pronation ;  then  to  run  the  lingers  of  his  other  hand  along  the  ulna,  with 
some  pressure,  so  as  to  determine  the  soundness  of  that  bone."'  ^"ext,  applying 
his  disengaged  hand  gently  but  closely  to  the  upper  part  of  the  forearm,  he 
rotates  the  patient's  hand,  with  slight  extension  ;  the  fragments  will  usually 
be  felt  to  rotate  upon  one  another,  and  at  one  point  the  movement  will 
cause  pain.  Greater  certainty  is  given  to  this  manoeuvre,  if  the  thumb  of  the 
surgeon  is  applied  to  the  head  of  the  radius,  which  may  often  be  felt  not  to 
lollow  the  motion  of  the  hand  as  it  normally  should.  The  precise  point  of 
fracture  may  be  determined  by  passing  one  or  two  fingers  lightly  but  firmly 
along  the  bone ;  a  certain  yielding,  with  crepitus,  will  be  felt  when  the  spot 
is  reached,  and  the  patient  will  experience  pain.  When  the  fracture  is  below 
the  mid-point  of  the  bone,  it  can  be  much  more  readily  perceived  than  above, 
where  the  examination  must  be  made- through  a  greater  or  less  thickness  of 
muscular  tissue. 

When  the  symptoms  are  ordinarily  distinct,  there  can  be  little  or  no  difii- 
culty  m  the  diagnosis  ;  but  it  may  readily  be  imagined  that  if  the  periosteum 
should  hQ  untorn,  and  the  fragments  be  thus  held  in  contact,  the  fact  of  frac- 
ture might  escape  detection.  Serious  displacement  would  not  under  such 
circumstances  be  likely  to  ensue ;  and  especially  if,  notwithstandino-  the 
absence  of  conclusive,  symptoms,  the  case  were  treated  as  one  of  fracture. 
^  I  may  mention  that  the  rotation  of  the  radius  in  an  uninjured  arm  some- 
times gives  rise  to  a  sound  somewdiat  resembling  crepitus,  either  by  contact 
of  the  head  of  the  bone  witli  the  condyle  of  the  humerus,  or  bv  friction  of 
the  tendons  in  their  sheaths.  Any  error  thus  induced  would,  however,  be 
on  the  safe  side. 

From  what  has  already  been  said,  it  ^vill  be  perceived  that  the  result  of 
tracture  of  the  shaft  of  the  radius,  if  left  to  itself,  would  be  likely  to  be  the 
loss  ot  much  of  the  usefulness  of  the  hand.  If  the  bone  were  broken  above  the 
insertion  of  the  pronator  teres,  the  upper  fragment  would  be  supinated,  and 
the  lower  pronated  ;  the  upper  would  be  tilted  forward,  and  the  lower  drawn 
inward  toward  the  ulna.  If  the  fracture  were  below  that  point,  the  upper  frao-- 
nient  might  be  but  little  rotated,  but  the  lower  would  be  drawn  away  from 
It,  and  Irom  its  shortness  even  more  strongly  pulled  toward  the  ulna.  And 
in  either  case  the  displacement  of  the  upper  end  of  the  lower  fragment  would 
be  favored  at  least  by  the  action  of  the  supinator  longus  muscle ;  of  this  a 

»  Atlanta  Med.  Register,  1881. 


164 


INJURIES  OF  BONES. 


Striking  illustration  is  given  by  Malgaigne  '  He  says,  "the  styloid  process 
Sis  been  drawn  up  to  the  level  of  that  of  the  ulna,  than  which  it  is  notably 
lower  in  the  normal  state  of  things."  How  this  was  done,  he  does  not  say; 
but  it  seems  to  me  to  be  best  explained  by  the  action  of  the  supinator  longus. 

In  treatinq  these  injuries,  two  objects  are  to  be  especially  aimed  at  :  to  place 
nnd  keep  the  fragments  in  their  normal  relation  as  to  their  axes,  and  to  main- 
tain the  inter-osseous  space.  Lonsdale,  long  ago,  urged  the  importance  of  the 
former  point,  but  I  think  that  some  later  writers  have  in  great  measure  lost 
sight  of  his  views,  and  have  given  attention  too  exclusively  to  keeping  the 

^^PeAapsltTs  not  making  too  sweeping  a  statement  to  say,  that  in  all  frac- 
tures above  the  middle  of  the  bone  the  forearm  should  be  supmated  while  m 
all  below  that  point  the  semiprone  posture  is  preferable.  For  m  the  tormer 
case  we  want,  to  use  Lonsdale's  words,  "to  place  the  hand  and  forearm  in 
such  a  position,  that  the  lower  portion  of  the  bone  may  be  supmated  to  the 
same  eltent  as  the  upper;"  but  in  the  latter  the  condition  of  supination  ot 
the  upper  fragment  does  not  exist.  .      „  ,  ,  . 

In  any  fracture  of  the  radius,  then,  above  the  msertion  of  the  pronator  teres, 
I  should  advise  the  use  of  an  anterior  angular  splint  of  wood,  carefully  padded; 
and  on  the  dorsal  (in  this  case  the  lower)  surface  ot  the  forearm  I  should 
place  a  narrow  slip  of  wood,  padded  so  as  to  act  as  a  compress  to  f^^V^'^^ 
maintain  the  interosseous  space.    The  angle  of  the  splint  may  be  about  90  , 
Ta  little  less  if  the  upper  fragment  of  the  hone  tends  to  be  strongly  tilted 
np    K  the  action  of  the  supinator  longus  muscle,  drawing  the  styloid  pro- 
cess of  the  radius  upward,  toward  the  elbow,  be  very  marked  it  may  be  wel 
to  apply  slight  but  steady  extension  of  the  hand  toward  the  ulnar  side; 
meaT o^f  dofng  this  will  readily  suggest  themselves    The  best  plan  in  my 
^pinion  would  be  to  put  on  the  hand  a  glove,  with  the  fingers  removed,  and 
wTthtapr  sewed  toit  by  means  of  which  it  could  be  tied  to  the  corner  of 
ihe  splint;  or  they  could  be  brought  up  over  a  notch  at  that  point,  to  be 
fastened  on  the  upper  surface  of  the  board.    To  make  this  dressing  effective, 
the  lower  part  of  the  forearm,  just  above  the  wrist,  must  be  steadied  on  the 
ulnar  side  -  which  may  be  done  by  means  of  a  wide  loop  of  adhesive  plaster, 
both  ends  of  which  may  be  brought  to  the  outside  of  the  splint,  on  its  upper 
or  palmar  surface,  and  there  fastened.  .       ^  ^    ^  +1,^ 

When  the  radius  is  broken  below  the  insertion  of  the  pronator  teres,  the 
best  appliance  is  an  internal  angular  splint  reaching  from  the  upper  part  of 
the  arm  to  the  ends  of  the  fingers,  and  with  the  part  correspondmg  to  the 
hand  so  shaped  as  to  draw  the  hand  somewhat  strong  y  downward,  or  toward 
the  ulnar  side.  The  forearm-part  of  this  splint  should  be  carefully  and  firmly 
pMded  along  the  middle,  especially  toward  the  wrist;  and  a  similarly  padded 
dorXJuntf  but  much  narrower,  should  be  laid  along  the  back  of  the  fore- 

"Tefore  applying  the  splints  in  any  case,  the  fragments  should  be  carefully 
resto  ed  to'^heir  normal  relation,  and  so  held  until  the  dressing  is  complete. 
The  banda-ing  should  be  done  with  the  utmost  care,_snugly,  but  not  tightW  ; 
and  the  su?gefn  will  do  well  to  remember  that  he  is  dealing  with  a  part  in 
which  ganfrene  has  repeatedly  been  induced  by  neglect  or  want  of  skill  in 
rppTyinI  apparatus.  Frequent  inspections  should  be  made,  and  the  state  of 
circulation  in  the  fingers  watched;  upon  the  slightest  appearance  of  con- 
gestion, or  complaint  of  undue  pressure,  the  limb  should  be  stripped  and  the 
dressing  reapplied,  with  such  modification  as  may  seem  to  be  demanded. 
Within  three  or  four  days  it  may  be  expected  that  the  swelling  will  sub- 

I  Atlas,  PI.  IX.    Fig.  5.    Translation,  Fig.  50. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


165 


fiide,  and  that  the  bandages  will  become  inefficient;  but  in  removing  them  care 
should  be  taken  not  to  allow  of  any  displacement  of  the  broken  bone. 

Compound  fractures  of  the  radius  in  its  shaft  may  of  course  occur ;  but  I  do 
not  remember  to  have  ever  seen  one,  except  from  gunshot  wound,  and  there 
are  no  special  points  which  require  comment  in  regard  to  the  i)henomena  or 
treatment  of  such  a  case. 

Fractures  of  ;rHE  lower  portion  of  the  radius  are  among  the  most  com- 
mon of  accidents,  and  must  always  have  been  so ;  yet  it  was  not  until  the 
present  century  that  they  were  distinctly  recognized  and  accurately  described. 
The  history  of  the  development  of  our  present  knowledge  of  these  injuries 
is  so  curious  us  to  merit  some  notice. 

^  PoLiteaui  had  thrown  out  the  idea  that  fractures  of  the  radius  in  the  vici- 
nity of  the  wrist,  caused  by  falls  on  the  hand,  Avere  "  generally  mistaken  for 
sprains,^  for  incomplete  luxations,  or  for  separations  between  the  ulna  and 
radius but  the  statement  seems  to  have  attracted  no  attention  at  the  time. 
The  same  view  was  promulgated  by  Desault  f  but  to  Colles,^  of  Dublin,  is 
due  the  credit  of  having  given  the  first  clear  and  practical  account  of  these  in- 
juries and  of  their  distinctive  features.  Dupuytren,^  Goyrand,^  Diday,^  and 
Voillenner,7  realized  the  importance  of  the  fracture  in  question,  althouo-h 
none  _ot  them  seem  to  have  been  aware  of  Colles's  paper ;  and  the  same  may 
be  said  of  Kelaton  and  Malgaigne.  Even  Sir  Astley  Cooper  makes  no  men- 
tion of  Colles's  name,  and  Fergusson  barely  alludes  to  his  bavins:  written  on 
the  subject.  In  fact,  this  first  real  investi2:ator  of  the  matter  would  seem  to 
have  been  forgotten  until  Prof.  R.  W.  Smtth  of  Dublin,  in  his  very  valuable 
work,8  accorded  him  the  credit  to  Avhich  he  was  so  justly  entitled.  At  pre- 
sent, the  name  "  Colles's  fracture"  is  generally  recognized  by  surgical  writers, 
and  employed  to  designate  fractures  of  the  radius  close  to  the  wrist,  even  if 
not  corresponding  exactly  to  the  description  Avhich  Colles  gave.  Prof.  Gor- 
don, ot  Belfast,  has  published^  some  researches  which  have  shed  further  light 
upon  the  mechanism  of  these  fractures,  as  well  as  upon  their  treatment ;  his 
views  have  found  confirmation  in  some  interesting  cases  recorded  by  Cameron 
ot  Glasgow.  ^»  ' 

In  the  United  States,  attention  Avas  first  draAvn  to  the  subject  by  Dr.  John 
Khea  Barton,"  of  Philadelphia ;  his  views  Avere  based  upon  clinical  observa- 
tion only,  and  not  upon  anatomical  facts,  yet  they  w^ere  ingenious  and  Avell 
stated,  and  found  extensive  acceptance  among  the  surgeons  of  this  country. 

After  this,  no  separate  original  American  paper  on  this  topic  appeared  for 
over  thirty  years,  until  Prof.  Moore,!^  of  Rochester,  advanced  the  opinion  that 
the  fracture  of  the  radius  was  a  less  important  lesion  than  the  luxation  of 
the  lower  end  of  the  ulna,  Avhich  certainly  is  often  a  marked  feature  of  these 
cases,  and  suggested  a  plan  of  treatment  based  upon  this  vicAv. 

»  (Euvres  Posthumes,  tome  ii.  p.  251.    Paris,  1783. 
2  (Euvres  Chirurgicales,  tome  i.  p.  155.    Paris,  1813. 
«  Edinburgh  Med,  and  Surg.  Journal,  April,  1814. 

S''^^^'',  l^^-  ^^1^^°^^  the  Injuries  and 

Dise^ases  of  Bones"  (Sydenham  Society,  1847),  which  consists  of  selections  from  the  above-named 

«  Gazette  Medicale,  1832,  and  Journal  Hebdomadaire,  1836. 
«  Arch.  Gen.  de  Medecine,  1837. 

Ibid.  1842  ;  article  republished  in  his  Clinique  Chirurgicale,  Paris,  1862. 

A  Treatise  on  Fractures  in  the  Vicinity  of  Joints,  etc.    Dublin  and  New  York,  1854.  (The 
preface  to  this  work  is  dated  1847.)  ^ 
m^?"^®^^^^®      Fractures  of  the  Lower  End  of  the  Radius,  etc.    London,  1875. 
^  ^lasgow  Med.  Journal,  March,  1878.  ii  Med.  Examiner,  1838. 

«  Iransactions  of  the  Med.  Society  of  the  State  of  New  York,  1870. 


166 


INJURIES  OF  BONES. 


Another  essay  which  has  attracted  much  attention,  and  which  has  shed 
additional  light  upon  the  mechanism  and  pathology  of  these  lesions,  has 
been  published  by  Pilcher,i  Brooklyn.  I  may  perhaps  mention  also  a 
paper  of  my  own,  read  before  the  surgical  section  of  the  American  Medical 
Association,  in  1878,^  the  views  contained  in  which  will  be  presented,  together 
with  those  of  the  authors  previously  named,  in  the  following  pages.^ 

The  brief  sketch  now  given  is  that  of  a  very  great  and  important  change 
in  professional  opinion.  Luxations  of  the  wrist,  which  were  fornierly  sup- 
posed to  be  of  very  common  occurrence,  and  described  in  (Retail,  in  at  least 
four  varieties,  have  been  relegated  to  a  place  among  the  rarest  lesions  ;  while 
fractures  of  the  lower  portion  of  the  radius  are  recognized  as  of  extreme 

frequency.  n-  l- 

A  careful  study  of  the  shape  of  the  bone  will  render  the  study  of  its  fractures 
much  easier.  In  speaking  of  it,  it  will  be  supposed  that  the  hand  is  hang- 
ino-  by  the  side,  with  the  palm  looking  forward,  so  that  the  anterior  surface 
is  the  palmar  and  the  posterior  the  dorsal,  that  the  inner  edge  is  the  ulnar, 
and  that  the  carpal  articulating  surface  is  downward.  Adduction  is  bending 
the  wrist  so  as  to  bring  the  band  toward  the  median  line,  or  the  side  of  the 
little  finger,  abduction  bringing  it  toward  the  outer  or  thumb-side ;  in  the 
former  case,  the  angle  on  the  ulnar  side,  between  the  hand  and  forearm,  and 
in  the  latter,  that  on  the  radial  side,  is  rendered  more  acute.  Points  to  be 
noted  are  the  projection  of  the  radial  styloid  process,  and  the  fact  that  it  is 
normally  at  a  lower  level  than  that  of  the  ulna  ;  the  sudden  swell  of  the  bone 
dow^nward,  just  above  the  joint,  so  that  there  is  an  enlarged  portion,  as  com- 
pared with  the  shaft,  somewhat  irregularly  cubical  in  shape  ;  and  the  forward 
curve  of  the  anterior  wall  of  the  bone,  making  a  decided  concavity  in  its 
outline  if  looked  at  from  either  side.  This  conformation  is  sometimes  more 
and  sometimes  less  marked.  The  fact  that  the  most  frequent  cause  of  frac- 
ture of  the  radius,  low  down,  is  falling  on  the  palm  of  the  hand,  may  readily 
be  seen  to  explain  its  comparative  infrequency  in  childhood,  as  the  weight  is 
smaller  and  the  leverage  less  than  in  similar  accidents  in  the  adult.  In 
youth,  epiphyseal  separations,  although  not  often  met  with,  are  not  unknown; 
and  at  all  later  periods  of  life  the  bone  gives  way  with  great  readiness. 
Both  sexes  are  alike  liable  to  these  injuries. 

As  already  said,  in  a  vast  majority  of  the  cases  the  cause  is  a  fall  on  the 
palm  of  the*'  hand ;  in  a  few,  however,  the  back  of  the  hand  comes  to  the 
ground,  and  the  difference  in  the  effect  produced  is  of  no  small  importance, 
as  I  shall  try  to  show  hereafter.  Direct  violence  is,  I  think,  still  more  rarely 
assignable  as  a  cause ;  Malgaigne  quotes  one  case  from  Hublier,  in  which  a 
young  girl,  whose  wrist  had  been  caught  between  a  carriage-pole  and  a  wall, 
had  a  transverse  fracture  of  the  lower  part  of  the  radius,  the  lower  fragment 
being  also  split  vertically  into  two  parts. 

Authors  have  expressed  very  divergent  views  as  to  the  lines  of  these  fractures. 
Without  quoting  these  at  length,  I  may  merely  say  that  the  practical  result  of 
the  examination  of  cases  and  specimens  seems  to  me  to  be  that  the  lines  of 
breakage  are  almost  infinitely  various.  Sometimes  the  bone  gives  way  almost 
exactly  transversely,  the  fragments  being,  however,  serrated  or  notched  ;  some- 
times the  fracture  is  oblique  from  before  backward,  or  from  within  outward, 
or  part  of  it  may  run  in  one  direction  and  part  in  another.  Sometimes  the 
separation  takes  place  very  close  to  the  joint,  sometimes  farther  from  it. 

>  Trans-actions  of  the  Med.  Society  of  the  County  of  Kings,  March,  1878. 
2  Puhlished  in  the  Am.  Journal  of  the  Med.  Sciences,  Jan.  1879. 

8  The  reader  will  of  course  understand  that  the  above  list  is  not  intended  to  embrace  all  that 
has  been  written  on  the  subject,  which  has  been  of  course  dealt  with  in  systematic  works,  as 
well  as  in  short  articles  containing  reports  of  cases,  suggestions  in  regard  to  treatment,  etc. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


167 


Sometimes  the  lower  fragment  is  split  or  fissured  in  various  directions,  so  as 
to  constitute  two  or  more  fragments  of  very  irregular  size  and  shape.  Occa- 
sionally the  fracture  begins  at  the  articular  surface,  and  runs  up  into  the 
substance  of  the  bone  to  a  greater  or  less  distance  ;  of  this  a  notable  example 
exists  in  the  Warren  Museum,^  and  another  is  mentioned  by  Dupuytren.^ 
In  another  specimen^  in  the  Warren  Museum,  there  is  a  double  fracture,  the 
result  of  direct  violence ;  it  is  described  as  "  comminuted  fracture  of  the 
lower  end  of  the  radius,  just  above,  and  into  the  joint,  and  a  second  fracture, 
two  and  a  half  inches  above  the  joint."  Dupuytren^  records  another  case,  in 
which  a  woman,  aged  sixty-two,  having  rolled  down  about  sixty  steps,  had 
"  one  fracture  about  an  inch  above  the  joint,  and  the  other  an  inch  and  a  half 
higher  up.  The  ulna,  which  was  dislocated  inward,  protruded  to  the  extent 
of  more  than  an  inch  through  the  skin."^  The  Museum  of  the  iS'ew  York 
Hospital  contains  a  specimen^  described  as  a  fracture  of  the  lower  end  of  the 
radius  "  obliquely  upward  and  backward,  from  within  a  quarter  of  an  inch 
of  the  palmar  edge  of  the  carpal  joint.  The  fracture  was  transverse  and 
incomplete ;  for  a  long  narrow^  fragment  passing  up  from  the  styloid  process 
was  still  continuous  with  the  shaft.  This  connecting  bony  bridge  was 
slightly  bent  so  as  to  permit  the  articular  surface  of  the  radius  to  be  slightly 
rotated  tow^ard  the  dorsal  surface  of  the  forearm."  In  the  other  foi-earm 
there  was  extensive  comminution  of  the  radius  for  the  space  of  two  inches, 
and  the  shaft  is  seen  to  be  invaded  by  a  longitudinal  fissure  running  up 
from  the  fractured  surface." 

Occasionally  there  is  a  separation  of  a  lateral  portion  of  the  articular 
extremity.  A  number  of  instances  are  on  record  in  which  the  styloid  pro- 
cess has  been  thus  broken  off.  Such  a  specimen  exists  in  the  Wistar  and 
Horner  Museum,  and  another  in  the  Warren  Museum  ;7  Callender^  speaks  of 
two  in  museums  in  London,  and  Hamilton  thinks  that  he  has  made  out  the 
lesion  twice  in  the  living  subject.  One  curious  case  is  recorded  by  Butler,^ 
in  which  a  boy  of  fourteen,  by  a  fall  from  a  height  of  thirty  feet,  had  the 
styloid  process  broken  off  and  drawn  upward  an  inch  and  a  half,  where  it 
became  firmly  united. 

In  the  IsTew  York  Hospital  Museum  there  is  a  specimen^<^  in  which  "  the 
only  fracture  of  the  radius  consists  in  a  chipping  ofi"  of  a  small  portion  of 
the  lower  extremity,  so  as  to  separate  the  articular  facet  for  the  ulna  from  the 
rest  of  the  bone.  One  of  the  carpal  bones  is  also  broken."  It  is  difficult  to 
entertain  any  other  theory  of  the  mechanism  of  this  lesion  than  that  of  direct 
violence. 

Gross^^  records  the  following:  "In  the  case  of  a  young  man  whom  I 
attended  along  with  Dr.  Chenowith,  the  lower  extremity  ot"  the  radius  was 
split  in  two  by  a  transverse  and  an  oblique  fissure,  the  larger  fragment  being 

i  Catalogue,  p.  174,  No.  1035.  2  injuries  and  Diseases  of  Bones,  p.  126. 

»  Catalogue,  p.  174,  No.  1038.  «  Op.  cit.,  p.  127. 

6  I  am  tempted  to  refer  here  to  an  instance  reported  by  Mr.  Godlee  (Med.  Times  and  Gazette, 
1883),  in  wtiich  a  man,  aged  twenty,  by  a  fall  backward  on  his  hands,  sustained  a  compound 
fracture  of  the  left  radius  at  the  junction  of  the  middle  and  lower  thirds,  with  displacement  for- 
ward of  the  lower  end  of  the  ulna,  which  projected  beneatli  the  skin.  "An  incision  was  made 
and  the  tendon  of  the  flexor  carpi  ulnaris,  which  had  slipped  behind  the  bone,  was  raised  up 
with  a  blunt  hook  ;  but  the  ulna  could  not  be  replaced  until  first  the  styloid  process  and  then 
the  end  of  the  bone  had  been  sawed  off."  The  mechanism  of  tliis  injury  seems  to  me  to  have 
been  clearly  the  same  as  that  in  Dupuytren's  case  above  mentioned,  in  which  the  removal  of  the 
end  of  the  ulna  was  also  practised,  but  not  with  so  complete  a  restoration  of  the  functions  of  the 
limb. 

6  Catalogue,  p.  80,  No.  130. 

'  No.  4631.    (Mentioned  in  a  letter  from  Dr.  Hodges.) 

8  St.  Bartholomew's  Hospital  Reports,  1865.  »  New  York  Medical  Journal,  1867. 

10  Catalogue,  p.  79,  No.  128.  »  Op.  cit.,  vol.  i.  p.  970. 


168 


INJURIES  OF  BONES. 


completely  detached  and  thrown  inward  and  forward  over  the  ulna,  whence, 
as  it  w-as  impossible  to  replace  it,  I  removed  it  by  incision.  A  good  reco- 
very took  place,  with  hardly  any  impairment  of  the  functions  of  the  wrist- 
joint." 

From  what  has  been  said,  it  is  evident  that  the  widest  variety  has  been 
observed  in  the  lines  of  breakage  in  the  neighborhood  of  the  wrist.  Yet  it 
is  none  the  less  true  that  in  the  vast  majority  of  cases  the  lower  end  of  the 
radius  is  fractured  in  a  direction  more  or  less  transverse,  and  that  the  defor- 
mity produced  is  nearly  the  same  in  all. 

Mention  has  already  been  made  of  the  fracture  theoretically  described  by 
Barton ;  and  as  his  paper,  the  first  one  published  on  this  special  subject  in 
America,  had  for  a  time  a  good  deal  of  influence  on  professional  opinion,  it 
may  be  well  to  explain  briefly  what  his  views  were.  He  says  that  in  the 
act  of  falling  "  the  hand  is  instinctively  thrown  out,  and  the  force  of  the  fall 
is  first  met  by  the  palm  of  the  hand,  which  is  violently  bent  back^vard  until 
the  bones  of  the  wrist  are  driven  against  the  dorsal  edge  of  the  articulating 
surface  of  the  radius,  which,  being  unable  to  resist,  gives  way.  A  fragment 
is  thus  broken  off  from  the  margin  of  the  articular  surface  of  this  bone,  and 
is  carried  up  before  the  carpal  bones  and  rested  upon  the  dorsal  surface  of 
the  radius ;  they  having  been  forced  from  their  position  either  by  the  vio- 
lence or  by  the  contraction  of  the  muscles  alone."  Again,  he  says:  "It 
sometimes  happens,  also,  though  rarely,  that  fracture  of  a  similar  character 
to  the  one  first  described  occurs  on  the  palmar  side  of  the  radius,  from  the 
application  of  force  against  the  back  of  the  hand  while  it  is  bent  forward  to 
its  ultimate  degree." 

In  the  forty-five  years  which  have  elapsed  since  the  publication  of  these 
views,  there  has  not  been,  as  far  as  I  have  been  able  to  ascertain,^  a  single 
instance  placed  on  record  in  which  they  have  been  confirmed  by  dissection. 
Voillemier^  quotes  one  case  from  Lenoir,  which  may  have  been  of  this  cha- 
racter, but  is  open  to  doubt ;  and  in  most  cases  of  comminution  of  the  lower 
fragment,  the  dorsal  portion  has  been  broken  ofl".  But  although  a  detached 
piece  might  be  carried  up  before  the  carpal  bones,  there  would  not  be,  as  he 
says,  "  on  the  palmar  side  a  prominence  w^hich  is  round  and  smooth,  and 
difiering  in  this  from  similar  projections  formed  by  the  fractured  ends  of 
bones."^  'Nor  is  it.  likely  that,  from  a  fracture  merely  of  the  posterior  lip  of 
the  articulating  surface  of  the  radius,  treated  with  ordinary  skill  or  care, 
such  bad  results  would  often  ensue  as  Barton  enumerates :  "  A  crooked  arm, 
deformities,  rigid  joints,  infiexible  fingers,  loss  of  the  pronating  and  supi- 
nating  motions."  Yet  consequences  like  these  are  frequently  seen  to  follow 
the  fractures  just  above  the  wrist. 

Fractures  presenting  such  various  conditions  must,  of  course,  be  due  to 
equally  various  mechanisms,  is'evertheless,  the  vast  majority  of  cases  must 
be  ascribed,  I  think,  to  the  "  cross-breaking  strain"  produced  by  over-extension 
of  the  wrist,  as  maintained  by  Callender,  Gordon,  and  Pilcher.  In  other 
words,  the  hand  being  forced  backward,  an  immense  tension  is  put  upon  the 
anterior  carpal  ligament,  and  thus  a  leverage  is  exerted  upon  the  lower  end 
of  the  bone,  beyond  the  resisting  power  of  its  structure.  First  the  palmar 
wall  gives  way,  then  the  columns  or  lamellse  in  succession,  and  finally,  the 
dorsal  wall. 

When  the  fall  takes  place  on  the  back  of  the  hand,  the  bone  gives  way  in 
like  manner,  but  in  a  reverse  direction ;  the  mechanism  is  the  same.  That 


1  Archives  Generales  de  Medecine,  Dec.  1839. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


169 


this  occurs,  I  think  there  is  ample  evidence,  although  it  has  been  doubted 
by  some  writers. 

Fractures  of  the  lateral  margins  of  the  articulating  surface  are  less  easily 
explained,  but  may  be  due  to  the  sudden  force  brought  to  bear  by  violent 
contact  of  the  carpal  bones,  and  the  same  may  be  said  of  the  rare  instances 
of  "  stellate  cracks." 

Upon  the  occurrence  of  transverse  fracture  in  the  way  above  stated,  the 
area  of  the  end  of  the  upper  fragment  is  less  than  that  of  the  opposed  surface 
of  the  lower ;  and  the  force  continuing  to  act,  the  former  is  driven  down  into 
the  cancellous  tissue  of  the  latter,  and  may  split  or  burst  it  into  several  lesser 
fragments,  thus  comminuting  it.  Or,  if  this  splitting  does  not  take  place, 
the  compact  wall  may  penetrate  the  spongy  texture  of  the  lower  fragment, 
constituting  an  impaction.  Experiments  on  the  dead  subject  have  been 
many  times  made  by  difterent  observers,  and  always  with  the  same  general 
result,  in  support  of  the  above  statements. 

With  regard  to  the  occurrence  of  impaction,  writers  have  been  greatly  at 
variance.  Gordon  says  that  in  Colles's  fracture  it  is  impossible.  Callender 
says  that  thirty-six  specimens  in  the  various  museums  in  London  show  de- 
formity in  all  clearly  due  to  "  the  impaction  of  the  proximal  into  the  distal 
end  of  the  bone."  Yoillemier  thought  the  impaction  so  marked  a  feature  of 
the  injury  that  he  would  rank  it  among  what  he  calls  "  fractures  by  penetra- 
tion." R.  W.  Smith  argues  that  the  appearances  which  led  Voillemier  to 
this  opinion  were  due  to  deposits  of  new  bone.  This  question  seems  to  me 
to  have  been  discussed  at  greater  length  and  with  more  zeal  than  its  import- 
ance really  warrants.  It  cannot  be  settled  upon  the  evidence  of  specimens  of 
old  and  long-healed  fractures  alone,  but  lesions  of  recent  date  must  be  examined 
also  ;  and  from  both  together  I  think  the  conclusion  is  unavoidable  that  impac- 
tion occurs  in  some  cases,  while  in  others  it  is  wanting.  Deposits  of  new  bone 
may  undoubtedly  take  place  in  some  cases,  simulating  impaction,  or  increasing 
its  apparent  extent. 

Probably  the  experience  of  most  surgeons  will  confirm  the  statement  of 
Pilcher,  that  a  fall  on  the  palm  of  the  hand  may  be  productive  of  a  mere 
strain  of  the  ligamentous  structures,  of  bruising  or  even  of  Assuring  of  the 
hone,  or  of  actual  fracture  with  separation,  according  to  the  grade  of  the  force 
brought  to  bear  in  over-extension  of  the  hand. 

The  symptoms  of  this  fracture  are,  as  a  general  rule,  very  decided.  There  is 
great  pain,  and  instant  helplessness  of  the  hand ;  the  wrist  is  almost  always 
deformed  in  a  marked  degree,  and  often  both  preternatural  mobility  and 
crepitus  are  present.  Swelling  comes  on  very  rapidly,  and,  in  some  cases, 
there  is  ecchymosis,  although,  by  reason  of  the  thickness  of  the  skin  of  the 
palm,  this  is  not  as  apt  to  occur  as  in  fractures  in  most  other  regions. 

The  deformity  requires  special  mention.  It  is  such  as  might  be  expected 
from  the  bending  backward  of  the  lower  extremity  of  the  radius ;  the  back 
of  the  wrist  is  humped  up,  and  there  is  a  corresponding  depression  at  the 
palmar  side,  with  a  sort  of  creasing  of  the  skin.  Sometimes  the  dorsal 
prominence  is  distinctly  greater  at  the  radial  side,  the  part  having  a  twisted 
appearance.  By  Velpeau  the  deformity  was  said  to  resemble  the  back  of  a 
silver  fork,  and  the  comparison  is  not  an  inapt  one.  Taken  together  with 
the  pain  and  loss  of  power  in  the  hand,  it  is  often  in  itself  conclusive  as  to 
the  nature  of  the  injury. 

Preternatural  mobility  may  usually  be  detected  by  grasping  the  patient's 
hand  (as  if  in  shaking  hands),  and  taking  hold  of  the  forearm ;  then  flexing 
and  extending  the  Avrist.  B}^  the  same  manoeuvre  crepitus  is  apt  to  be 
elicited,  but  it  may  be  very  slight.  In  the  case  of  decided  impaction,  both 
of  these  symptoms  may  be  but  slightly  marked  ;  when  they  are  very  readily 


170 


INJURIES  OF  BONES. 


perceived,  there  is  reason  to  suspect  comminution.  Maisonneuve^  records  the 
following  case :  A  woman,  aged  seventy,  fell,  striking  the  palm^  of  her  right 
hand.  She  had  instantly  great  pain  and  tenderness  of  the  wrist,  and  com- 
plete loss  of  power  in  the  hand,  which  hecame  swollen ;  but  there  was  no 
deformity  nor  crepitus.  If,  however,  the  hand  was  strongly  extended,  there 
was  perceptible  a  yielding  of  the  radius  about  an  inch  above  the  joint.  She 
died  on  the  fourteenth  day,  and  the  diagnosis  of  fracture  was  verified ;  but 
the  periosteum  on  the  dorsal  face  of  the  bone  was  nntorn.  The  styloid  pro- 
cess of  the  ulna  had  been  wrenched  off,  and  was  adherent  to  the  internal 
lateral  ligament. 

Besides  the  silver-fork"  deformity,  there  is  in  these  cases  an  abduction  of 
the  hand,  so  that  its  radial  border  forms  with  that  of  the  forearm  an  entering 
angle,  and  the  ulna  projects  strongly  on  the  other  side  of  the  wrist.  This  is 
due  largely  to  the  fracturing  force,  the  hand  being  stopped  while  the  weight 
of  the  body  continues  to  drive  the  upper  fragment  downward  and  forward, 
and  thus  to  push  it  into  the  cancellous  tissue  of  the  lower.  It  is  easy  to  see 
that  in  the  majority  of  cases  the  impact  comes  chiefly  upon  the  radial  side  of 
the  palm,  in  falls  upon  the  hand,  and  hence  that  the  penetration  of  the  lower 
by  the  upper  fragment  would  naturally  be  greater  on  that  side.  But  this  is 
in  fact  a  shortening  of  the  forearm  on  this  margin  by  a  change  in  the  posi- 
tion and  plane  of  the  lower  articulating  surface  of  the  radius,  and  the  angle 
of  the  hand  with  the  forearm  must  be  correspondingly  changed.  The  ulna 
does  not  move ;  it  cannot,  by  reason  of  its  very  close  articulation  with  the 
humerus  above.  Hence,  it  seems  to  me  incorrect  to  speak  of  luxation  of  the 
ulna  as  an  element  of  this  lesion ;  it  is  the  hand  which,  with  the  low^er  frag- 
ment of  the  radius,  assumes  a  new  position  with  regard  to  that  bone.  And 
in  strictness  the  ulna  should  not  be  said  to  project,  although  the  expression 
may  be  retained  as  a  matter  of  convenience. 

Perhaps  I  may  best  speak  here  of  the  views  of  Prof.  Moore,  of  Rochester, 
who  maintains  that  "  luxation  of  the  ulna"  is  the  key  to  the  pathology  and 
treatment  of  the  lesion  in  these  cases.  It  has  been  already  stated  that  there 
is  often  a  twisting  of  the  wrist  along  with  the  mere  over-extension  which 
breaks  the  radius,  and  when  the  change  of  angle  between  the  hand. and  fore- 
arm, just  spoken  of,  takes  place,  there  must  of  necessity  be  also  a  change  in 
the  relations  between  the  carpal  bones  and  the  lower  end  of  the  ulna.  And 
by  entanglement  in  the  annular  ligament  or  a  tendon  (generally,  I  think,  that 
of  the  extensor  carpi  ulnaris),  the  correction  of  this  latter  displacement  may 
be  rendered  very  diflacult.  Admitting,  however,  that  such  a  state  of  things 
exists,  as  claimed  by  Prof.  Moore,  in  one-half  of  the  cases,  it  seems  to  me 
that  its  absence  in  the  other  half  certainly  makes  it  secondary  to  the  lesion 
which  is  always  present.  With  all  deference  to  his  learning  and  practical 
ability,  I  am  myself  unable  to  accept  his  theory,  to  which  I  believe  the  above 
statement  does  justice  ;  of  the  treatment  based  upon  it,  which  has  some  great 
merits,  more  will  be  said  presently. 

It  has  been  already  stated  that  swelling  takes  place  very  rapidly  after  frac- 
ture in  this  region.  When  the  lesion  involves  the  articular  surface,  or  in 
other  words  enters  the  joint,  there  is  copious  effusion  into  this  cavity,  and 
active  inflammation  may  be  set  up.  And  in  any  case  the  sheaths  of  the  ten- 
dons are  thus  distended ;  besides  which,  although  at  a  somewhat  later  stage, 
the  subcutaneous  areolar  tissue  becomes  the  seat  of  lymphization,  and  some- 
times, especially  in  feeble  or  aged  persons,  of  oedematous  fulneSs. 

Simultaneous  fracture  of  both  radii  near  their  lower  extremities  has  been 
observed  in  many  instances,  the  reason  of  its  frequency  being  obvious. 


1  Clinique  Chirurgicale,  tome  i.  p.  164. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


171 


i^'othiiig  special  iiee<l  be  said  in  regard  to  it,  as  each  lesion  is  as  independent 
of  the  other  as  if  the  limbs  belonged  to  different  bodies. 

Co7n pound  fracture  is  very  rare  in  this  region;  except  in  gunshot  injuries, 
or  in  railroiid  or  machinery  accidents,  indeed,  I  do  not  know  that  it  is  ever 
seen.  The  neighboring  bones  and  soft  parts  would  in  such  a  case  be  likely 
to  be  also  involved,  and  the  sum  of  the  injur^^  would  be  great  enough  to 
demand  amputation.  In  a  number  of  instances  recorded  by  Hamilton  and 
others,  the  lower  extremity  of  the  ulna  has  been  driven  through  the  skin, 
having  had  the  carpus  torn  away  from  it  along  with  the  distal  fragment  of 
the  radius;  but  here  the  fracture  is  still  a  simple  one,  and  the  lesion  just 
mentioned  is  a  complication  only. 

Bryant^  mentions  a  very  curious  complication,  produced  by  a  fall  from  a 
height,  in  a  man  aged  thirty.  "  There  was  an  impacted  Colles's  fracture  of 
the  right  radius,  and  a  vertical  fracture  of  the  head  of  the  same  bone  into 
the  joint."  A  much  more  common  complication,  especially  apt  to  occur  in 
cases  due  to  direct  violence,  is  fracture  of  one  or  more  of  the  carpal  bones, 
the  scaphoid  and  semilunar  being  those  oftenest  affected. 

Epiphyseal  separations  of  the  lower  end  of  the  radius  have  been  spoken  of 
by  some  authors  f  but  they  do  not  present  any  special  features  as  compared 
with  ordinary  fractures  in  this  region. 

When,  as  happens  in  a  small  proportion  of  the  cases,  the  fracture  is  the 
result  of  a  fall  on  the  back  of  the  hand,  the  distal  fragment  is  driven  forward, 
so  that ^ the  articulating  surface  looks  toward  the  palmar  instead  of  toward 
the  dorsal  aspect  of  the  limb.  The  leverage  is  then  exerted  in  the  direction 
of  flexion,  and  not  of  extension,  and  the  hand  is  bent  forward,  so  that  in  the 
state  of  pronation  it  makes  an  angle  downward  with  the  forearm.  Of  this  I 
have  lately  seen  a  striking  instance,  which  will  be  further  spoken  of  in  con- 
nection with  the  subject  of  treatment. 

In  such  cases  the  symptoms  are  very  nearly  the  same  as  in  those  of  the 
ordinary  form  of  the  injury  before  detailed;  but  there  is  a  slight  difference 
in  the  character  of  the  deformity,  such  as  will  readily  be  understood.  The 
lower  fragment,  instead  of  rising  up  on  the  dorsal  surface,  drops  forward,  and 
the  "  silver-fork"  shape  of  the  wrist  is  much  less  distinct. 

The  course  of  these  cases  is  extreihely  variable.  Unfortunately,  an  oppor- 
tunity is  not  seldom  presented  of  seeing  the  results  of  treatment  so  inefficient 
as  to  amount  to  almost  nothing.  Often  the  deformity  is  uncorrected,  and  the 
patient  goes  through  life  with  the  w^rist  misshapen.  But  as  union  takes 
place,  and  as  the  irritation  in  the  sheaths  of  the  tendons  and  in  the  neighbor- 
ing soft  parts  subsides,  the  usefulness  of  the  limb  is  restored,  and  the  hand 
regains  its  strength,  except  for  actions  consisting  in  pushing,  and  such  as 
require  its  complete  flexion  on  the  forearm. 

When  the  force  has  acted  on  the  back  of  the  hand,  it  is  extension  that  is 
apt  to  be  thus  interfered  with,  and  the  member  acquires  a  claw-like  appear- 
ance, aggravated  in  one  case  which  has  come  under  my  notice  by  nerve-lesions, 
impairing  the  nutrition  of  the  part,  shrivelling  the  fingers,  and  totally  abolish- 
ing strength  and  freedom  of  motion. 

Under  proper  treatment,  however,  a  far  more  favorable  condition  of  things 
is  brought  about.  Union  generally  takes  place  readily,  and  if  the  fragments 
have  been  put  into  proper  apposition,  the  shape  and  strength  of  the  wrist,  as 
well  as  the  motions  of  the  part,  are  completel}'  restored. 

Between  these  two  extremes — union  with  great  deformity  and  union  with 
perfect  restoration  of  shape,  there  are  of  course  innumerable  gradations.  In 

*  Manual  for  the  Practice  of  Surgery,  2d  Am.  edition,  p.  788. 

*  Holmes,  Surgical  Treatment  of  Children's  Diseases,  p.  254 ;  R.  W.  Smith,  op.  cit.,  p.  165. 


172 


INJURIES  OF  BONES, 


the  majority  of  cases,  tlie  result  obtained  is  a  useful  hand,  with  perhaps  a 
degree  of  disfigurement  not  sufficient  to  be  a  serious  annoyance,  unless  the 
patient  be  a  woman  in  the  higher  walks  of  life.  A  city  surgeon  may  almost 
daily  see  the  most  laborious  occupations  pursued  by  persons  who  have  been 
the  subjects  of  this  fracture,  as  testified  to  by  the  unmistakable  distortion  of 
the  aftected  limb — the  projection  of  the  ulna,  the  abduction  of  the  hand, 
and  the  thickening  of  the  wrist. 

Anchylosis  of  the  joint  very  seldom  occurs  ;  a  fact  which  may  be  accounted' 
for  by  the  rarity  of  actual  involvement  of  the  articular  surface.  Even 
when  there  has  been  extreme  distension  of  the  tendinous  sheaths,  and  the 
stiffening  of  the  wrist  is  at  first  strongly  marked,  the  parts  ultimately  resume 
their  suppleness,  except  in  the  case  of  very  old,  feeble,  or  rheumatic  subjects. 
Barometric  pains  are  sometimes  complained  of  subsequently,  but  not,  I  think, 
as  often  as  after  most  other  fractures. 

The  diagnosis  of  these  fractures  does  not  generally  offer  very  much  diffi- 
culty. Luxations  of  the  wrist,  with  w^hich  they  would  be  most  likely  to  be 
confounded,  are  so  rare  as  practically  to  be  almost  excluded  from  considera- 
tion. One  case,  observed  by  Lenoir,  and  published  by  Voillemier,^  is  undis- 
puted, having  been  verified  by  dissection  after  the  patient's  death.  Another, 
mentioned  by  Hamilton,^  seems  to  me  to  be  beyond  doubt.  ITearly  fifty 
others  have  been  recorded  as  such,^  but  none  of  them  can  be  accepted  upon 
the  evidence  offered.  I  have  had  one  case  in  which  the  character  of  the 
deformity,  the  ease  of  complete  reduction,  and  the  speedy  resumption  of  the 
normal  condition  and  use  of  the  hand,  convinced  me  that  there  had  been  a 
luxation  of  the  carpus  backward ;  and  two  others  which  I  had  reason  to 
believe  were  of  that  nature,  but  in  regard  to  which  I  feel  less  positive. 

Admitting  that  luxation  can  occur,  it  is  of  course  desirable  that  the  dis- 
tinctive features  of  the  two  lesions  should  be  known,  so  far  as  they  can  be 
from  the  limited  facts  at  command. 

The  pain,  helplessness  of  the  hand,  and  deformity,  are  alike  in  both.  But 
on  examination,  instead  of  the  rough  and  irregular  edges  of  the  broken 
bone,  the  fingers  of  the  surgeon  will,  in  the  case  of  a  dislocation,  find  on  one 
side  the  smooth  concavity  of  the  articulating  ends  of  the  bones  of  the  fore- 
arm, and  on  the  other  the  rounded  convexity  formed  by  those  of  the  carpus. 
The  styloid  processes,  accoixling  to  Hamilton,  were  plainly  felt  in  his  case. 
Preternatural  mobility,  apt  to  be  present  in  fracture,  although  perhaps  in  but 
slight  degree,  will  be  wanting  in  dislocation,  and  so  also  will  crepitus.  Re- 
duction, often  very  difficult  in  fracture,  gradually  effected,  and  attended  with 
a  grating  sound,  is  easy,  sudden,  and  marked  by  a  click  or  snap,  in  luxation. 

The  only  other  lesion  with  which  fracture  could  be  confounded  is  a  severe 
sprain,  and  the  limits  between  these  injuries  are,  as  already  said,  very  ill  de- 
fined. It  seems  quite  possible  that  cases  are  not  very  rare  in  which  the  bone 
is  partially  broken  through,  and  that  sometimes,  when  the  bone  is  completely 
divided,  the  fragments  may  remain  in  contact,  the  fibrous  structures  being 
imtorn.  A  mistake,  however,  would,  under  such  circumstances,  be  really 
a  matter  of  no  moment. 

The  treatment  of  fracture  of  the  lower  end  of  the  radius  has  been  very  ex- 
tensively discussed,  and  different  surgeons  have  held  widely  different  views 

'  Archives  Generales  de  Merlecine,  Dec.  1839  ;  also  in  his  Clinique  Chirurgicale,  p.  120.  It 
may  also  be  found  in  R.  W.  Smith's  work  before  quoted. 

2  Practical  Treatise  on  Fractures  and  Dislocations,  p.  712. 

3  The  reader  who  wishes  to  follow  up  the  matter  can  fii'd  in  Malgaigne  (op.  cit.,  tome  ii.  p. 
681  et  ser/.),  and  in  a  valuable  prize  essay  by  Dr.  T.  K.  Cruse,  published  in  the  Transactions  of 
the  Med.  Society  of  the  State  of  New  York  for  1874,  the  references  to  these  reports.  I  am  at  a 
loss  to  account  for  the  want  of  correspondence  between  the  lists  given  by  these  two  authors. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


173 


as  to  the  best  means  of  accomplishing  the  indications,  which  in  themselves 
are  simple  enough— to  correct  the  malposition  of  the  fragments,  and  to  main- 
tain them  in  accurate  contact  until  union  shall  have  occurred. 

I  do  not  know  how  to  express  strongly  enough  my  conviction,  that  the 
great  reason  why  deformity  so  often  follows  fractures  of  the  radius  close  to 
the  wrist,  is  because  of  failure  to  carry  out  the  first  of  the  above  indications. 
Reduction  is  not  effected  at  all.  If  this  is  once  thoroughly  accomplished,  a 
^ood  result  can  be  obtained  with  almost  any  form  of  apparatus  fitted  to  the 
case  with  ordinary  skill  and  care.  If  it  is  not  properly  attended  to,  it  makes 
no  ditterence  how  elaborate  may  be  the  appliances  used,  the  deformity  will 
surely  become  permanent. 

Authors  have  ditiered  greatly  as  to  the  condition  of  such  fractures  with  re- 
o;ard  to  reducibility.  Callender  said,  that in  a  great  number  of  cases  the  im- 
paction so  fixes  the  fragments  that  they  cannot  be  unlocked,  and  the  deformity 
is  permanent."  CoUes,  on  the  other  hand,  said :  "  If  the  surgeon  lock  his 
hand  in  that  of  the  patient  and  make  extension,  even  with  moderate  force,  he 
restores  the  limb  to  its  natural  form  ;  but  the  distortion  of  the  limb  instantly 
returns  on  the  extension  being  removed."  Sir  A.  Cooper  thought  that  power- 
ful extension  was  required,  but  that  the  moment  it  was  relaxed  the  deformity 
recurred.  Moore  holds  that  if  the  head  of  the  ulna  is  disengaged  from  the 
annular  ligament  and  tendon  of  the  extensor  carpi  ulnaris,  the  whole  difia- 
culty  is  overcome.  Pilcher  regards  the  dorsal  periosteum  and  the  ligament 
between  the  cuneiform  bone  and  the  styloid  process  of  the  ulna,  the  former 
especially,  as  the  parts  at  fault. 

I  venture  to  suggest  that  each  of  these  practical  surgeons  could  have  cited 
cases  in  proof  of  his  special  views  ;  and  that,  in  fact,  the  conditions  met  with 
are  anything  but  uniform.  Therefore  I  think  it  vain  to  insist  on  any  one 
method  of  reduction  as  the  proper  one ;  each  case  is  to  be  studied  for  itself, 
and  such  manipulation  adopted  as  seems  to  promise  best.  Failing  this,  some 
other  plan  may  be  tried. 

Moore's  method  is  a  very  good  one :  he  grasps  the  prone  hand  of  the  patient 
with  one  hand,  the  forearm  with  the  other,  his  thumbs  being  applied  against 
the  head  of  the  ulna  so  as  to  act  as  a  sort  of  double  fulcrum.  I  have  once  or 
twice  succeeded  by  using  my  knee  as  a  fulcrum,  grasping  the  hand  and  frag- 
ment with  one  hand,  while  steadying  the  forearm  with  the  other.  Lonsdale^ 
says :  "  The  ends  of  the  bone  may  often  be  unlocked  by  suddenly  supinating 
the  arm  to  the  utmost." 

One  thing  seems  to  me  of  great  importance,  viz.,  to  act  as  much  as  possible 
directly  upon  the  fragments  themselves.  Too  often  extension  is  made  upon 
the  hand  alone ;  and  although  in  old  persons,  with  soft  or  brittle  bones,  such 
a  procedure  may  disengage  the  lower  fragment,  yet  in  others,  and  especially 
if  the  fracturing  force  have  been  severe,  and  if  the  upper  fragment  have 
been  strongly  driven  into  the  lower,  it  may  totally  fail.  By  such^  a  ma- 
noeuvre the  soft  parts  may  be  drawn  out  into  something  approaching  the 
normal  shape,  the  fragments  still  remaining  in  their  false  relation,  so  that 
no  real  good  is  efi:ected.  Often,  as  Hamilton  points  out,  the  ligaments  are 
torn.  The  circumduction  recommended  by  Moore  for  disentangling  the 
head  of  the  ulna  will  sometimes  free  the  lower  fragment  also. 

Precise  directions  cannot,  however,  be  given  for  every  case.  It  is  of  the 
utmost  consequence  that  the  surgeon  should  know  what  is  the  normal  form 
which  he  wishes  to  restore,  and  that  he  should  have  suflicient  ingenuity  and 
mechanical  dexterity  to  ascertain  and  overcome  whatever  difficulty  may 
exist  in  each  case,  as  far  as  it  is  possible  to  do  so. 


'  Op.  cit.,  p.  146. 


174 


INJURIES  OF  BONES. 


The  fragments  having  been  disengaged,  if  there  have  been  no  crashing  of 
the  cancellous  substance,  their  apposition  can  be  readily  maintained,  and  it 
will  be  found  that  the  articular  face  of  the  bone  has  resumed  its  natural  posi- 
tion, looking  slightly  toward  the  palmar  aspect  of  the  limb.  The  "silver- 
fork"  deformity  will  be  markedly  diminished,  although  it  may  be  that  swell- 
ing will  already  have  taken  place  to  such  an  extent  as  to  constitute  a  fulness 
on  the  dorsum  of  the  w^rist.  The  concavity  of  the  palmar  surface  of  the  radius 
will  be  restored,  and,  if  the  hand  be  placed  in  a  natural  position,  neither 
Hexed  nor  extended  u]3on  the  forearm,  the  ball  of  the  thumb  will  be  seen  to 
bulge  strongly  downward,  thus  apparently  increasing  the  concavity  just 
mentioned.  At  the  same  time  the  ulna  will  have  gone  back  into  its  proper 
place,  and  the  ulnar  edge  of  the  wrist  and  hand  will  make  with  it  a  slight 
entering  angle. 

It  must  be  remembered  that  if  there  have  been  crushing  of  tlie  substance  of 
either  fragment,,or  if  the  lower  one  be  comminuted,  this  complete  restoration 
may  be  impossible,  and  a  certain  amount  of  distortion  will  remain  in  spite  of 
the  surgeon's  best  directed  efforts.  When  such  is  the  case,  the  patient  should 
be  notified  that  he  has  to  expect  more  or  less  deformity  to  be  permanent. 

In  the  rare  cases  in  which  the  displacement  has  occurred  in  the  opposite 
direction,  namely,  w^ith  the  lower  fragment  bent  toward  the  palm,  the 
manoeuvres  must  be  modified  accordingly ;  the  details  wall  readily  suggest 
themselves. 

I  need  hardly  say  that  in  cases  which  present  any  degree  of  difficulty,  the 
surgeon's  task  will  be  rendered  much  easier  by  having  the  patient  in  a  state 
of  complete  anaesthesia. 

A  very  large  array  of  splints  has  been  devised  for  the  treatment  of  frac- 
tures of  the  lower  end  of  the  radius.  By  the  older  surgeons,  the  dorsal  and 
palmar  boards  were  employed,  with  pads  to  push  the  fragments  into  place. 
Dupuytren,  in  the  hope  of  correcting  the  projection  of  the  ulna  and  the  ab- 
duction of  the  hand,  applied  a  curved  bar.  along  the  ulnar  edge  of  the  forearm 
and  hand;  it  is  best  known,  perhaps,  by  its  French  name,  as  the  "  attelle 
cubitale."  The  same  end  has  been  sought  by  means  of  a  pistol-shaped  board, 
placed  on  the  dorsum  of  the  forearm  and  hand ;  some  surgeons  have  thought 
that  this  answered  a  better  purpose  if  laid  along  the  palmar  surface.  By 
most  authors  this  contrivance  has  been  called  "  Nelaton's  splint ;"  but  it  is 
not  mentioned  in  that  author's  Fathologie  Chiriirgicale,  published  in  1844. 
Malgaigne  speaks  of  wooden  splints,  "  w^hich  should  first  cover  the  forearm 
in  the  ordinary  way,  and  which  at  the  wrist  should  bend  sharply  inward, 
not  by  their  surfaces,  but  by  their  edges."  These,  he  says,  were  proposed  by 
Blandin  in  1836,  but  had  been  "previously  known."  The  fact  is  that  the 
pistol-shaped  splint  is  clearly  described  by  Goyrand,^  as  an  improved  form  of 
apparatus  devised  by  himself. 

Skey  thought  that  the  hand  ought  to  be  sedulously  supported ;  Gordon,  of 
Belfast,  believes  that  its  weight  may  be  made  useful  as  an  adducting  force. 

"Bond's  splint,  proposed  in  1852,  has  had  a  very  wide  popularity  in  Ame- 
rica, and  with  some  modification  is  a  very  good  one.  It  consists  of  a  board 
cut  to  the  outline  of  the  normal  hand  and  forearm,  and  furnished  with  a  pal- 
mar block,  over  which  the  fingers  are  flexed.  Leather  strips  are  generally 
tacked  along  its  edges  to  keep  the  parts  more  secure.  This  splint  is  greatly 
improved  by  fastening  along  its  radial  margin  a  block  of  wood,  so  shaped 
as  to  fill  up  the  concavity  before  noted  as  normal  in  this  part  of  the  limb. 
Without  this,  and  especially  with  the  palmar  block  as  large  as  is  usually 
made.  Bond's  splint  can  only  keep  up  the  deformity  it  is  meant  to  correct.  I 


1  Journal  Hebdomadaire  des  Progres  des  Sciences  Medicales,  F6v.  1836,  p.  177. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


175 


make  this  statement  from  the  examination  of  a  number  of  cases  treated  by 
most  able  hands  on  this  plan.  Hays's  splint,  a  mere  temporary  substitute  for 
Bond's,  is  open  to  the  same  objection.  Hamilton  uses  a  splint  on  the  same 
principle,  but  padded  with  horsehair,  kept  in  place  by  a  sack-like  envelop. 
He  employs  a  dorsal  splint  also. 


Fig.  834. 


Bond's  splint  for  fracture  of  the  radius. 

A  number  of  years  ago  a  splint  was  made  by  Carr,  a  surgeon  in  New 
Hampshire,  which  consisted  of  a  slip  of  board  to  tit  along  the  palmar  surface 
of  the  forearm,  narrowing  at  the  wrist,  and  having  nailed  across  it,  by  way 
of  palmar  block,  a  cylindrical  bit  of  wood  like  a  section  of  broomstick  (which, 
I  believe,  the  first  one  really  was).  Very  good  results  are  said  to  have  been 
obtained  with  this,  and  it  is  certainly  correct  in  principle.  More  elaborate 
and  complicated  contrivances,  on  the  same  general  plan,  but  with  adjustable 
blocks,  have  been  made  by  others. 

Coover's  splint,  shaped  out  of  wood,  so  as  to  fit  the  palmar  surface  of  the 

Fig.  835. 


Coover's  splint  for  fracture  of  the  radius. 

forearm  and  hand,  is  sold  in  pairs,  and  of  various  sizes.  I  have  repeatedly 
used  it  with  great  satisfaction. 

Levis's  splint,  made  of  tin,  answers  a  very  good  purpose ;  its  shape  and 
mode  of  use  are  shown  in  the  cuts,  Figs.  836  and  837.  A  very  similar  one,  of 
what  material  is  not  stated,  is  described  as  having  been  exhibited  by  Schede, 
of  Hamburg,  at  a  recent  congress  of  the  German  Society  of  Surgery.^ 

Gordon's  splint  deserves  mention,  although  it  is  awkw^ard  in  appearance ; 
it  consists  of  a  board  for  the  palmar  surface  of  the  forearm,  Avith  a  block 
along  its  radial  side,  filling  up  the  natural  concavity  of  the  part.  This  board 
extends  only  as  far  as  the  flexure  of  the  wrist,  the  hand  hanging  free  and 
tending  to  adduction.  A  shaped,  dorsal  splint,  and  straps  and  buckles,  com- 
plete the  apparatus.  Both  by  its  contriver  and  by  others  it  is  said  to  have 
been  found  efiicient. 

Much  bolder  plans,  allowing  more  liberty  to  the  limb,  have  been  proposed 
and  employed,  it  is  said,  with  good  results.  Moore,  having  eftected  reduc- 
tion in  the  manner  before  mentioned,  applies  a  small  roller  firmly  over  the 


»  Gaz.  Medicale  de  Paris,  19  Aout,  1882. 


176 


INJURIES  OF  BONES. 


head  of  the  ulna,  and  then  makes  pressure  over  the  injured  part  by  means  of 
a  wide  band  of  adhesive  plaster.  Pilcher  discards  the  compress,  and  uses  the 
plaster  only.  I  have  myself  used  simply  what  may  be  called  a  very  short 
splint — a  slip  of  wood  shaped  so  as  to  fill  up  the  concavity  just  above  the 


Figs.  836,  837. 


Levis's  splint  for  fractured  radius. 


wrist,  held  in  place  by  adhesive  plaster  first,  and  then  with  a  bandage. 
When  reduction  has  been  completely  efitected  in  simple  cases,  vvithout  com- 
minution, either  of  these  retentive  means  will  suffice  ;  but  they  must  be 
applied  with  grsat  accuracy,  and  should  be  carefully  watched,  so  that  ad= 
ditional  safeguards  may  be  resorted  to,  if  necessary. 

It  should  never  be  forgotten,  in  dressing  these  fractures  particularly,  that 
undue  tightness  of  the  bandage  may  lead  to  the  most  deploTable  results. 
Reduction  having  been  once  eftected,  a  properly  fitted  splint  will  keep  the 
fragments  in  place,  and  permit  the  arm  to  be  supported  without  any  great 
constriction.  All  that  is  needed  is  that  the  roller  should  be  put  on  snugly 
and  uniformly. 

My  own  rule  is  to  examine  the  condition  of  the  parts  every  second  day  for 
the  first  two  weeks,  although  this  may  be  modified  if  there  is  no  derange- 
ment of  the  apparatus,  and  if  at  the  third  or  fourth  time  the  fracture  is 
found  in  perfectly  satisfactory  condition.  Under  such  circumstances  the  in 
terval  may  be  extended  to  four  or  five  days. 

Malgaigne's  practice  in  this  respect,  as  stated  by  himself,  seems  to  me  to 
be  scarcely  a  safe  one  to  follow.    He  says : — 

"  I  remove  the  apparatus  at  from  the  eighteenth  to  the  twenty- second  day,  to  ascertain 
the  condition  of  things,  and  to  remedy  any  displacement  which  may  have  occurred  ;  after 
this  1  do  not  touch  it  until  the  thirtieth  day,  when  I  leave  the  limb  entirely  at  liberty. 
I  would  repeat,  that  by  pursuing  this  method  I  have  always  found  this  fracture  one  of 
the  easiest  to  cure,  without  stiffening,  deformity,  or  the  slightest  impairment  of  the 
motions  of  the  limb  ;  excepting,  of  course,  in  those  very  grave  cases  complicated  with 
actual  luxation  of  the  ulna." 

Schede,  whose  splint  has  already  been  alluded  to,  uses  a  starched  bandage 
over  one  of  flannel,  and  makes  passive  motion  every  eighth  day ;  removing  the 
apparatus  altogether  at  the  end  of  three  weeks.  The  starched  or  plaster-of- 
Paris  bandage  may,  I  think,  be  used  with  advantage  in  some  cases  after  the 
second  or  third  week,  especially  in  the  case  of  a  restless  child,  or  when  the 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


177 


patient  cannot  be  seen  again  for  some  time.  Passive  motion  need  only  be 
made  in  exceptional  instances,  where  there  is  a  strong  tendency  to  stiffen- 
ing, such  as  sometimes  occurs  in  old  people,  or  where  the  violence  producing 
the  injury  has  been  very  great. 

I  have  recently  had  under  my  care  a  woman  who,  by  a  fall  on  the  back  of 
the  hand,  had  a  fracture  of  the  radius  just  above  the  wrist,  with  displace- 
ment of  the  lower  fragment  forward.  Her  attendant  had  simply  applied  a 
Levis's  splint,  which  of  course,  in  such  a  case,  merely  kept  up  the  deformity. 
(I  presume  no  effort  to  correct  it  had  been  made.)  When  she  came  to  me, 
about  two  months  afterward,  the  wrist  was  greatly  deformed,  the  hand  and 
fingers  flexed,  and  their  nutrition  impaired,  as  shown  by  the  wrinkled,  glossy, 
and  shrunken  skin.  She  had  constant  and  severe  pain,  and  the  hand  was 
useless.  By  breaking  up  the  adhesions  (under  ether),  and  prolonged  treat- 
ment in  the  way  of  frictions  and  gentle  passive  motion,  I  succeeded  in  im- 
" proving  the  condition  of  things,  but  she  has  not  yet  regained  anything  like 
free  use  of  the  hand. 

^on-union  must  certainly  be  very  rare  in  fractures  of  the  lower  portion  of 
the  radius.  Muhlenberg^  gives  five  cases  in  which  this  condition  obtained  in 
the  '^ower  third"  of  the  bone;  but  it  is  not  stated  that  either  was  one  of 
fracture  close  to  the  wrist. 

When  union  has  taken  place  with  deformity,  if  too  much  time  lias  not 
elapsed,  an  attempt  may  be  made  to  separate  the  fragments  by  force,  and  to 
bring  them  into  proper  relation.  Little^  adopted  such  a  course  with  success 
after  a  period  of  six  weeks.  More  risk  would  attend  a  procedure  of  this  kind, 
in  proportion  to  the  nearness  of  the  fracture  to  the  joint ;  and  in  very  many 
cases  it  would  be  better  to  trust  to  the  chance  of  improvement  by  the  model- 
ling processes  of  nature. 

Fractures  of  both  bones  of  the  forearm  are  of  very  frequent  occurrence, 
in  children  especially.  In  this  respect  they  difter  markedly  from  the  other 
fractures  in  this  region,  which  are  more  commonly  met  with  in  adult  life. 
Thus,  in  the  tables  given  by  Flower  and  Hulke,^  derived  from  the  records  of 
the  Middlesex  Hospital  for  sixteen  years,  out  of  a  total  of  2705  fractures,  there 
were  1142  affecting  the  forearm,  viz.,  the  radius  and  ulna  191,  or  about  16 
per  cent.,  tlie  ulna  alone  (including  the  olecranon)  183,  or  about  16  per  cent., 
and  the  radius  alone  768,  or  about  67  per  cent.  Of  these  1142  cases,  401,  or 
35  per  cent.,  w^ere  in  subjects  below  the  age  of  15  ;  and  here  the  proportions 
were :  for  the  radius  and  ulna  119,  or  over  29  per  cent. ;  for  the  ulna  alone 
(including  the  olecranon)  45,  or  over  11  per  cent. ;  and  for  the  radius  alone 
237,  or  over  59  per  cent. 

With  regard  to  the  total  of  fractures  affecting  patients  under  the  age  of 
fifteen  years,  1154,  there  were  for  the  radius  and  ulna  over  10  per  cent.";  for 
the  ulna  alone  nearly  4  per  cent. ;  and  for  the  radius  alone  over  20  per  cent. 

As  compared  with  the  grand  total  of  2705  fractures,  the  cases  under  the 
age  of  fifteen  were :  in  the  radius  and  ulna  over  4  per  cent. ;  in  the  ulna  alone 
1  per  cent. ;  and  in  the  radius  alone  nearly  9  per  cent. 

Agnew^'s  general  table^  includes  8667  cases  of  fracture  treated  at  the  Penn- 
sylvania Hospital  in  forty-four  years ;  of  these,  1802,  or  nearly  21  per  cent., 
concerned  the  bones  of  the  forearm,  and  were  distributed  as  follows:  In  the 
radius  and  ulna  599,  or  over  33  per  cent. ;  in  the  ulna  alone  218,  or  something 
over  12  per  cent. ;  and  in  the  radius  alone  985,  or  over  54  per  cent.  The 
reader  will  note  a  discrepancy  of  result  between  these  figures  and  those  pre- 

1  Agnew,  op.  cit.,  vol.  i.  p.  768.  a  Medical  Record,  March  4,  1882. 

'  Holmes's  System  of  Surgery,  3d  ed.,  vol.  i.  p.  946.  *  Op.  cit.,  vol.  i.  p.  824. 

VOL.  IV. — 12 


178 


INJURIES  OF  BONES. 


viously  quoted,  which  is  sufficient  to  attract  attention,  but  which  it  is  not 
easy  to  explain.  Agnew's  tables  are  not  so  arranged  with  regard  to  the  ages 
of  the  patients  as  to  enable  a  comparison  to  be  made  in  this  respect. 

Among  the  316  cases  of  fracture  before  quoted  from  the  records  of  the 
Children's  Hospital,  in  Philadelphia,  105,  or  a  little  over  33  per  cent.,  affected 
the  bones  of  the  forearm.  Of  this  number,  36,  or  over  34  per  cent.,  affected 
both  the  radius  and  ulna ;  15,  or  over  14  per  cent.,  the  ulna  alone  (including 
the  olecranon) ;  and  54,  or  over  51  per  cent.,  the  radius  alone. 

As  to  the  influence  of  sex,  Malgaigne  says  that  "  they  are  equal  in  number 
from  two  to  fifteen  years ;  from  fifteen  to  twenty,  there  are  eighteen  males  to 
one  female  ;  from  twenty  to  forty-five,  the  number  of  men  is  just  double  that 
of  the  women ;  after  forty-five,  the  women  regain  th^ir  equality,  and  even 
exceed  it,  being  twenty-two  to  nineteen." 

It  is  in  this  region,  as  stated  in  the  early  part  of  this  article,  that  bending 
or  incomplete  fracture  has  been  chiefly  observed. 

The  causes  of  fractures  of  both  bones  of  the  forearm  are  most  frequently 
indirect,  such  as  falls  on  the  hand.  The  mechanism  is  not  always  clear ;  that 
is,  it  does  not  appear  why  a  fall  of  this  kind  should  sometimes  give  rise  to 
fracture  of  the  radius  alone,  close  to  the  wrist,  while  in  otlier  cas^s  both  bones 
give  way  in  their  shafts.  ProTbably  it  is  sometimes  due  to  a  difference  in  the 
mode  of  impact,  and  sometimes  to  the  elasticity  and  toughness  of  the  radius, 
and  the  thickness  of  the  periosteum,  which  prevents  yielding,  except  at  the 
thinner  and  less  protected  position  of  the  shaft,  the  ulna  breaking  an  instant 
afterward  for  want  of  support. 

Direct  violence  may  affect  this  part  of  the  skeleton  in  various  ways:  ma- 
chinery accidents,  falls  against  resisting  objects,  crushing  forces,  as  by  the 
passage  of  a  wheel,  the  kick  of  a  horse,  blows,  etc.  Muscular  action,  in  a 
case  recorded  by  Malgaigne,  and  in  two  other  instances,^  has  been  known  to 
cause  fracture  of  the  forearm. 

Occasionally  there  is  double  fracture,  each  bone  giving  way  at  two  points ; 
and  comminution  is  not  seldom  met  wdth.  Either  of  these  conditions  is 
apt  to  occur  in  cases  due  to  direct  violence,  especially  in  machinery  accidents, 
as  when  the  arm  is  drawn  around  a  revolving  shaft. 

Sometimes  the  two  bones  are  broken  at  the  same  level,  but  they  may  give 
way  at  different  points,  and  then  the  fracture  of  the  radius  is  apt  to  take 
place  higher  up— nearer  to  the  elbow— than  the  fracture  of  the  ulna.  This  fact 
may  be  accounted  for  partly  by  the  comparative  slenderness  of.  the  radius 
above,  and  of  the  ulna  below ;  partly,  perhaps,  by  the  muscular  attachments 
of  the  former  bone. 

Hamilton  mentions  one  case  seen  by  him,  in  which  "  the  radius  was  broken 
three-quarters  of  an  inch  above  the  lower  end,  and  the  ulna  about  one  inch 
below  the  coronoid  process."  This  is  certainly  very  rare,  and  it  is  to  be  re- 
gretted that  no  details  are  given  either  as  to  the  cassation  or  the  ultimate 
result  of  the  injury.  Fractures  situated  so  far  apart  might  almost  be  con- 
sidered as  wholly  separate  lesions. 

Upon  the  occurrence  of  fracture  of  both  bones  of  the  forearm,  however 
caused,  more  or  less  displacement  of  the  fragments  commonly  ensues.  Yery 
often  the  fracturing  force  has  much  to  do  with  this,  but  muscular  action  can 
scarcely  fail  to  influence  it.  The  resulting  condition  may  be  very  simple,  but 
it  may  be  very  complex.  Sometimes  the  bones  retain  their  parallelism,  but 
are  bent  backward,  forward,  or  to  either  side.  Sometimes  the  two  upper 
fragments  are  pressed  together,  and  the  two  lower  ones  separated,  or  vice  versa. 
Again,  either  by  the  fracturing  force  or  by  subsequent  changes  of  position  of 


»  Gurit,  op.  cit.,  Bd.  i.  S.  244. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


179 


the  hand,  a  twisting  may  take  place  which  brings  the  four  fragments  into 
most  complicated  abnormal  relations  to  one  another.  Occasionally  the  inter- 
osseous ligament  is  torn  at  the  time  of^the  accident,  or  it  may  be  penetrated 
by  one  of  the  fragments,  and  in  either  case  a  most  puzzling  and  intractable 
entanglement  may  ensue. 

Fortunately,  such  embarrassing  conditions  are  infrequent ;  in  the  great 
majority  of  cases  the  forearm  is  simply  bent  at  an  angle,  the  two  bones  remain- 
ing parallel.  Most  commonly  the  angle  thus  formed  is  salient  on  the  dorsal 
surface. 

It  will  very  readily  be  seen,  however,  that  even  a  slight  bending  of  the 
bones  will  do  away  altogether  with  the  freedom  of  rotation  of  the  radius 
upon  which  the  use  of  the  hand  so  largely  depends ;  and  this,  whether  one 
bone  or  both  be  involved.  And  if,  in  addition  to  the  formation  of  an  angle, 
there  is  rotation  of  either  of  the  three  fragments  which  can  be  so  affected  (for 
the  upper  portion  of  the  ulna  is  fixed  by  its  connection  with  the  humerus), 
the  limitation  of  movement  may  by  this  fact  be  made  materially  greater. 
Such  rotation  is  most  likely  to  take  place  in  the  upper  fragment  of  the'radius, 
acted  upon  by  the  biceps  and  supinator  brevis ;  but  it  is^^not  impossible  that 
by  pronation  of  the  hand,  aided  by  the  pronator  muscles,  the  lower  fragment 
of  this  bone  may  be  turned  in  the  opposite  direction.  The  position  of  the 
lower  portion  of  the  ulna  may  be  slightly  afifected  by  the  upper  fibres  of  the 
pronator  quadratus,  drawing  it  toward  the  radius,  but  it  is  more  likely  to  be 
influenced  by  the  position  of  the  hand. 

Whatever  abnormalities  of  relation  may  be  assumed  by  the  fragments,  and 
by  means  of  whatever  agencies,  the  action  of  the  muscles  passing  down  along 
the  forearm  can  scarcely  be  ignored  among  the  causes  promoting  displacement. 
These  muscles,  left  to  themselves,  tend  to  shorten  the  forearm^  and  when  the 
continuity  of  the  bones  is  lost  at  any  point,  they  must  draw  the  fragments 
past  one  another,  and  in  this  way  aggravate  their  distortion. 

The  evils  to  be  apprehended  from  the  changed  position  of  the  fragments  are 
not  limited  altogether  to  angulation  of  the  bones.  Non-union  may  follow,  and 
so  far  from  the  motions  of  the  hand  being  hampered,  the  bones  may  be  so 
loose  as  to  be  unavailable  for  any  ordinary  purpose.  Or  the  wrong  frag- 
ments may  become  attached  one  to  another  ;  or  a  mass  of  callus  may  be  thrown 
out  and  fuse  all  the  broken  ends  into  a  rigid  and  useless  block.  Eare  as  these 
unfortunate  occurrences'  are,  they  have  been  met  with,  and  illustrations  of 
them  are  to  be  found  in  most  pathological  collections. 

The  si/Mptoms  of  the  fractures  in  question  are  not  often  obscure;  deformity 
18  sometimes  present  in  so  marked  a  degree  as  to  reveal  at  once  the  nature 
of  the  lesion ;  pain,  loss  of  power  in  the  hand,  abnormal  mobility,  and  crepi- 
tus, are  seldom  absent.    Hence,  the  diagnosis  need  not  be  discussed. 

From  what  has  now^  been  said,  it  will  be  perceived  that  the  consequences 
of  these  injuries  may  be  very  disastrous,  if,  as  in  cases  occurring  at  sea,  no 
treatment  can  be  had  for  some  time ;  or  if  the  surgeon  be  careless  or  unskil- 
ful, or  the  patient  unruly.  And  although  under  favorable  circumstances 
good  results  can  generally  be  obtained,  the  chance  of  some  degree  of  impair- 
ment of  motion  should  always  be  borne  in  mind,  and  should  qualify  the 
prognosis  given  to  the  patient  or  his  friends. 

The  treatment  must  be  based  on  general  principles,  but  must  be  carefully 
adapted  to  the  features  of  each  case.  It  consists  in  the  reduction  of  the 
fragments  to  their  proper  relation,  and  in  maintaining  them  thus  until  they 
have  become  united. 

When  the  deformity  consists  in  a  simple  bending  of  the  forearm  in  either 
direction,  it  may  often  be  corrected  by  the  mere  application  of  the  surgeon's 
hands ;  but  sometimes  it  is  necessary  to  make  extension  also.    During  any 


180 


INJURIES  OF  BONES. 


manoeuvre  of  this  kind,  the  elbow  should  be  flexed  to  a  right  angle,  and  the 
hand  placed  semiprone.  It  is  much  better  to  have  the  extension  and  coun- 
ter-extension made  by  an  assistant,  leaving  both  hands  of  the  surgeon  free  to 
manipulate  the  injured  part.  Along  with  the  extension,  some  rotary  move- 
ments may  be  needful  in  order  to  the  disengagement  of  the  fragments  from 
one  another,  or  from  the  interosseous  ligament.  All  this  must  be  done  with 
the  utmost  gentleness,  the  amount  of  force  used  being  determined  hy  the 
resistance  met  with  ;  each  movement  should  be  made  with  a  definite  purpose, 
and  its  efiJect  carefully  noted,  lest  the  existing  displacement  be  only  increased, 
and  further  damage  done  to  the  soft  parts. 

Some  idea  may  be  formed  beforehand  of  the  objects  to  be  aimed  at  in  this 
procedure,  by  a  careful  study  of  the  seat  of  fracture,  and  of  the  condition  of 
the  parts — the  degree  and  direction  of  obliquity  of  each  fracture,  the  relation 
of  the  fragments  to  one  another,  the  point  at  which  each  bone,  but  especially 
the  Vadius,  has  given  way,  and  the  amount  of  entanglement  of  the  soft  parts. 
But  in  cases  presenting  much  complexity,  there  may  be  much  that  must  be 
left  to  be  ascertained  during  the  manipulation. 

Having  brought  the  fragments  into  proper  apposition,  the  next  point  is  to 
keep  them  so.  As  to  the  best  mode  of  doing  this,  authors  are  not  entirely 
in  accord  ;  some  advising  supination  of  the  forearm,  others  semi-pronation.  I 
think  that  the  rule  here  should  be  the  same  as  that  given  for  fractures  of  the 
radius  alone,  viz.,  that  when  this  bone  is  broken  above  the  insertion  of  the 
pronator  teres,  supination  is  best,  because  it  allows  the  lower  fragment  to 
follow  the  upper ;  whereas  in  fractures  below  this  point  the  upper  fragment 
is  not  so  liable  to  be  supinated.  I  do  not  think  that  this  latter  fact  is  due 
as  much  to  the  action  of  the  pronator  teres  muscle,  as  to  the  greater  length 
of  the  fragment  and  the  more  superficial  position  of  its  lower  end,  making 
it  more  controllable.  Ramonet^  thinks  that  the  forearm  should  be  kept  in. 
semi-pronation  for  two  weeks,  as  the  most  comfortable  position ;  and  that 
passive  motion  should  then  be  carefully  and  skilfully  made:  Either  in  supi- 
nation or  in  semi-pronation  there  is  no  difficulty  in  maintaining  the  interos- 
seous space,  if  the  fragments  are  onoe  properly  placed. 

The  practice  of  applying  an  "  immediate"  roller  to  the  limb  is  more  objec- 
tionable here  than  in  any  other  region  of  the  body,  for  the  obvious  reason 
that  its  tendency  is  to  press  the  fragments  together,^  and  thus  to  destroy  the 
interosseous  space,  and  to  permanently  impair  the  rotation  of  the  hand. 

When  the  supine  position  is  to  be  maintained,  the  best  splint  for  the  pur- 
pose is  the  ordinary,  anterior,  right-angled  one,  with  a  small,  narrow,  firm  pad 
laid  along  the  middle  of  the  forearm  part.  This  pad  should  reach  from 
about  an  inch  below  the  elbow  to  about  the  same  distance  above  the  w^rist. 
It  is  not  intended  to  be  forced  in  between  the  bones,  but  merely  to  compress  the 
muscles  and  push  theni  gently  into  the  interosseous  space.  In  some  arms  a 
corresponding  splint  may  be  employed  on  the  under  or  dorsal  side ;  but  it 
must  be  very  carefully  applied,  and  should  not  extend  upward  far  enough  for 
the  prominent  ridge  formed  by  the  ulna  to  interfere  with  its  usefulness. 

Extension  may  be  made,  if  necessary,  from  the  end  of  the  upper  splint, 
either  by  means  of  a  glove  with  the  fingers  cut  off",  or  by  strips  of  adhesive 
plaster.  The  splint  should,  therefore,  extend  two  or  three  inches  beyond  the 
ends  of  the  fingers. 

Another  very  good  splint  in  principle,  but  I  should  suppose  rather  more 
difficult  of  eft'ective  application,  is  that  of  Dr.  X.  C.  Scott,  already  mentioned 
in  connection  with  the  treatment  of  fractures  affecting  the  radius  only. 

»  On  the  influence  of  retraction  of  the  interosseous  membrane  on  the  loss  of  supination  in  frac- 
tures of  the  forearm  ;  Archives  Generales,  Aout,  1881. 


FRACTURES  OF  THE  BONES  OF  THE  FOREARM. 


181 


In  cases  suitable  for  semi-proiiation,  the  best  splint  is  an  'internal  angular" 
one,  extending  from  about  the  middle  of  the  arm  to  the  ends  of  the  fingers, 
or  further,  if  extension  needs  to  be  made.  A  dorsal  splint,  padded  somewhat 
more  thickly  along  the  middle  than  at  the  edges,  and  extending  from  oppo- 
site the  bend  of  the  elbow  to  a  point  just  above  the  wrist,  should  also  be 
employed.  These  splints  should  be  just  the  width  of  the  arm  at  each  point; 
if  they  are  wider,  the  forearm  may  be  bent  toward  the  radial  or  ulnar  side, 
and  if  narrower,  the  pressure  of  the  bandage  may  drive  the  fragments  toward 
one  another.  Hence  my  own  practice  is  to  shape  the  splints  beforehand  by 
taking  an  outline  from  the  sound  limb,  and  cutting  away  the  parts  outside 
of  this  outline. 

4  When  binders'  board  is  used  as  the  material  for  the  splints,  the  ulnar  edge 

of  the  forearm-part  may  be  slightly  turned  up,  so  as  to  afford  support  to 
this  portion  of  the  limb. 

By  most  surgeons,  anterior  and  posterior  splints  are  applied  to  the  forearm 
only,  and  by  many  the  pads  for  preserving  the  interosseous  space  are  thought 
to  be  "  if  useful,  intolerable;  if  tolerable,  useless."^  I  can  only  say  that,  in  my 
opinion,  one  cause  of  disturbance  of  the  fragments,  in  these  cases,  is  the  con- 
stant, slight,  irregular,  but  unopposed  pulling  of  the  muscles,  due  to  continual 
slight  movements  of  the  elbow ;  hence  I  would  put  the  forearm  at  absolute 
rest  by  confining  the  elbow  also.  Another  disturbing  cause  is  the  rotation 
of  the  forearm,  which  is  effectually  prevented,  and  the  thumb  kept  upward, 
by  simply  adding  the  arm-part  to  the  palmar  splint.  As  to  the  pads,  the 
mistake  generally  made  is  to  have  them  too  large  in  every  w^ay,  and  thus  to 
get  pressure  where  it  is  not  wanted.  I  think  that  they  should  be  exactly 
adapted  in  size  to  the  space  between  the  bones  in  each  case,  and,  above  all, 
that  they  should  not  be  too  long. 

I  attach  much  importance,  not  only  to  keeping  the  upper  fragments  at  rest 
by  confining  the  elbow,  but  to  doing  the  same  for  the  lower  fragments  by 
giving  due  support  to  the  hand,  which  should  be  placed  at  the  proper  or 
natural  angle  with  the  forearm,  slightly  adducted.  The  hand  should  never 
be  allowed  to  hang  down,  as  this  would  tilt  up  the  lower  fragments  of  both 
bones,  and  cause  an  angle  salient  toward  the  radial  edge  of  the  forearm.  The 
sling  should  be  wide,  and  should  give  the  forearm  perfect  support ;  but  if  the 
previous  dressing  have  been  properly  done  in  the  manner  above  described,  there 
can  be  no  risk  of  bending,  even  if  only  a  narrow  sling  be  used. 

After  the  first  dressing,  there  may  be  no  occasion  to  disturb  the  apparatus 
for  several  days,  if  it  continue  firm,  causing  no  pain,  and  if  the  circulation  be 
.  shown  by  the  state  of  the  fingers  to  be  properly  carried  on.  The  splints  should 
then  be  removed  for  the  purpose  of  thorough  examination,  and  immediately 
reapplied.  After  this  the  dressings  should  be  renewed  about  once  in  forty- 
eight  hours,  and  at  the  end  of  three  weeks  very  gentle  passive  motion  may 
be  attempted,  the  surgeon  taking  hold  of  the  forearm  above  and  below  the 
seat  of  fracture,  and  rotating  the  two  parts  in  exact  accord.  The  fracture 
remaining  firm,  at  the  end  of  the  fourth  week  the  fingers  may  be  left  free, 
and  two  or  three  days  afterwards  the  part  of  the  splint  corresponding  to  the 
hand  may  be  removed,  as  well  as  the  arm-part.  After  this  the  dressing  may 
be  left  on  until  it  becomes  loose,  and  then,  on  its  removal,  it  will  probably  be 
6afe  to  leave  it  off*  entirely. 

In  children  union  takes  place  more  quickly ;  I  recently  attended  a  little 
girl,  three  years  old,  whose  forearm,  broken  at  about  the  middle,  was  quite 
firm  on  the  fourteenth  da}^ 

These  fractures  afford  a  striking  illustration  of  the  fact,  noted  in  the  early 

Caswell,  in  Holmes's  System  of  Surgery,  Am.  ed.  vol.  i.  p.  861. 


182 


INJURIES  OF  BONES. 


part  of  this  article,  that  the  absence  of  paiii  or  discomfort  in  a  broken  limb 
does  not  give  assurance  that  it  has  been  properly  and  efficiently  dressed. 
'Not  a  few  cases  have  been  observed  in  which  the  fragments  have  been  twisted 
into  utterly  abnormal  relations,  while  yet  the  patient  has  been  wholly  uncon- 
scious of  anything  being  wrong. 

The  great  risk  of  gangrene  in  this  part,  from  too  tight  bandaging,  has 
already  been  referred  to,  and  ought  always  to  be  borne  in  mind  when  the 
dressings  are  applied.  Sometimes  it  is  questionable  whether  an  accident  of 
this  kind  is  not  due  to  the  contact  of  the  fragments  with  the  vessels,  which 
by  thorough  reduction  would  have  been  obviatedo 

Dr.  Hamilton,  in  his  report^  before  quoted,  mentions  three  cases  of  young 
children,  in  which  no  dressings  whatever  were  employed,  yet  in  which  the 
results  obtained  were  perfect. 

He  refers  to  another  instance,^  in  which  a  boy  of  ten  years,  after  a  fracture 
near  the  lower  end  of  the  forearm,  had  so  great  a  deformity  that  refracture 
was  seriously  thought  of  by  his  attendant ;  gradually,  however,  the  limb 
became  straight,  and  eighteen  years  afterward  there  was  no  trace  whatever  of 
the  injury. 

•  IN^on-union  has  occurred  many  times  in  fractures  affecting  both  bones  of  the 
forearm,  and  for  obvious  reasons  is  a  cause  of  more  complete  disability  here 
than  in  some  other  regions.  Moreover,  the  chance  of  affording  relief  by  pro- 
thetic  apparatus  is  less  ;  so  that  operative  interference  is  very  apt  to  be  called 
for.  References  to  published  cases  of  this  kind  maybe  found  in  the  first 
part  of  this  article.^ 

Refracture  sometimes  occurs  in  the  forearm,  and  may  affect  either  one  or 
both  of  the  bones  previously  broken.  When  only  one  suffers,  the  other,  of 
course,  acts  as  a  splint ;  when  both  are  broken,  the  case  demands  the  same 
care  and  attention  as  in  the  first  instance,  but  union  is  apt  to  take  place  more 
rapidly. 

Compound  fractures  of  both  bones  of  the  forearm  are  very  often  met  with 
in  hospital  practice,  as  the  result  of  railroad  and  machinery  accidents.  They 
vary  widely  in  their  extent  and  gravity,  and  in  the  complications  which  they 
present.  No  directions  can  be  given  for  the  management  of  these  injuries 
when  amputation  is  not  called  for,  other  than  the  general  laws  elsewhere  laid 
down.  Often  the  real  treatment  of  the  fracture  can  only  begin  at  a  compara- 
tively late  stage  of  the  case,  and  with  very  little  hope  of  saving  a  shapely  and 
useful  limb.  Yet  it  sometimes  happens  that  nature,  aided  by  care,  attention, 
and  skill,  accomplishes  unexpectedly  good  results ;  and  as  even  a  maimed 
limb  is  apt  to  be  better  than  an  artificial  substitute,  the  surgeon's  trouble  and 
the  patient's  endurance  will  be  well  expended  in  its  preservation. 

Fractures  of  the  Hand. 

Fractures  of  the  Carpal  Bones. — These  have  been  observed  almost  ex- 
clusively in  connection  w^ith  fractures  of  the  lower  part  of  the  radius,  and  as 
the  result  of  direct  violence.  Malgaigne  mentions  two  cases  seen  by  Cloquet, 
and  one  by  Jarjavay  ;  but  he  does  not  say  expressly  that  there  was  no  other 
lesion  present.  The  scaphoid  and  semi-lunaj*  would  seem  to  be  the  bones 
almost  always  involved,  as  might  naturally  be  expected  from  their  close 
connection  with  the  radius.    I  can  only  say,  theoretically,  that  if  by  direct 

1  Trans,  of  Am.  Med.  Association,  1856,  pp.  198  and  199. 

2  Case  28  ;  op.  cit.,  p.  201. 

'  Page  63.  See  also  oases  recorded  by  Diikes  (Lancet,  Dec.  7,  1878)  and  by  Gant  (Ibid.,  May 
8,  1880). 


FRACTURES  OF  THE  HAND. 


183 


violence  fracture  of  these  bones  alone  should  occur,  inflanmiation  of  the 
neighboring  joints  would  be  very  apt  to  follow.  The  injury  would  scarcely 
present  any  distinctive  features,  and  would  be  amenable  only  to  the  same 
treatment  as  a  severe  contusion  of  the  pai't.  Unless  caries  or  necrosis  should 
ensue,  or  the  inflammation  extend  to  the  synovial  membrane  between  the 
rows  of  carpal  bones,  no  permanent  disability  would  be  likely  to  result. 

Fractures  of  the  Metacarpal  Bones. — These  are  not  very  unfrequent  in 
men  of  the  laboring  class.  They  are  sometimes  met  with  in  machinery  acci- 
dents, and  then  are  almost  always  compound.  Indirect  violence,  cither  from 
falls  on  the  hand,  or  from  striking  a  blow,  is  a  common  cause  of  the  simple 
fractures.  I  have  seen  one  case,  in  a  powerful  sailor,  in  which  necrosis  had 
ensued  upon  a  fracture  of  the  fourth  metacarpal  bone,  sustained  by  striking 
another  man  on  the  jaw.  Malgaigne  quotes  from  Velpeau  an  instance  in 
which  "  a  water-carrier  had  his  fore  and  middle  Angers  pulled  upon  by  a 
carter  with  such  force  as  to  break  the  third  metacarpal  bone."  lie  also 
quotes  from  Dupuytren  a  case  in  which  fracture  was  due  to  forcible  bending 
backward  of  the  bone :  "  Two  men  were  trying  which  could  pull  back  the 
other's  wrist;  their  Angers  were  interlocked,  the  heads  of  the  metacarpal 
bones  directly  opposed  to  each  other,  and  the  phalanges  bent  back  and  press- 
ing firmly  against  the  dorsum  of  the  hand;  the  stronger  of  the  two  broke  his 
adversary's  third  metacarpal  bone."  Usually  only  one  bone  is  broken,  and 
the  experience  of  surgeons  seems  to  have  been  strangely  different  as  to  the 
one  most  likely  to  suffer.  Accordhig  to  some,  it  is  that  of  the  index  finger; 
according  to  others,  the  fourth  or  fifth.  Agnew  says  that  he  has  never  seen 
fracture  of  the  first  named,  nor  have  I ;  but  Hamilton  records  a  number  of 
cases  observed  by  himself. 

I  have  said  that  these  injuries  were  apt  to  affect  men  of  the  laboring  class, 
but  Agnew^  says  that  he  had  one  case  in  a  child  of  three  years,  and  another 
in  a  man  of  eighty-five.  Hamilton  mentions  one  in  a  boy  of  eight,  and 
another  in  a  young  lady  of  eighteen.  Children,  from  the  smallness  of  the 
bones,  the  slight  leverage  therefore  afforded,  and  their  customary  protection 
from  the  violence  apt  to  cause  such  fractures,  are,  in  great  measure,  exempt 
from  them  ;  and  the  same  may  be  said  of  women. 

The  seat  of  fracture,  in  cases  due  to  direct  force,  may  be  at  any  point ;  in 
such  as  are  produced  by  indirect  violence,  the  bone  is  most  apt  to  jdeld  a 
little  below  its  mid-point,  so  that  the  distal  fragment  is  slightly  the  shorter. 
The  line  of  fracture  is  oblique,  the  proximal  fragment  being  bevelled  at  the 
expense  of  its  palmar  face. 

The  symptoms  are  pain  and  deformity,  the  distal  fragment  and  head  of  the 
bone  sinking,  so  that  the  knuckle  seems  to  be  as  it  w^ere  efiaced;  there  is  a  dor- 
sal projection  at  the  seat  of  fracture;  abnormal  mobility  may  be  very  distinct, 
but  is  sometimes  only  slight ;  crepitation  may  be  felt,  but  obscurely,  from  the 
small  size  of  the  bone.  The  proximal  fragment  is  comparatively  fixed,  and 
in  the  examination  the  distal  fragment  must  be  grasped  between  the  surgeon's 
thumb  and  finger,  applied  on  the  dorsal  ajid  palmar  surface  of  the  head  of  the 
bone ;  or  it  may  be  moved  by  means  of  the  finger. 

As  to  the  diagnosis^  although  Sir  A.  Coopei-^  says  that  the  appearance  is 
that  of  dislocation,  I  have  never  seen  a  case  in  which  a  mistake  could  be 
made  between  the  two  lesions.  If  there  is  no  prominence  at  the  seat  of  frac- 
ture, there  will  always  be  tenderness  there,  and  perhaps  a  -sense  of  yielding 
under  firm  pressure.  Cases  may,  however,  occur  in  which  the  fracture  is 
situated  very  near  the  head  of  the  bone,  and  especially  if  swelling  comes  on 


«  Op.  cit.,  vol.  i.  p.  918. 


2  Op.  cit.,  p.  506. 


184 


INJURIES  OF  BONES. 


rapidly,  when  the  diagnosis  is  a  matter  of  more  difficulty.  Such  an  instance 
has  been  placed  on  record  by  Townsend.^  Occurring,  as  they  do  for  the 
most  part,  among  people  of  the  rougher  class,  these  fractures  are  apt  to  be 
less  carefully  looked  after  than  those  of  greater  apparent  importance ;  and 
hence  persistent  deformity  is  often  seen,  and  non-union  is  occasionally  met 
with.  Serious  interference  with  the  function  of  the  hand  is  very  rai^e. 
Hamilton,  however,  saw^  a  case  in  which,  the  metacarpal  bone  of  the  index 
finger  having  been  broken  in  striking  a  blow,  suppuration  followed,  and  four 
months  after  the  injury  ^' there  existed  complete  anchylosis  at  the  wrist-joint, 
and  partial  anchylosis  in  the  fingers.  The  hand  was  deflected  forcibly  to  the 
radial  side.  At  "the  point  of  fracture  the  fragments  were  salient  backward  and 
quite  prominent,  but  firmly  united."  It  w^ould  seem  that  here  there  had  been 
thecal  abscess,  involving  the  joints  secondarily ;  but  such  lesions  often  occur 
quite  independently  of  any  fracture. 

The  treatmeM  consists  in  restoring  the  shape  of  the  bone,  by  filling  up  the 
cavity  of  the  palm  with  some  firm  body,  such  as  a  ball  or  a  mass  of  tow,  and 
confining  it  in  place  by  means  of  a  roller  or  adhesive  plaster.  Agnew  advises 
a  splint,  to  extend  along  the  palmar  surface  from  the  elbow  to  the  ends  of  the 
fingers,  with  a  wad  of  tow  in  the  palm.  I  think  that  the  ordinary  Bond's 
splint,  with  the  block  cut  away  into  an  oval  shape,  would  answer  as  w^ell. 
Malgaio;ne,  in  one  case,  found  two  small  transverse  splints,  w^ell  padded, 
eftectual. 

E^on-union  would  in  most  cases  be  productive  of  so  little  real  inconvenience, 
that  it  would  not  be  justifiable  to  resort  to  any  operative  procedure  to  remedy 
it.  Possibly,  if  the.  metacarpal  bone  of  the  index  finger  were  the  one  con- 
cerned, some  of  the  less  severe  measures  might  be  adopted  ;  but  it  would  be 
very  unfortunate  if  the  result  should  be  thecal  abscess,  and  a  great  aggrava- 
tion of  the  disability. 

Fractures  of  the  phalanges  are  not  very  uncommon ;  the  bones  of  the 
thumb  are  more  rarely  broken  than  those  of  the  fingers.  Of  the  latter,  I  think 
the  index  and  middle  fingers  are  most  liable  to  fracture,  but  the  others  are  by 
no  means  exempt ;  the  experience  of  dift'erent  surgeons  varies  in  this  respect. 
The  distal  phalanges  would  seem  to  be  less  apt  to  suffer  than  the  proximal, 
and  the  intermediate  ones  less  than  either.  ,  These  injuries  have  been  met 
with  at  all  ages,  and  in  both  sexes,  although  men  are  much  more  exposed 
than  women  to  the  direct  violence  which  is  their  usual  cause.  They  are 
very  apt  to  occur  to  machinists,  masons,  etc.,  and  are  not  unfrequent  in  base- 
ball players.  One  case  of  fracture  of  the  proximal  extremity  of  the  index- 
finger  by  muscular  action,  has  been  recorded  by  Bellamy. ^  The  patient,  a 
man  at>:ed  fifty-five,  made  a  miss  in  striking  a  back-handed  blow.  It  must  be 
obvious  that  force  sufficient  to  break  one  of  these  bones  w^ould  be  very  likely 
to  comminute  it,  and  to  inflict  serious  damage  upon  the  soft  parts  also ;  hence 
these  fractures  are  very  often  compound. 

I  once  saw  a  separation  of  the  palmar  margin  of  the  articular  face  of 
the  first  phalanx  of  the  index  finger,  in  a  young  lady,  caused  by  a  blow 
against  the  sharp, edge  of  a  bedstead;  the  fragment  was  plainly  to  be  felt. 
Ko  serious  inflammation  followed,  and  union  took  place  favorably.  Most  of 
these  injuries  are  much  more  grave.  A  year  or  two  since  I  was  called  into 
the  street  late  at  night  to  see  a  gentleman  who,  in  going  home,  had  slipped 
upon  the  icy  pavement,  and  catching  at  a  spiked  railing,  had  impaled  his 
middle-finger  upon  one  of  the  points,  splitting  the  first  phalanx  from  end  to 

1  Philadelphia  Medical  Times,  Oct.  16,  1871. 

2  British  Med.  Journal  March  28,  1874. 


FRACTURES  OF  THE  LOWER  EXTREMITY.  185 

end.  I  had  to  cut  through  the  soft  parts  of  the  side  of  the  finger  to  liberate 
the  hand.  Amputation  was  unavoidable,  and  was  performed  the  next  day, 
with  an  excellent  ultimate  result. 

The  symptoms  need  hardly  be  detailed,  as  they  are  those  of  fractures  gener- 
ally, and  from  the  small  amount  of  covering  of  the  bones  are  readily  to  be 
made  out.  On  account  of  the  strength  of  the  flexors,  the  deformity  is  apt  to 
be  an  angle,  salient  at  the  back  of  the  finger ;  but  this  rule  is  not  uniform, 
as  the  fracturing  force  may  drive  both  fragments  toward  the  palmar  surface. 
Occasionally  these  fractures  are  complicated  with  dislocation,  but  this,  except 
in  the  thumb,  is  in  general  reducible  without  great  difi&culty.  Union  almost 
always  takes  place  without  hindrance ;  but  I  have  reported*  the  case  of  a 
child  three  years  old,  who  had  two  years  previously  sustained  a  fracture  of 
the  first  phalanx  of  the  thumb,  with  the  subsequent  formation  of  a  false  joint, 
and  on  whom  an  operation  was  performed  with  success. 

Necrosis  of  the  fragments  sometimes  occurs,  especially  in  compound  and 
comminuted  fractures ;  and  in  these  cases  more  or  less  thecal  inflammation  is 
very  apt  to  ensue,  and  may  travel  up  and  even  beyond  the  wrist.  Under  the 
most  favorable  circumstances  some  degree  of  stifl:ening  and  deformity  is  often 
permanent,  although  it  may  not  interfere  with  the  usefulness  of  the  finger. 
Stoker^  showed  to  the  Pathological  Society  of  Dublin  the  skeleton  of  an 
index-finger,  illustrating  union  of  a  fracture  of  the  second  phalanx.  The  first 
phalanx  was  entire  and  healthy ;  the  articulation  between  the  first  and  the 
second  had  disappeared,  and  there  was  firm  osseous  union  between  these  bones. 
Strong  ligamentous  union  existed  between  the  second  and  third  phalanges. 
Occasionally  patients  find  fingers  which  are  thus  stiftened  so  much  in  the 
way  that  they  are  anxious  for  their  removal ;  but  in  general  they  learn  in 
time  to  disregard  their  presence.  A  far  greater  annoyance  is  sometimes 
caused  by  the  twisting  of  a  broken  finger,  so  that  it  either  crosses  another, 
or  constantly  rubs  against  it  in  the  movements  of  the  hand. 

As  to  the  treatment  of  these  cases,  a  good  deal  of  ingenuity  has  been  ex- 
pended upon  the  devising  of  splints  of  various  kinds.  I  believe  that  the  best 
plan  is  to  employ  a  piece  of  sheet  zinc  of  suitable  size,  bent  up  so  as  to  fit  the 
palmar  surface  of  the  finger;  this  being  very  carefully  padded  and  applied, 
may  be  secured  by  means  of  the  best  procurable  adhesive  plaster,  or  by  a  band- 
age imbued  with  a  solution  of  silicate  of  potassium.  If  sheet  zinc  cannot  be 
had,  small  strips  of  wood  may  be  employed,  carefully  padded,  and  placed  one 
on  the  dorsal  and  one  on  the  palmar  surface  of  the  finger.  As  a  temporary 
expedient  this  would  answer  perfectly.  When  no  other  means  of  solidifying 
the  bandage  can  be  had,  flour  and  white  of  egg  may  be  employed.  The 
finger  should  be  slightly  flexed,  but  at  the  joints  only.  Passive  motion  may 
be  carefully  and  gently  made  at  the  end  of  ten  days  or  two  weeks. 

In  cases  of  compound  fracture  the  question  of  amputation  comes  up,  and 
must  be  settled  on  general  principles.  Excisions  are  not  available  here,  and 
if  any  portion  of  bone  must  be  lost,  it  is  better  to  remove  the  finger.  I  have 
several  times  seen  very  unsatisfactory  results  follow  the  less  decided  course. 


Fractures  of  the  Lower  Extremity. 

These  injuries  differ  from  those  of  the  upper  extremity  in  some  important 
respects.  As  a  general  rule,  they  involve  the  necessity  of  confinement,  often 
keeping  the  patient  in  bed.  The  greater  size  of  the  bones  renders  the  repair 
a  more  tedious  process,  and  entails  some  additional  dangers,  as  for  example, 

1  Am.  Journal  of  the  Med.  Sciences,  July,  1875. 

2  British  Med.  Journal,  Dec.  31,  1881. 


186 


INJURIES  OF  BONES. 


those  of  fat  embolism  and  of  pysemia.  Extension  is  demanded  in  a  larger 
proportion  of  cases,  and  by  more  powerful  means.  All  the  apparatus  used 
must  be  on  a  larger  scale.  Arrangements  must  be  made  for  the  evacuation 
of  the  bowels  and  bladder,  without  disturbance  of  the  broken  bones.  Often 
the  risk  of  bedsores  has  to  be  guarded  against. 

Yet  the  same  general  principles  are  to  be  observed — the  same  methods  of 
study,  the  same  rules  as  to  diagnosis,  and  the  same  care  for  the  avoidance  of 
deformity. 

Fractures  of  the  Femur. 

The  femur,  the  largest  bone  in  the  body,  and  the  most  complicated  in 
shape,  is  among  those  most  frequently  broken.  The  proportion  varies  in  the 
experience  of  different  observers,  and  even  in  the  same  hospital  at  different 
periods.    Gurlt  cites  tables^  from  which  I  derive  the  following  statements : — 

Middeldorpf,  among  325  fractures  treated  in  the  Allerheiligen  Hospital,  at  Breslau, 
from  1849  to  1853,  found  25,  or  something  over  7  per  cent,  of  the  femur. 

Lonsdale,  at  the  Middlesex  Hospital,  in  London,  between  1831  and  1837,  found 
among  1901  fractures  181,  or  over  9  per  cent. 

Gurlt,  in  the  Hospitals  and  Surgical  PolycHnic  in  Berlin,  from  1851  to  1856,  found 
510,  or  less  than  12  per  cent,  out  of  4310. 

Blasius,  in  the  Surgical  CHnic  and  Polyclinic  at  Halle,  between  1831  and  1856, 
found  97,  or  over  12  per  cent,  out  of  778. 

Malgaigne,  from  the  statistics  of  the  Hotel-Dieu  from  1806  to  1808,  and  from  1830 
to  1837,  embracing  2328  fractures,  found  that  those  of  the  femur  were  308,  or  over  13 
per  cent. 

Lente,  studying  the  records  of  the  New  York  Hospital  between  1839  and  1851, 
found  that  out  of  1722  fractures  there  were  280  affecting  the  femur,  or  over  15  per 
cent. 

Matiejowsky  gives  from  the  Allgemeiner  Krankenhaus,  at  Prague,  from  1843  to 
1855,  1086  fractures,  of  which  those  of  the  femur  were  199,  or  over  18  per  cent. 

Thus  it  appears  that,  from  these  seven  sources,  are  derived  results  varying 
between  7  per  cent,  and  18  per  cent.;  a  fact  probably  to  be  accounted  for 
partly  by  the  circumstances  of  the  populations  from  which  the  patients  were 
respectively  drawn,  and  partly  by  the  fact  that,  in  some  institutions,  the 
general  statistics  are  swelled  b}^  the  inclusion  of  walking  cases,  while  in 
others  these  are  referred  to  dispensaries,  etc. 

From  the  statistics  of  the  Pennsylvania  Hospital  for  ei2:hty-seven  years, 
from  1751  to  1838,  Wallace  gives,  out  of  1810  fractures,  291,  or  about  16 
per  cent,  of  the  femur ;  while  Morris,  for  the  period  of  twelve  years,  from 
1838  to  1849  inclusive,  found  among  1441,  195,  or  over  13  per  cent,  of  the 
lemur.  This  difference,  although  not  very  marked,  is  not  easy  to  explain. 
On  the  other  hand,  it  is  readily  seen  why,  out  of  the  316  cases  of  fracture 
before  quoted  from  seven  years'  records  of  the  Children's  Hospital,  in  Phila- 
delphia, only  14,  about  4 J  per  cent,  affected  the  femur;  for  by  reason  of  the 
unwillingness  of  parents  to  send  their  children  to  public  institutions,  a  large 
proportion  of  these  cases  are  treated  at  their  homes. 

This  statement  is  singularly  at  variance  with  that  of  Holmes,^  that  "  frac- 
tures of  the  shaft  of  the  femur  are  among  the  commonest  of  all  fractures  in 
childhood;"  and  Gurlt's  table,^  of  1383  fractures,  arranged  according  to  age, 
shows,  among  330  below  the  age  of  fifteen  years,  60,  or  a  little  over  18  per 
cent.,  in  the  femur. 

'  Op.  cit.,  S.  6.  8  Surgical  Treatment  of  Children's  Diseases,  p.  258. 

s  Op.  cit.,  S.  11. 


FRACTURES  OF  THE  FEMUR. 


187 


The  records  of  the  Pennsylvania  HospitaP  show,  out  of  248  cases  of  frac- 
ture of  the  femur  in  which  the  age  is  noted,  80,  or  32  per  cent.,  under  twenty 
years  of  age  ;  47,  or  nearly  19  per  cent.,  between  twenty  and  forty  years  of 
age ;  71,  or  over  28  per  cent.,  between  forty  and  sixty  ;  and  beyond  sixty,  50, 
or  20  per  cent. 

The  influence  of  sex  on  the  frequency  of  occurrence  of  fractures  of  the 
femur  is  strongly  marked,  but  not  equally  so  with  regard  to  all  portions  of 
the  bone.  During  childhood  and  youth,  when  the  neck  of  the  bone  is  almost 
exempt,  the  number  of  cases  in  males  is  very  much  greater  than  that  in 
females.  Afterwards,  the  ratio  of  the  two  sexes  becomes  more  nearly  equal ; 
but  in  old  age,  when  the  neck  is  the  part  of  the  bone  most  frequently  broken, 
the  proportion  of  women  is  in  excess. 

The  analogy  which  exists  between  the  anatomical  form  of  the  femur  and 
that  of  the  liumerus  obtains  also  in  regard  to  their  fractures.  Thus,  we  have 
in  the  femur,  fractures  of  the  neck,  of  the  trochanters,  of  the  shaft  just  below 
the  trochanters,  of  the  shaft  in  other  parts  of  its  length,  and  of  the  condyles. 
But  it  will  be  noted  that  while  the  upper  portion  of  the  humerus,  as  stated 
in  a  previous  part  of  this  article,  is  less  frequently  broken  than  the  lower,  the 
converse  is  true  of  the  femur ;  and  the  anatomy  of  the  neck  of  the  femur  is 
more  complex  than  that  of  the  condyles,  while  in  the  humerus  the  upper  ex- 
tremity of  the  bone  is  much  the  simpler.  The  epiphyses  of  the  humerus  are 
far  more  frequently  separated  by  violence  than  those  of  the  femur.  In  fact, 
according  to  Holmes,^  separations  of  the  upper  epiphysis  of  the  femur  are 
"  unknown,  except,  perhaps,  in  the  foetus ;"  this  statement  is  too  sweeping, 
but  the  lower  is  much  ofteuer  detached,  as  will  hereafter  appear. 

A  correct  knowledge  of  the  external  anatomy  and  internal  structure  of  each 
portion  of  the  femur  is  essential  to  the  understanding  of  its  fractures.  The 
general  mechanical  principles  concerned  have  already  been  laid  dow^n.^ 

Fractures  of  the  upper  part  of  the  femur  are  such  as  involve  the  neck 
of  the  bone,  or  the  trochanters,  or  both.  On  examining  a  normal  femur,  it  is 
seen  that  the  neck,  projecting  upward  from  the  oblique  inter-trochanteric 
line,  is  set  at  an  angle  more  or  less  obtuse  with  the  shaft.  In  front,  the 
surfaces  of  the  two  portions  are  nearly  continuous,  whereas  posteriorly  the 
line  is  a  very  marked  ridge,  and  defines  a  deep  hollow  between  it  and  the 
head.  Hence,  the  greater  trochanter  projects  backward,  and  the  general 
shape  of  the  neck  of  the  bone  is  slightly  convex  in  front,  deeply  concave 
behind. 

The  angle  at  which  the  neck  is  set  on  to  the  shaft,  is  found,  on  comparison 
of  femora  from  different  subjects,  to  vary  considerably.  Ward  says  that  it  is 
on  an  average  about  125°.  Whether  it  changes  in  the  same  skeleton  from 
youth  to  old  age,  has  never  been  determined,  although  it  has  been  so  supposed 
by  almost  all  writers  on  anatomy  and  surger}^  Sir  Astley  Cooper^  gives  a 
very  clear  description  of  degenerative  changes  seen  by  him  in  old  bones,  and 
in  the  excellent  illustrations  accompanying  his  text,  there  may  be  perceived 
an  arrangement  of  the  cancellous  structure,  which,  as  I  shall  presently  try  to 
show,  has  much  to  do  with  the  clinical  features  of  all  fractures  in  this  region. 
But  although  these  changes  may  undoubtedly  occur,  and  are  more  frequent 
in  old  age,  they  are,  I  think,  only  parts  of  a  degeneration  which,  in  some 
individuals  only,  affects  the  entire  skeleton.  In  many  old  bones  no  such 
change  is  to  be  noted ;  the  neck  is  at  a  very  obtuse  angle  with  the  shaft,  and 
its  structure,  like  that  of  the  bony  system  at  large,  resembles  that  of  most 


1  Surgery  in  the  Pennsylvania  Hospital,  p.  280. 

2  Surgical  Treatment  of  Children's  Diseases,  p.  258. 

3  See  pp.  13  et  seq.  *  Op.  cit.,  pp.  134  et  seq. 


188 


INJURIES  OF  BONES. 


bones  at  earlier  periods  of  life.  On  the  other  hand,  as  shown  by  Gulliver/ 
such  changes  may  occasionally  occur  as  the  result  of  injury  in  young  persons 
and  adults. 

Another  point  to  be  noted,  which  also  varies  in  ditFerent  individuals,  is  the 
constriction  of  the  neck  close  to  the  head.  Sometimes  very  marked,  this 
constriction  is  in  some  bones  scarcely  present  at  all.  When  it  exists,  it  must 
obviously  influence  the  probability  of  fracture  taking  place  at  this  point, 
especially  if  the  nutrition  of  the  skeleton  becomes  impaired  by  age  or  any 
other  cause. 

The  relation  of  the  head  of  the  bone  to  its  neck  also  varies.  Sometimes 
the  neck  extends  more  upward  at  the  lower  surface,  so  as  to  give  the  outline 
of  its  junction  with  the  head,  as  seen  either  from  before  or  from  behind,  an 
S -shape,  and  so  as  to  lessen  the  relative  length  of  the  upper  surface  of  the  neck. 

Variations  exist  also  in  the  actual  length  of  the  neck.  It  is  in  general 
proportionate  to  that  of  the  shaft,  but  not  always  so ;  as,  for  instance,  in 
dwarfs,  or  short  persons,  it  is  longer,  and  in  very  tall  persons  shorter,  than  it 
would  be  according  to  such  a  rule. 

The  antero-posterior  is  usually  less  than  the  transverse  diameter  of  the 
cervix. 

A  careful  examination  of  vertical  sections  in  the  length  of  the  head  and  neck 
of  the  femur  shows,  as  pointed  out  by  Ward,  Wyman,  and  others,  that  a  num- 
ber of  the  lamellae,  beginning  at  the  upper  end  of  the  inner  wall  of  the  shaft  of 
the  bone,  close  to  the  lesser  trochanter,  diverge  upward  to  the  concavity  of  the 
thin  layer  of  compact  substance  covering  the  head,  so  as  to  receive  the  weight 
of  the  body  upon  their  extremities.  Another  series  of  columns  may  be  seen 
running  outward  from  the  same  point,  and  meeting  other  colunms  running 
up  inward  from  the  outer  wall  of  the  shaft ;  these  two  sets  of  columns 
forming  a  series  of  groined  arches  culminating  at  the  upper  wall  of  the  neck 
of  the  bone,  a  little  to  the  inner  side  of  the  greater  trochanter.  By  this 
arrangement,  the  shifting  of  the  weight  toward  the  outer  or  upper  portion 
of  the  head  is  provided  for,  the  pressure  coming  in  greater  degree  on  the 
outer  wall  of  the  shaft,  the  inner,  however,  receiving  its  share  through  the 
inner  columns  of  the  arches.  The  remainder  of  the  lamellae  run  in  various 
directions,  not  capriciously  nor  at  random,  but  so  as  to  afford  in  the  aggre- 
gate a  very  strong  support  to  the  solid  but  thiii  wall  of  the  bone. 

The  capsular  ligament,  properly  so  called,  extends  from  the  edge  of  the 
cotyloid  ligament  to  the  base  of  the  neck  of  the  bone ;  that  is,  to  the  root  of 
each  trochanter,  and  to  the  ridges  which  connect  them  before  and  behind. 
When  laid  open,  this  is  found  to  be  lined  by  the  synovial  membrane,  which 
is  reflected  from  it  to  the  neck  of  the  bone,  the  line  of  reflection  not  corre- 
sponding, however,  with  that  of  the  attachment  of  the  capsule.  A  portion 
of  the  cervix  is,  therefore,  surrounded  only  by  fibrous  tissue,  the  outer  layer 
of  which  belongs  to  the  capsular  ligament,  while  the  deeper  is  the  perios- 
teum, the  two  being  inseparable  by  dissection. 

I  think  that  generally  the  distance  between  the  reflection  of  the  synovial 
membrane  and  the  inter-trochanteric  lines  is  about  half  an  inch ;  one  or  two 
pockets,  however,  existing,  where  the  joint  cavity  is  somewhat  prolonged 
outward.  One  of  these  pockets  is  usually  just  within  the  gemelli  muscles  in 
the  digital  fossa,  behind  the  greater  trochanter.  Differences  exist  between 
different  individuals  in  regard  to  the  precise  relative  extent  of  the  synovial 
membrane  and  the  neck  of  the  bone. 

An  arrangement  of  the  immediate  investment  of  the  neck  of  the  femur 
(called  by  Amesbury  "  the  close  coverings")  which  seems  to  have  escaped  the 

1  Edinburgh  Med.  and  Surg.  Journal,  July  and  October,  1836. 


FRACTURES  OF  THE  FEMUR. 


189 


notice  of  writers  on  anatomy,  is,  I  think,  of  importance.  Under  this  portion 
of  the  synovial  membrane  are  often  to  be  noticed,  raising  it  into  longitudinal 
folds,  several  strong  ligamentous  bands.^  (Fig.  838.)  Once,  in  a  fresh  sub- 
ject, a  vessel  of  some  size  was  seen  by  me  running  along  one  of  these  folds. 
Another  subject,  a  woman,  had  in  each  hip-joint  three  such  folds,  directed 
obliquely  (spirally)  from  left  to  right  in  that  of  the  left  side,  and  from  right 
to  left  in  that  of  the  right ;  these  were  in  addition  to  the  longitudinal  bands 
above  described. 

When  these  folds  exist,  they  must  obviously  exert  an  influence  in  diminish- 
ing the  chance  of  fracture  of  the  cervix,  and  in  the  event  of  such  fracture, 

Fig.  838.  Fig.  839. 


Ligamentous  bands  beneath  synovial  capsule  of  Diagram  showing  lines  of  fracture  in  upper  part  of 

hip-joint.    (After  Amesbury.)  femur. 

such  of  them  as  are  unbroken  must  tend  to  prevent  displacement.  Possibly, 
vessels  borne  by  them  may  be  of  importance  in  the  nutrition  of  the  pelvic 
fragment. 

The  principal  lines  of  fracture  in  the  upper  part  of  the  femur  are  shown  in 
the  diagram.  (Fig.  839.)  The  neck  may  be  broken  across  just  below  the 
head  ;  or  the  fracture  may  begin  below,  just  at  or  near  the  lesser  trochanter, 
and  run  up  obliquely  across  the  neck,  with  more  or  less  serration ;  or  the 
greater  trochanter  may  be  broken  off.  In  not  a  few  instances  the  latter  lesion 
has  been  produced  by  the  wedge-like  action  of  the  pelvic  fragment,  the  main 
breakage  being  of  the  preceding  form ;  and  sometimes  the  lesser  trochanter 
also  has  been  detached.  Of  course,  in  such  a  case,  the  fracture  would  be 
properly  called  a  comminuted  one. 

In  the  many  and  voluminous  discussions  bestowed  upon  this  subject  of 
fractures  of  the  neck  of  the  thigh-bone,  it  seems  to  me  that  certain  facts, 
anatomical,  mechanical,  and  pathological,  have  been  too  much  disregarded. 
The  anatomical  facts  have  been  set  forth  above,  and  the  others  will  presently 
be  mentioned. 

Authors  have  been  generally  agreed  in  c'.ividing  these  fractures  into  intracap- 
sular, extracapsular,  and  mixed.   Under  tne  first  head  are  those  which  separate 

*  Called  by  Weitbreclit  "  Retinacula."  They  are  spoken  of  hv  Harrison,  in  the  Dublin  Dis- 
sector, and  by  Todd,  in  the  Cyclopaedia  of  Anatomy  and  Physiology,  Art.  Hip-Joint. 


190 


INJURIES  OF  BONES. 


the  neck  in  a  direction  almost  or  quite  transverse ;  under  the  second,  those  which 
involve  the  portion  of  bone  close  to  the  lesser  trochanter ;  and  under  the  third, 
those  which  beo-in  near  the  trochanter  and  run  upward  across  the  neck  of  the 
bone  to  a  point  close  to  the  margin  of  the  head.  But  unless  the  description 
above  given  of  the  extent  and  attachments  of  the  capsular  lig^ament  is  incor- 
rect, all  these  fractures  are  within  the  capsule.  A  more  correct  phraseology 
would  be  "intra-articular"  for  those  which  concern  the  part  of  the  bone  beneath 
the  synovial  membrane  of  the  hip-joint,  and  "extra-articular"  for  those  which 
are  wholly  outside  of  it.  Of  the  latter  class,  I  think,  very  few  examples  can 
be  found,  the  great  majority  of  cases  being  those  in  which  the  fracture  affects 
the  bone  partly  beneath  the  synovial  membrane  and  partly  beyond  its  limits. 
Bigelow  says :  "  In  lecturing  upon  this  subject,  I  have  been  in  the  habit 
of  dividing  the  injuries  of  the  neck  of  the  femur  into  the  impacted  fracture 
of  the  base  of  the  neck  and  the  unimpacted  fracture  of  the  rest  of  the  neck, 
without  regard  to  the  capsule — a  practical  classification,  embracing  a  majority 
of  cases,  and  to  which  the  other  lesions  may  be  regarded  as  exceptional." 

Viewed  mechanically,  the  femur  is  a  bent  lever,  arranged  for  the  purpose  of 
receiving  the  weight  of  the  body,  and  of  being  moved  so  as  to  transfer  it  from 
place  to  place.  Any  force  brought  to  bear  upon  the  femur  so  as  to  tend  to 
diminish  the  angle  between  the  neck  and  the  shaft,  in  other  words,  any  force 
driving  the  head  downward  or  the  shaft  upward,  the  opposite  end  being  pre- 
vented from  yielding,  may  cause  a  fracture  beginning  at  the  lesser  trochanter, 
and  tearing  away  the  mass  of  lamellae  described  as  radiating  upward  from  that 
point  tow^ard  the  head.  This  will  only  happen  if  the  force  is  excessive,  or  if 
it  bears  upon  the  bony  texture  out  of  the  proper  line  of  transmission  of  the 
weight  of  the  body.  A  blow  upon  the  greater  trochanter  may  do  it,  or  a 
blow  either  in  front  or  behind  the  base  of  the  neck  of  the  bone ;  in  either 
case  the  central  point  of  the  neck,  as  it  might  perhaps  be  called — the  apex  of 
the  pyramid  of  columns — is  the  starting-point  of  the  rending  of  the  bone. 
This  idea  can  readily  be  understood  by  any  one  who  will  carefully  examine 
a  vertical  section  of  the  upper  portion  of  a  well-developed  femur.  Moreover, 
such  a  section  will  show  also  how  the  greater  trochanter  may  be  split  off. 

Out  of  a  very  large  number  of  specimens  of  fracture  of  the  neck  of  the 
femur  which  I  have  examined,  every  one  which  belonged  to  the  "  extracap- 
sular" class,  that  is,  every  one  in  which  the  fracture  was  not  clearly  within 
the  limits  of  the  synovial  membrane,  presented  a  long  point  running  down 
close  to  the  lesser  trochanter,  embracing  the  lower  wall  of  the  neck  of  the 
bone,  and  the  pyramidal  mass  of  columns  already  so  often  mentioned.  And 
in  this  statement  may  also  be  included  all  those  specimens  which  would  be 
placed  under  the  head  of  "mixed."  In  other  words,  I  feel  warranted  in  say- 
ing that  all  fractures  of  the  neck  of  the  femur  are  divisible  into  two  classes : 
one  in  which  the  line  of  separation  runs  across  the  neck  of  the  bone  between 
the  reflection  of  the  synovial  membrane  and  the  margin  of  the  head,  the 
other  in  which  the  line  begins  close  to  the  trochanter  and  runs  up  obliquely, 
and  more  or  less  irregularly,  to  the  upper  surface  of  the  neck  near  the  head. 
This  long,  wedge-like  point  is  very  apt  to  be  driven  into  the  cancellous  struc- 
ture of  the  uppermost  part  of  the  shaft,  and  .may  split  or  burst  away  several 
fragments  of  it,  one  of  which  will  probably  consist  of  the  greater  trochanter. 

By  a  mechanism  not  materially  clifierent  from  that  now  described,  fracture 
may  be  caused  by  any  force  acting  upon  the  shaft  of  the  femur  as  a  lever,  the 
head  of  the  bone  being  fixed  ;  the  enormous  advantage  aftbrded  by  the  length 
of  the  shaft  must  be  at  once  apparent. 

As  to  the  production  of  the  intra-articular  fractures — those  in  wdiich  the 
neck  of  the  bone  is  broken  nearly  or  quite  transversely — they  are  generally 
due,  I  believe,  to  a  twist  impressed  upon  the  part.   In  some  cases  this  is  very 


FRACTURES  OF  THE  FEMUR. 


191 


obvious,  as,  for  example,  when  the  bone  gives  way  hy  reason  of  the  patient 
tripping,  or  in  merely  turning  around  suddenly.  Here  the  great  leverage 
afforded  by  the  length  of  the  femur  is  almost  doubled  by  the  addition  to^it 
of  the  length  of  the  leg ;  and  it  can  scarcely  be  a  matter  of  surprise  that  the 
neck  of  the  bone  should  yield. 

The  accidents  which  cause  these  fractures  may  be  various:  falls  on  the  feet 
or  knees,  driving  the  femur  upward,  or  falls  or  blows  upon  the  trochanter,  in 
whatever  direction  these  may  come.  Sometimes  it  is  difficult  to  tell  whether 
the  fall  is  the  cause  or  the  result  of  the  fracture,  in  the  cases  especially  of  old 
people,  and  when  the  fracture  is  evidently  within  the  joint. 

.  I  may,  perhaps,  anticipate  somewhat  here,  by  saying  that  in  practice  the 
distinction  is  not  always  easily  drawn  between  the  two  forms  of  fracture. 
The  differential  signs  so  clearly  laid  down  by  authors  may  not  exist,  or  they 
may  be  masked  by  swelling,  or  by  the  obesity  of  the  patient. 

After  what  has  been  said  of  the  mode  of  production  of  these  injuries  gen- 
erally, it  will  not  be  difficult  to  see  how  the  capsular  ligament  and  periosteum 
may  be  only  partially  torn,  and  may  sometimes  even  remain  entire.  Under 
but  slight  stress,  momentarily  sustained,  the  fibrous  structures  may  be  only 
stretched.  If  they  give  way  at  one  part  only,  that  part  will  correspond  to 
the  greatest  separation  of  the  bone.    Such  cases  are  by  no  means  rare. 

One  instance  is  on  record,  and  the  specimen  is  preserved  in  the  Warren 
Museum,^  of  partial  fracture  or  fissure  of  the  neck  of  the  femur.  It  was 
taken  from  a  man  aged  forty-two,  who  had  fallen  through  two  stories  of  a 
building,  upon  a  hard  floor.  The  shaft  of  the  bone  was  also  broken  trans- 
versely at  about  the  middle.  "The  fissure  involves  about  three-fourths  of 
the  circumference  of  the  neck,  the  inner  anterior  portion  only  being  spared ; 
and  to  a  considerable  extent  it  runs  along  very  near  to  the  head  of  the  bone! 
It  is  quite  closed,  but  there  is  considerable  motion  between  the  head  and 
neck,  when  the  head  and  shaft  are  grasped,  and  moved  upon  each  other ;  and 
the  fissure  would  undoubtedly  result  in  a  perfect  fracture  if  much  force  were 
used." 

Coulon  is  quoted  by  Holmes^  as  having  seen  "  the  neck  of  the  femur  frac- 
tured m  straightening  a  diseased  hip,  though  no  chloroform  was  given,  and 
the  extension  so  gently  conducted  that  the  child  did  not  cry." 

The  sym.ptom,s  of  fractures  of  the  neck  of  the  femur  are  very  variable  in 
the  degree  of  their  distinctness.  Cases  sometimes  occur  in  which  a  mistake 
would  be  impossible,  while  in  others  the  utmost  care  and  skill  cannot  enable 
the  surgeon  to  arrive  at  a  positive  conclusion. 

In  well-marked  cases  there  is  loss  of  power  in  the  limb,  standino-  and  walk- 
ing are  out  of  the  question,  and  the  patient  cannot  even  raise  the* knee  as  he 
lies  m  bed.  The  limb  is  drawn  upward,  or  shortened ;  this  fact  beino-  appa- 
rent at  a  glance,  and  verified  by  measurement  made  from  the  anterior  supe- 
rior spme  of  the  ilium,  or  from  the  umbilicus,  to  the  inner  malleolus.  Vari- 
ous forms  of  apparatus  for  making  this  measurement  have  been  devised  by 
Morton3  and  others,  but  are  scarcely  available  except  in  hospital  practice,  and 
equally  accurate  results  may  be  arrived  at  with  a  good  tape-line,  carefully 
used.  The  patient  should  be  laid  perfectly  straight,  on  a  level  surface,  such 
as  that  of  a  hard  mattress,  or  upon  blankets  folded  and  placed  on  the  floor- 
and  care  should  be  taken  to  have  the  pelvis  exactly  transverse.  I  do  not 
think  It  of  any  use  to  mark  the  points  upon  the  skin,  as  is  the  practice  of 
some  surgeons,  since  such  marks  cannot  but  be  movable.    The  tape  should  be 

T'^^'-P-        .^""'.^^^-.l^.l'^^'         Hamilton,  pp.  98  and  396  ;  and  Mussey,  Am.  Journ. 
ot  the  Med.  Sciences,  April,  1857. 

2  Surgical  Treatment  of  Children's  Diseases,  1st  ed.,  p.  244. 

®  Surgery  in  the  Pennsylvania  Hospital,  p.  288. 


192 


INJURIES  OF  BONES. 


carried  from  the  upper  point  down  along  the  inner  side  of  the  knee  to  the 
lower  edge  of  the  inner  malleolus,  on  the  shortened  side  first,  and  then  on  the 
normal  limb.  During  this  procedure  the  coverings  should  be  all  removed, 
and  the  parts  concerned  completely  exposed  ;  although  in  women  the  genitals 
should  be  concealed  by  folding  in  the  clothing  over  them. 

Sometimes  the  shortening,  scarcely  perceptible  at  first,  becomes  more 
marked  within  a  few  days,  and,  if  uncorrected,  continues  to  increase  until  it 
reaches  its  maximum.  Sometimes  it  is  suddenly  produced,  a  week  or  more 
after  the  accident,  by  the  disengagement  of  the  fragments.  Sometimes, 
again,  it  is  at  first  very  slight,  but  gradually  augments  as  the  injured  bone 
undergoes  atrophic  change. 

Besides  the  measurement  of  the  length  of  the  limb,  just  mentioned,  it  is 
well  to  determine  the  distance  between  the  trochanter  and  the  anterior  supe- 
rior spine  of  the  ilium,  and  so  compare  it  with  that  on  the  sound  side. 

A  result  of  the  shortening,  to  which  attention  has  recently  been  called  by 
Allis,  is  the  relaxation  of  the  fascia  between  the  trochanter  and  the  crest  of 
the  ilium.  As  a  diagnostic  sign,  it  does  not  seem  to  me  that  this  would  be 
as  valuable  as  an  accurate  measurement. 

To  determine  the  position  of  the  trochanter  several  methods  have  been  sug- 
gested. iN'elaton's  line  is  determined  by  carrying  a  tape  from  the  anterior 
superior  spine  of  the  ilium,  round  the  outer  side  "  to  the  most  prominent 
part  of  the  tuber  ischii.  In  the  natural  condition,  the  top  of  the  trochanter 
in  every  position  is  in  some  part  of  that  line."^  Bryant  drops  a  vertical  line 
from  the  anterior  superior  spine  of  the  ilium  to  the  mattrtss  on  which  the 
patient  lies,  and  then  ascertains  the  distance,  measured  horizontally,  from  the 
top  of  the  trochanter  to  this  line. 

As  a  general  rule,  the  foot  is  everted.  So  constant  is  this  symptom,  that 
the  diagnosis  may  sometimes  be  settled  in  the  surgeon's  mind,  in  the  case  of 
an  elderly  patient,  by  this  and  the  shortening  exclusively.  It  would  seem  to 
be  due  partly  to  the  fracturing  force,  partly  to  the  weight  of  the  foot  and 
the  natural  shape  of  the  limb,  and  partly  to  the  action  of  the  rotator  muscles, 
the  glutei  especially.  A  number  of  cases,  however,  are  upon  record  in  which 
the  foot,  instead  of  being  everted,  w^as  turned  inward  ,2  probably  by  reason  of 
impaction  of  the  fragments.  Sometimes,  as  in  a  case  under  Stanley's  care, 
recorded  by  Ormerod,^  the  foot  is  neither  turned  outward  nor  inward,  but 
remains  straight,  the  explanation  being  the  same.  Ormerod  says  "the  neck 
was  broken  irregularly,  so  that  the  lower  portion  was  wedged  slightly  into 
the  upper,  and  overlapped  by  it  in  front." 

Pain  is  rarely  absent,  although  it  varies  in  degree.  Sometimes  it  is 
referred  to  the  groin,  a  fact  explained  by  the  derivation  of  the  nerves  sup- 
plj'ing  the  hip-joint  from  the  obturator  nerve. 

On  grasping  the  thigh  and  leg,  and  rotating  the  entire  limb,  it  will  often 
be  found  that  the  trochanter  describes  a  less  extensive  arc  than  normally. 
This,  however,  is  a  fact  not  always  easy  to  verify,  and  in  the  case  of  impac- 
tion the  fragments  may  move  together,  the  pelvic  one  rolling  naturally  in  the 
acetabulum,  so  as  to  be  altogether  deceptive.   Agnew  recommends  that  during 

1  Holmes's  System  of  Surgery,  3d  ed.,  vol.  i.  p.  1003. 

2  Cooper,  Dislocations  and  Fractures,  p.  131,  note,  and  Case  Ixxxvii.  p.  158.  See,  also,  cases 
by  Guthrie  and  Stanley,  in  the  Med.-Chir.  Transactions,  vol.  xiii.  In  Stanley's  case  the  frac- 
tTire  "  extended  obliquely  through  the  middle  of  the  neck  of  the  femur,  but  entirely  within  the 
capsule."  The  inversion  of  the  foot  led  to  a  suspicion  of  luxation,  and  to  attempts  at  reduction. 
"  A  portion  of  the  fibrous  and  synovial  membrane  on  the  anterior  side  of  the  neck  of  the  bone 
had  escaped  laceration."  R.  W.  Smith  has  recorded  several  cases.  Bigelow  mentions  one  in 
his  work  "On  the  Hip,"  and  Hamilton  has  seen  one.  Another  instance  has  recently  been 
reported  by  Dr.  Conklin,  of  Ohio,  in  the  Columbus  Medical  Journal  for  November,  1882. 

8  Op.  cit.,  p.  44. 


FRACTURES  OF  THE  FEMUR.  193 

this  procedure  the  thigh  should  be  flexed  to  nearly  a  right  angle  with  the 
body.  The  great  leverage  given  by  the  leg  (the  knee  being  of  course  flexed 
also),  should  not  be  forgotten,  as  the  fragments  may  be  readily  displaced,  and 
damage  done. 

Crepitus  may  be  elicited  by  this  manoeuvre,  and  is  often  perceptible  even 
if  the  degree  of  impaction  be  considerable  ;  although  in  such  a  case  it  will  be 
slighter  and  less  distinct  than  if  the  fragments  are  freely  movable  upon  one 
another.  This  and  the  preceding  sign  are  apt  to  be  in  the  same  ratio  of 
clearness. 

By  Maisonneuve,^  and  more  recently  by  Levis,^  it  has  been  advised  that 
the  patient  should  be  laid  on  his  face,  and  the  limb  lifted  up  from  the  bed  in 
a  backward  direction  ;  if  the  cervix  be  intact,  the  movement  will  be  very  soon 
arrested.  This  procedure  should  be  executed  with  the  utmost  gentleness,  if 
at  all,  on  account  of  the  risk  of  doing  mischief  by  separating  the  fragments 
bwelhngand  ecchymosis,  although  Very  apt  to  occur  when  the  injury  is 
the  result  of  force  applied  over  the  trochanter,  are  sometimes  wholly  wantin^r 
when  the  bone  has  yielded  to  slight  and  indirect  violence. 

The  cowr^g  of  fractures  of  the  femoral  neck  varies  greatly,  accordina;  to 
the  age  and  constitution  of  the  patient  and  the  character  and  severity  of  the 
local  injury.  In  the  old  and  infirm,  there  may  be  such  a  shock  induced  as 
to  undermine  the  general  health,  and  to  lead  to  the  extinction  of  life  within  a 
lew  wrecks  or  months. 

Occasionally  the  fatal  result  is  brought  about  by  suppuration.  McTyer^ 
recorded  the  case  of  a  woman,  aged  fifty-six,  who  fell  on  her  side,  and  had 
atterward  a  slight  halt  m  walking.  She  was  admitted  to  the  Infirmary 
three  months  after  the  accident,  for  "  ervsipelas  in  the  thigh."  A  puncture 
was  made,  and  a  large  quantity  of  pus  evacuated;  the  discharge  continued, 
and  death  took  place  on  the  eleventh  day.  The  neck  of  the  femur  was 
broken  within  the  synovial  membrane ;  "  the  abscess,  which  was  situated  in 
the  thigh,  communicated  through  the  lacerated  capsular  ligament  with  the 
hip-joint.  Reference  has  already  been  made^  to  Hunt's  ca^se  of  fracture  of 
the  neck  of  the  femur  in  a  man  aged  twenty-six,  who  died  on  the  twenty- 
second  day,  of  pelvic  abscess  and  pyaemia. 

More  commonly,  in  the  old,  the  limb  remains  in  a  great  degree  useless,  so 
that  the  patient  becomes  either  bed-ridden  or  a  crippte.  The  extent  of  the 
loss  of  power  may  be,  however,  but  slight,  especially  if  the  fracture  have  been 
an  impacted  one.  Even  when  bony  union  does  not  take  place,  there  may  be 
such  a  thickening  of  the  capsule  of  the  joint  as  to  enable  the  weight  of  the 
body  to  be  suspended,  as  it  were,  upon  the  fibrous  band  so  formed.  Perhaps 
the  Y-ligament  may  add  firmness  to  this  support ;  and  it  would  seem  that 
occasionally  tliere  are  adventitious  bands  formed,  as  in  an  instance  reported 
by  Parkman,^  m  which  there  were  shown  "  certain  bands  of  lymph  pmceed- 
ing  from  the  internal  surface  of  the  capsule  to  the  broken  surface  of  the 
upper  portion  or  head  of  the  bone."  Morgagni^  states  that  in  a  case  observed 
by  Kuysch,  ligamentous  union  had  occurred  betwen  the  broken  surfaces  and 
not,  as  asserted  by  Salzmami,  through  the  periosteum  alone;  and  numerous 
specimens  of  this  kind  may  be  found  in  museums. 

As  to  bony  union  between  the  fragments,  there  can  be  no  question  of  its 
trequent  occurrence  m  cases  involving  the  base  of  the  neck,  close  to  the  tro- 
chanters, or  m  what  are  commonly  called  extra-capsular  fractures  Some- 
times It  IS  very  firm,  and  the  accuracy  of  adaptation  of  the  portions  of  the 

1  Clinique  Chirurgicale,  tome  i.  p.  169.  2  Phiiadelpliia  Medioal  Times,  Jan.  31  1874. 

3  Glasgow  Medical  Journal,  Feb.  1831.  <  See  pacre  24 

*  Am.  Journal  of  the  Med.  Sciences,  Jan.  18521  ^ 
^  Op.  cit.,  Letter  LVI.  Art.  4. 
VOL.  IV. — 13 


194 


INJURIES  OF  BONES. 


bone  is  sucli  that  the  motions  of  the  joint  are  very  largely  recovered.  Thus 
Oanti  records  a  case  of  impacted  fracture  of  the  neck  of  the  femur,  with 
slio-ht  shortening,  in  which  recovery  took  place  w^ith  firm  union  and  a  freely 
movable  joint.  I  exhibited  to  the  Philadelphia  Academy  of  Surgery,  a  few 
years  since,  a  man  who  had,  when  seventy-two  years  of  age,  sustained  such 
a  fracture  by  falling  backward  upon  a  pile  of  timbers  ;  he  recovered  so  com- 
pletely that  it  w^as  not  apparent  from  his  gait  that  any  injury  had  ever  been 
received.  This  man  could  lift  either  knee  to  his  chin,  could  go  up  and  down 
stairs,  and  in  fact  had  no  disability  whatever.  A  very  similar  case  was  re- 
ported to  Sir  A.  Cooper,^  in  1840,  by  Mr.  Sheppard.  The  fracture,  in  a  man 
in  his  sixty-fourth  year,  w^as  thought  to  be  within  the  joint;  yet  at  tbe  end 
of  eighteen  months  he  was  able  to  resume  his  occupation  as  a  mail-coach 
guard,  climbing  up  and  down  from  his  box  "with  facility,  and  even  dexter- 
ously." 

Although  bony  union  may  be  obtained,  and  be  perfectly  firm,  yet  the  mo- 
tions of  the  joint  may  be  impaired  by  either  one  of  two  circumstances :  the 
broken  surfaces  may  be  so  displaced,  either  by  impaction  or  by  sliding  past 
one  another,  that  the  extent  of  motion  is  limited  in  one  or  another  direction; 
or  there  may  be  irregular  deposits  of  new  bone  about  the  seat  of  fracture, 
and  these  may  come  in  contact  w4th  the  edges  of  the  acetabulum,  or  even  with 
the  surrounding  portions  of  the  os  innominatum.  On  the  other  hand,  there 
may  be  absorption  of  some  portion  of  the  fragments,  leading  to  a  shortening, 
i:»erhaps  extreme,  of  the  neck  of  the  bone,  so  that  the  head  rests  down  against 
the  upper  end  of  the  shaft,  between  the  trochanters.  A  case  was  recently 
mentioned  to  me  by  Dr.  Townsend,  of  Bridesburg,  Pa.,  in  which  the  neck  of 
the  femur  was  broken,  and  the  shaft  was  strongly  drawn  upward.  Union 
occurred  between  the  pelvic  fragment  and  the  shaft  below  the  trochanter,  so 
that  when  the  patient  recovered  he  had  not  only  great  shortening  of  the  limb, 
but  its  abduction  was  singularly  hindered  by  the  contact  of  the  trochanter 
w^ith  the  ilium. 

The  question  has  been  often  discussed,  w^hether  or  not  bony  union  could 
take  place  in  cases  of  intra-capsular,  or  to  speak  more  correctly  intra-articular, 

fracture.  A  number  of  instances  have  been  recorded 
as  of  this  character,  and  from  time  to  time  others  are 
likely  to  be  brought  forward.  In  1867,1  published 
a  paper^  in  which  I  suggested  w^hat  still  seems  to  me 
to  be  the  true  explanation  of  the  majority  of  these 
cases,  namely,  that  they  are  originally  either  wholly 
or  in  part  outside  of  the  joint,  and  become  solidly 
united  by  bone  ;  after  which  a  gradual  absorption  of 
the  pelvic  fragment  takes  place,  allowing  the  head 
of  the  bone  to  settle  down  between  the  trochanters. 
(Fig.  840.)  Since  the  publication  of  these  views. 
Professor  P.  W.  Smith  has  reported^  to  the  Patholo- 
gical Society  of  Dublin  a  case  of  bony  union  of  a 
fracture,  believed  to  have  been  within  the  capsule ; 
Shortening  of  cervix  femoris  con-  and  auothcr  casc  was  reported  by  Dr.  Senn,  of  Chi- 
secutive  to  fracture.  cago,  to  thc  Amcrlcau  Surgical  Association,  in  1882.^ 

^  Am.  Journal  of  the  Med.  Sciences,  July,  1866,  from  Med.  Times  and  Gazette,  April  14. 

2  Op.  cit.,  p.  566. 

3  Am.  Journal  of  the  Med.  Sciences,  Oct.  1867.  Three  cases  claimed  to  have  been  seen  by 
Fabri  (Ibid.  Jan.  1863),  had  escaped  my  notice,  but  they  are  too  meagrely  described  to  be  of  any 
value. 

*  Dublin  Journal  of  Med.  Science,  Jan.  1873. 
5  Medical  News,  June  17,  1882. 


FRACTURES  OF  THE  FEMUR. 


195 


But  it  seems  to  me  that  the  same  explanation  applies  in  these  as  in  the  other 
cases. 

I  have  seen,  however,  one  specimen  which  I  believe  to  have  been  unques- 
tionably  an  intra-articular  fracture  of  the  cervix  femoris,  united  by  bone. 
It  was  presented  to  the  College  of  Physicians  of  Philadelphia*  by  Dr.  J.  M. 
Adler.  The  patient  was  an  old  lady  of  sixty-live,  paraplegic,  who  fell  out 
of  bed.  Her  foot  was  inverted,  and  the  limb  shortened  ;  there  was  pain  in 
the  groin  and  .hip-joint,  and  crepitus.  She  died  live  months  afterward,  and 
the  bone  was  removed  and  dried.  On  its  presentation  to  the  College,  it  was 
referred  to  a  committee  consisting  of  Dr.  A.  Ilewson,  Dr.  John  Ashhurst,  Jr., 
and  myself.  We  carefully  examined  it,  and  reported  unanimouslj^  that  it 
was  an  impacted,  intra-capsular  (intra-articular)  fracture,  united  by  bone. 

Let  me  say  that  some  time  since,  when  in  Cincinnati,  I  had  an  opportunity, 
by  the  kindness  of  Dr.  IS".  P.  Dandridge,  of  inspecting  one  of  the  specimens 
reported  and  figured  by  Mussey,^  and  that  the  line  of  fracture  was  readily 
traceable,  extending  down  close  to  the  lesser  trochanter,  according  to  the  rule 
stated  on  a  previous  page ;  thus  proving  in  the  case  of  that  specimen  that 
the  fracture  had  not  been  entirely  within  the  limits  of  the  joint.^ 

Various  causes  have  been  assigned  for  the  frequent  occurrence  of  non-union 
in  the  intra-articular  fractures  of  the  cervix.  One,  which  has  been  very 
generally  regarded  as  the  chief,  is  the  want  of  nourishment  of  the  pelvic  frag- 
ment, which  loses  all  connection  with  the  vascular  system  except  through  the 
ligamentum  teres.  Another  is  the  excess  of  synovia  formed  under  the  irrita- 
tion induced  by  the  injury,  by  which  the  reparative  material  is  continually 
washed  away  from  the  broken  surfaces.  Still  another,  and  probably  not  the 
least  important,  is  the  readiness  of  movement  between  the  pelvic  and  distal 
fragments,  which  indeed  are,  in  some  cases,  completely  separated.  But,  how- 
ever it  may  be  accounted  for,  the  fact  remains,  and  !3ony  union  must  be  re- 
garded as  practically  unattainable  by  any  care  or  foresight  on  the  part  of  the 
sura-eon. 


very  great  difficulties.  It  is  by  no  means  always  easy  to  determine  whether 
the  fracture  is  wholly  within  the  joint,  or  wholly  outside  of  it,  or  partly 
intra-articular  and  partly  extra-articular.  When,  however,  the  patient  is  old 
and  infirm,  and  the  violence  infiicted  has  been  very  slight,  such  as  is  caused 
by  tripping  in  a  fold  of  the  carpet ;  when  the  shortening  of  the  limb  is 
immediate  and  marked  ;  and  when  there  is  great  mobility  of  the  fragments 
upon  one  another,  as  shown  by  the  ready  rotation  of  the  limb,  the  trochanter 
describing  a  small  arc— the  presumption  is  that  the  separation  has  taken  place 
near  the  bead  of  the  bone. 

When"  the  accident  has  been  a  severe  one,  such  as  a  fall  upon  the  hip ;  if 
the  patient  is  heavy,  and  especially  if  the  age  is  such  as  to  make  it  improbable 
that  the  bones  have  undergone  such  degenerative  change  as  to  w^eaken  their 
texture  ;  when  the  shortening  is  but  slight,  and  the  fragments  show  no  signs 
of  free  mobility  upon  one  another,  it  may  be  regarded  as  probable  that  the 
fracture  is  outside  of  the  joint,  and  that  more  or  less  impaction  exists. 

Prof.  R.  W.  Smith's  assertion  that  "  the  extra-capsular  fracture  is  always 
acconjpanied  by  a^  fracture  of  one  or  both  trochanters"  would,  if  proved, 
1  a  \  aluable  diagnostic  sign,  as  the  mobility  of  the  greater  trochanter 
could  in  general  be  ascertained,  and  this,  along  with  the  other  symptoms, 

1  Summary  of  Transactions,  in  the  Am.  Journal  of  the  Med.  Sciences,- April,  1870. 

2  Am.  Journal  of  the  Med.  Sciences,  April,  1857. 

3  The  reader  who  desires  to  examine  further  into  this  subject  will  find  the  references  to  the 
supposed  cases  of  bonj  union  in  intra-capsular  fractures  of  the  cervix  femoris  in  mv  paper, 
before  mentioned  ;  also  in  Hamilton's  work  on  Fractures  and  Dislocations. 


sometimes  clear,  may  present 


196 


INJURIES  OF  BONES. 


would  be  conclusive.  But,  al though  Prof.  Smith  adduces  a  large  number  of 
cases  in  support,  of  his  opinion,  there  are  many  specimens  of  the  fracture  in 
question,  in  which  the  trochanter  remains  unbroken ;  and  hence  this  idea 
cannot  form  a  ground  for  diagnosis.- 

The  other  lesions  with  which  fracture  of  the  cervix  femoris  may  be  con- 
founded, and  from  which  it  needs  to  be  distinguished,  are  luxation  of  the 
hip-joint,  and  fracture  of  the  acetabulum.  Of  the  latter,  an  instance  is 
recorded  by  Mr.  Marsh  ;^  the  main  symptoms  were  shortening  and  eversion 
of  the  limb,  and  the  true  nature  of  the  lesion  was  only  discovered  upon 
examination  after  death.  As  to  the  means  of  distinguishing  fractures  about 
the  hip  from  luxations  of  that  joint,  the  foregoing  discussion  of  the  symp- 
toms of  fracture  leaves  very  little  to  be  said.  I  may,  however,  again  call 
attention  to  the  fact,  elsewhere  referred  to,^  that  while  in  luxation  there  is 
limitation  of  passive  motion  in  one  or  more  directions,  in  fracture  it  is  apt 
to  be  rather  abnormally  free.  Great  difficulties  may,  especially  in  persons 
below  middle  age,  surround  this  question.  In  one  instance  within  my 
knowledge,  a  man  was  twice  examined,  under  anaesthesia,  by  four  expe- 
rienced surgeons,  who  decided  that  he  had  a  fracture  of  the  cervix  femoris, 
but  after  the  swelling  had  subsided  it  was  discovered  that  the  head  of  the 
femur  was  resting  upon  the  dorsum  ilii,  and  there  it  remained,  all  attempts 
at  reduction  failing. 

After  middle  life,  and  in  proportion  to  the  development  of  the  peculiarities 
belonging  to  advancing  age,  the  chances  in  favor  of  fracture  as  against  luxa- 
tion steadily  increase,  until  in  the  very  old  the  latter  lesion  is  almost  out  of 
the  question.  The  few  instances  of  the  kind  on  record  should,  however, 
inspire  caution,  and  prevent  too  hasty  a  judgment.  Malgaigne  quotes  with- 
out question  the  observation  by  Gauthier  of  a  luxation  of  the  hip  in  a  woman 
of  eighty -six,  and  Hamilton  another  in  a  woman  of  seventy-three,  which  was 
unreduced  when  she  was  seen  thirteen  years  later. .  Hence,  in  any  case  in 
which  there  is  room  for  doubt,  a  careful  and  thorough  examination  should 
be  instituted  before  pronouncing  a  positive  opinion. 

The  prognosis  in  these  fractures  is  always  grave.  Although  life  may  not 
be  destroyed,  the  chance  is  that  the  patient  will  be  a  cripple  for  the  remain- 
der of  his  days,  and  no  surgeon  should  hold  out  hopes  of  complete  recovery  in 
such  cases.  At  the  same  time,  much  depends  upon  keeping  up  the  courage 
of  the  old  and  feeble,  and  it  will  often  require  tact  and  skill  to  do  this. 

As  to  the  treatment^  it  must  vary  with  the  circumstances  of  each  case. 
Sometimes  all  that  can  be  done  is  to  promote  the  comfort  of  the  patient  and 
to  sustain  his  strength.  Often  the  inconvenience  and  even  distress  caused  by 
the  application  of  confining  apparatus,  especially  in  cases  of  very  old  persons, 
will  outweigh  all  the  advantage  derived  from  it.  Yet  there  are  manj 
instances,  in  those  who  may  reasonably  look  forward  to  a  considerable  term 
of  life,  in  which  suitable  treatment  may  do  much  to  mitigate,  if  not  to  pre- 
vent, lameness.  In  the  former  class  of  cases,  the  knee  should  be  supported  on 
a  pillow,  and  the  limb  placed  in  the  easiest  position,  with  the  muscles  relaxed. 
The  patient  should  be  allowed  to  lie  as  may  suit  him  best ;  sometimes  a  reclin- 
ing chair,  enabling  him  to  sit  up  and  lie  back  alternately,  answers  an  excellent 
purpose.  Bed-sores  must  be  carefully  guarded  against  by  cleanliness,  by  fre- 
quent washing  of  the  prominent  bony  points  with  whiskey,  and  by  the  use  of 
India-rubber  air-cushions.  Sometimes  these  cases  are  complicated  by  drib- 
bling of  urine,  especially  in  old  men  with  prostatic  enlargement ;  and  then 
the  bladder  should  be  emptied  with  the  catheter  at  stated  times. 

In  cases  of  the  other  class,  extension  is  called  for,  and  may  be  best  effected 


»  British  Med.  Journal,  March  18,  1882. 


2  See  p.  29. 


FRACTURES  OF  THE  FEMUR. 


197 


by  means  of  adhesive  plaster,  carried  along  the  entire  limb,  and  attached 
below  to  a  cord  running  over  a  pulley  and  having  a  weight  at  the  end  of  it. 
This  weight  need  not  be  more  than  two  or  three  pounds,  and  should  never  be 
sufficient  to  annoy  the  patient.  The  object  is  not  so  much  to  draw  the  limb 
down,  as  to  steady  it,  and  prevent  any  increase  of  the  shortening.  Sand-bags 
should  be  placed  along  the  sides  of  the  limb,  and  the  foot  should  be  supported 
as  nearly  upright  as  possible.  By  elevating  the  foot  of  the  bed  on  bricks, 
the  weight  of  the  body  is  made  to  afford  counter-extension.  My  own  prac- 
tice is  to  direct  the  patient,  after  ten  days  or  two  weeks,  to  sit  up  in  bed  a 
little  while  each  day,  the  extension  being  kept  up ;  thus  preventing  the  hip- 
joint  from  becoming  stiffened. 

Excision  of  the  detached  head  of  the  bone  has  been  proposed,  but  I  know 
of  but  one  instance^  in  which  such  a  procedure  has  been  adopted,  and  in  that 
the  result  was  a  useless  limb.  It  seems  to  me  that  this  operation  could  only 
be  justified  in  cases  in  which  suppuration  had  taken  place,  and  that  even  then 
its  advantage  would  be  questionable.  The  same  may  be  said  of  the  operative 
measures  proposed,  and  in  a  few  instances  carried  out,  for  fastening  the  frag- 
ments together,  and  avoiding  the  non-union  so  apt  to  ensue  after  fractures  in 
this  region.  Such  a  course  would  be  useless  in  the  old  and  feeble,  and  unne- 
cessary in  younger  persons,  in  whom  fairly  satisfactory  results  can  be  obtained 
by  less  difficult  and  less  dangerous  means. 

Fractures  of  the  neck  of  the  femur  may  occasionally  be  complicated  with 
luxation  of  the  head  of  the  bone.  Such  a  case  was  met  with  by  Thornhill,^ 
who  effected  reduction,  by  means  of  pulleys,  at  the  end  of  six  weeks.  Tunne- 
cliff^  has  reported  the  case  of  a  farmer,  thirty  years  old,  who  was  caught 
under  a  falling  tree,  and  had  a  fracture  of  the  cervix,  the  head  of  the  bone 
being  also  displaced  into  the  sciatic  notch  ;  reduction  was  accomplished  by 
manipulation  on  the  thirty-eighth  day.  Another  instance  was  recorded  by 
Douglas.'*  It  was  observed  after  death  in  the  body  of  an  old  fisherman,  who 
had  twelve  years  previously  sustained  a  hurt.  The  head  of  the  femur  was 
in  the  groin,  under  the  middle  of  Poupart's  ligament,  "the  femoral  vein  and 
artery  being  to  its  outer  side  and  upon  it ; "  the  neck  of  the  bone  was  broken 
outside  of  the  capsule.  In  these  cases  the  luxation  must  have  been  first 
produced  and  then  the  fracture ;  for  otherwise  there  would  not  have  been 
purchase  enough  to  dislodge  the  head  of  the  bone. 

Mr.  Henry  Morris^  recently  reported  to  the  Royal  Medical  and  Chirurgical 
Society  a  case  of  impacted  fracture  of  the  neck  of  the  femur,  in  an  old  man 
who  had  for  years  had  an  unreduced  dorsal  dislocation  of  the  same  thigh. 
Under  examination  the  impaction  was  broken  down,  and  union  occurred  with 
the  limb  in  a  much  better  position.  Occasionally,  but  very  rarely,  the  vessels 
sufier.  Thus,  Brainard^  mentions  a  case  in  which  aneurism  of  the  femoral 
artery  was  developed  as  a  result  of  fracture  of  the  cervix  femoris  produced 
b}^  a  blow  against  a  wheel ;  the  external  iliac  artery  was  successfully  ligated. 
Robinson^  reported  a  similar  case,  in  which  an  operation  was  proposed,  but 
refused  by  the  patient,  who  died.    ^N'o  autopsy  could  be  obtained. 

Separation  of  the  upper  epiphysis  of  the  femur  may  be  mentioned  here. 
It  is  very  analogous  to  fracture  of  the  neck  of  the  bone  close  to  the  head,  but 

•  Howe,  Med.  Record,  Nov.  ]6,  1878.  In  the  Index  Medicus  for  May,  1882,  there  is  a  reference 
to  a  work  by  Wiesenthal  :  Ueber  operative  Behandlung  intracapsularen  Schenkelhalsbriiche 
durch  Excision  des  abgebrochenen  Gelenkkopfes.    Halle,  1881.    I  have  not  had  access  to  it. 

2  London  Med.  Gazette,  July  20,  1836. 

•  Am.  Journal  of  the  Med.  Sciences,'  July,  1868. 

•  London  and  Edinburgh  Monthly  Journal  of  Medical  Science,  Dec.  1843. 

«  Lancet,  Feb.  18,  1882.  6  Am.  Jour,  of  the  Med.  Sciences,  Oct.  1843. 

'  London  Medical  Gazette,  June  28,  1834. 


198 


INJURIES  OF  BONES. 


occurs,  of  course,  only  in  the  young,  the  epiphysis  uniting  with  the  neck  at 
about  the  eighteenth  year.  Another  important  difference,  as  appears  from 
the  recorded  cases,  is  the  much  greater  violence  generally  assigned  as  the 
cause  of  the  epiphyseal  disjunction.  Six  instances  of  this  lesion  may  be 
found  described  by  Hamilton,  one  of  which  he  himself  saw.  Hutchinson^ 
met  with  one,  and  refers  to  two  others.  Stimson^  quotes  a  case  in  which  the 
diagnosis  was  verified  by  dissection.  Di\  J.  M.  Barton  has  recently^  reported 
the  case  of  a  boy  of  fifteen,  in  which  he  suspected  a  lesion  of  this  character, 
but  the  evidence  does  not  seem  to  me  to  have  been  conclusive. 

Far  more  may  be  expected  from  treatment,  in  a  lesion  of  this  kind,  than 
in  the  fractures  which  affect  the  same  region  in  advanced  life.  Such  short- 
ening as  exists,  may  be  corrected  by  extension  with  the  weight  and  pulley, 
and  the  joint  may  be  immobilized  by  means  of  a  well-applied  plaster-of-Paris 
bandage  around  the  pelvis  and  thigh.  This  confinement  may  be  continued, 
with  sand-bags  on  either  side  of  the  limb,  and  the  extension  kept  up,  for 
tw^o  or  three  weeks  in  the  case  of  a  child ;  a  longer  confinement  would  be 
advantageous  in  patients  beyond  the  age  of  puberty.  Cautious  experiments 
should  be  made  at  first  in  allowing  flexion  of  the  hip-joint,  but  if  they  are 
productive  of  no  pain  or  irritation,  more  and  more  freedom  may  be  accorded 
to  the  patient,  until  be  can  move  the  limb  without  hindrance ;  after  which, 
with  equal  caution,  he  may  be  encouraged  to  put  the  foot  to  the  ground,  and 
to  bear  his  weight  upon  it. 

A  number  of  years  ago,  I  had  a  patient,  nineteen  years  of  age,  w^ho,  by  a 
fall  from  a  very  high  wagon-seat,  had  sustained  a  fracture  of  the  cervix 
femoris,  the  existence  of  which  w^as  verified,  with  the  patient  under  ether, 
by  Dr.  Nancrede  and  myself.  He  was  treated  in  the  manner  above  men- 
tioned, and  in  six  weeks  was  driving  his  wagon  again,  with  scarcely  any 
perceptible  lameness  in  walking.  My  belief  is,  that  the  lesion  was  really  a 
separation  of  the  epiphysis. 

Fracture  of  the  trochanter  major  is  by  no  means  uncommon  as  a  complica- 
tion of  fracture  of  the  neck  of  the  bone ;  and  it  has  been  known  to  occur  by 
itself,  but  the  recorded  instances  are  very  few.  Mr.  Key's  case,  published  by 
Sir  A.  Cooper,*  which  occurred  in  1822,  was  the  first,  as  far  as  I  know.  It 
was  that  of  a  young  girl  who  fell  in  the  street,  striking  the  trochanter  against 
a  curb-stone ;  the  nature  of  the  lesion  was  only  discovered  after  the  patient's 
death.  Mr.  B.  Cooper^  gives  an  account  of  another  case  which  was  seen  by 
him,  and  in  which  the  diagnosis  was  justified  by  the  symptoms  as  described, 
although  the  patient  recovered,  and  hence  absolute  certainty  could  not  be 
arrived  at.  The  man's  age  is  not  stated.  Stanley^  has  reported  two  cases, 
but  in  regard  to  one  at  least  there  is  room  for  doubt  whether  it  was  not  really 
an  ordinary  extra-capsular  fracture  of  the  cervix,  the  trochanter  also  being 
separated.  Bryant  mentions  one  in  a  boy  aged  twelve,  treated  by  Mr.  Poland. 
McCarthy^  reports  that  a  girl  of  eight,  having  fallen  on  her  left  side,  had  an 
abscess  in  the  hip,  and  that  this  communicated  with  one  within  the  pelvis ; 
she  had  also  pyaemia,  with  pericarditis,  pleurisy,  and  pneumonia,  and  the 
trochanter  was  found  detached.  Roddick^  saw  a  young  man,  aged  sixteen, 
who  had  a  strain  while  exercising,  and  a  few  days  afterward  symptoms  of 
abscess  about  the  trochanter,  which  was  found  necrosed  and  separated. 

1  Med.  Times  and  Gazette,  Feb.  24,  1866. 

2  Op.  cit.,  p.  496  ;  from  Bull,  de  la  Society  Aiiatomique  for  1867. 

3  Medical  News,  July  14,  1883. 

*  Dislocations  and  Fractures  of  the  Joints,  p.  186. 

5  Ibid.,  p.  187.  ^  Med.-Chir.  Transactions,  vol.  xiii. 

7  Trans,  of  the  Pathological  Society,  vol.  xxv.    London,  1874. 

8  Canada  Medical  and  Surgical  Journal,  Nov.  1875. 


FRACTURES  OF  THE  FEMUR. 


199 


Hamilton^  quotes  from  Clarke  a  ease  of  supposed  comminuted  fracture  of 
the  great  trochanter,  with  the  comment  that  it  was  probably  ''an  example  of 
fracture  of  the  neck  without  the  capsule,  accompanied  with  impaction  and 
extensive  comminution."  He  also  candidly  expresses  a  doubt  as  to  au 
instance  of  the  kind  which  he  had  himself  recorded,  and  upon  which  he  m 
now  inclined  to  put  a  similar  construction. 

F.  W.  Warren  is  reported^  to  have  shown,  at  a  meeting  of  the  Dublin 
Pathological  Society,  a  specimen  of  fracture  of  the  trochanter  major,  taken 
from  the  body  of  a  male  subject  almost  fifty  years  of  age.  ^  "  It  was  without 
history ;  but  from  the  entire  absence  of  signs  of  recent  injury,  and  from  the 
fact  that  the  line  of  separation  followed  that  of  the  epiphysary  junction,  the 
inference  seems  justified  that  it  was  really  a  case  of  epiphyseal  detachment, 
dating  hack  perhaps  thirty  years." 

The  cause  of  fracture  of  the  great  trochanter  would  seem  to  be  invariably 
direct  violence ;  and  the  majority  of  the  subjects  are  distinctly  stated  to  have 
been  below  the  age  at  which  this  epiphysis  becomes  united  to  the  shaft. 
In  such  cases  it  may  reasonably  be  supposed  that  the  separation  takes  place 
through  the  cartilaginoid  uniting  substance,  but  that,  as  in  separations  of 
other'epiphyses,  it  may  in  part  run  through  the  true  bone,  detaching  a  layer 
of  it  of  very  irregular  size,  shape,  and  thickness. 

The  syriiptoms  of  this  lesion  can  scarcely  be  confidently  detailed  from  the 
scanty  experience  recorded.  Some  of  the  symptoms,  however,  of  the  usual 
fractures  of  the  cervix  must  be  wanting;  there  cannot  be  shortening  of  the 
limb,  and  in  rotating  the  thigh  the  trochanter  cannot  describe  a  smaller  arc 
than  normal,  but  will  either  "fail  to  follow^  the  movements  of  the  limb,  or  if 
the  fibrous  coverings  are  untorn,  wdll  behave  as  under  normal  conditions. 

Pain  and  disability  of  the  limb  must  exist,  the  former  being  aggravated 
by  pressure  on  the  part ;  but  these  symptoms,  as  well  as  swellnig  and  ecchy- 
mosis,  would  be  equally  likely  to  attend  a  mere  contusion.  When  the  tro- 
chanter is  broken  completely  away  from  the  shaft,  it  will  probably  be  drawn 
upward,  inward,  and  backward,  by  the  action  of  the  muscular  fibres  inserted 
into  it ;  and  in  such  a  case  it  will  be  transferred  from  its  normal  place  to 
that  occupied  by  the  head  of  the  femur  in  backward  and  upw^ard  luxation. 
Stanley,  speaking  of  the  danger  of  confusion  between  these  two  lesions, 
urges  "  the  positive  resemblance  of  the  fractured  portion  of  the  trochanter  to 
the  head  of  the  femur,  tlie  former  occupying  the  same  place  which  the  latter 
would  in  dislocation ;  and  if  w^ith  these  circumstances  there  should  happen 
to  be  an  inversion  of  the  injured  limb,  the  difiiculty  of  the  diagnosis  must 
be  considerably  increased."  Crepitus  wx)uld  of  course  be  wanting  in  such  a 
condition  of  things,  and  could  only  be  elicited  by  bringing  the  fragment 
again  into  contact  with  the  surface  from  w^hich  it  had  been  separated. 

The  diagnosis  has,  perhaps,  been  sufiiciently  discussed. 

As  to  the  treatment  of  this  injury,  it  need  scarcely  be  said  that  the  attempt 
should  be  made  to  bring  back  and  to  hold  in  place  the  fragment ;  but  as  to 
the  best  means  of  so  doing  very  little  is  known-  Sir  Astley  Cooper's  belt 
and  pad,  although  theoretically  very  good,  would  be  difficult  to  apply  in 
practice,  and,  unless  accurately  adjusted,  might  increase  the  displacement  it 
was  intended  to  correct.  I  think  that  the  object  could  be  quite  as  well  accom- 
plished with  an  ordinary  compress,  so  arranged  as  to  confine  the  trochanter 
in  its  proper  position,  and  kept  in  place  by  bands  of  adhesive  plaster.  And 
if  the  diagnosis  were  clearly  made  out,  a  device,  such  as  that  suggested^  for 
keeping  the  fragment  of  the  olecranon  in  place,  might  be  employed ;  a  double 

'  Treatise  on  Fractures,  etc.,  6th  ed.,  p.  429. 

*  Dublin  Journal  of  Med.  Science,  July,  1876. 

*  See  page  152. 


200 


INJURIES  OF  BONES. 


recurved  hook,  to  be  driven  into  the  upper  part  of  the  separated  portion,  and 
attached  by  means  of  adhesive  plaster  to  the  skin  of  the  limb  below. 

From  the  slight  data  available,  it  would  seem  that  some  advantage  might 
be  gained  by  abducting  and  everting  the  limb,  as  suggested  by  Malgaigne, 
so  as  to  make  the  shaft  follow  the  fragment  into  the  position  into  which  the 
muscles  are  likely  to  pull  it.  It  is  very  pi-obable  that  the  lameness  which 
might  be  mduced  by  the  injury  would  not,  after  all,  be  so  serious  as  to  make 
it  worth  while  to  subject  the  patient  to  long  and  rigorous  confinement. 

Fracture  of  the  lesser  trochanter  is  not  described  hy  authors  as  a  separate 
lesion,  although  sometimes,  as  in  a  case  quoted  from  Guthrie^  by  Sir  A. 
Cooper,^  it  is  incidentally  mentioned  as  an  attendant  upon  other  and  more 
important  injuries. 

In  1874  I  saw,  with  Dr.  Cohen,  an  old  gentleman,  who  had  slipped  on  an 
icy  pavement,  and  in  attempting  to  avoid  falling,  had  met  with  a  hurt  about 
the  hip.  He  could  stand,  but  was  unable  to  walk,  and  especially  to  draw  the 
knee  up  toward  the  belly,  although  this  position,  with  the  hip-joint  flexed, 
was  the  most  comfortable  to  him.  There  was  no  shortening  of  the  limb,  no 
crepitus,  and  no  aversion  of  the  foot ;  but  there  was  pain  in  the  groin,  and 
tenderness  at  the  inner  and  upper  part  of  the  thigh.  After  a  time,  he  got 
about  on  crutches,  and  could  even  walk  a  few  steps  without  them ;  but  he 
never  fully  recovered  the  use  of  the  limb.  He  died  five  or  six  years  after- 
ward, but  no  autopsy  could  be  obtained. 

I  thought  at  the  time,  and  still  think,  that  in  this  case  there  was  a  tear- 
ing ofi:'  of  the  trochanter  minor ;  he  was  very  thin,  and  I  could  feel  the  bone 
on^  the  other  side,  but  possibly  the  swelling  and  tenderness  prevented  my 
doing  so  at  the  seat  of  injury.  I  regret  very  much  that  the  true  state  of  the 
parts  could  not  be  determined  by  dissection,  but  feel  that  even  without  such 
completion  the  case  is  of  sufiicient  interest  to  be  presented  for  what  it  is 
worth. 

Fractures  of  the  shaft  of  the  femur  are  in  adults  very  common  acci- 
dents. By  some  authors,  those  which  aflect  the  bone  just  below  the  trochan- 
ters are  placed  in  a  separate  class  ;  but  although,  like  those  of  the  surgical 
neck  of  the  humerus,  they  present  some  special  features,  these  are  not  so 
marked  that  they  cannot  be  pointed  out  in  the  course  of  the  discussion  of  the 
general  subject. 

^  The  shaft  is  much  more  frequently  broken  in  its  middle  portion  than  near 
either  end ;  and  this  statement  holds  good  in  regard  to  both  sexes  and  all 
ages.  Adult  males  are  more  liable  to  the  accidents  producing  this  injury 
than  females  or  children,  and  hence  afford  a  majority  of  the  cases.  Hofmokl 
has  reported^  the  case  of  a  child,  not  rachitic,  born  with  a  united  fracture  of 
the  femur,  and  I  have  known  of  more  than  one  instance  in  which  this  bone 
,has  given  way  during  the  process  of  artificial  delivery.  When  the  accident 
is  due  to  the  use  of  the  blunt  hook,  in  breech  presentations,  the  upper  por- 
tion of  the  bone  is  for  obvious  reasons  most  likely  to  sutfer. 

Looked  at  from  without,  the  shaft  of  the  femur  always  presents  a  more 
or  less  marked  curve,  convex  anteriorly,  and  a  slighter  curve  convex  exte- 
riorly. Very  rarely  it  is  found  to  be  almost  straight.  On  examination  in 
section,  the  anterior  wall  is  seen  to  be  thinner  than  the  posterior,  where  the 
bony  substance  is  massed  into  a  very  thick  and  strong  ridge,  the  linea  aspera. 
Partly  on  account  of  this  arrangement,  and  partly  by  reason  of  the  bone's 


1  Med.-Chir.  Transactions,  vol.  xiii.  2  Qp,  ^[^^^  ^  2Y2. 

3  Archiv  fur  Kinderkranklieiten,  Bd.  iii.  S.  370.    Stuttgart,  *188l! 


FRACTURES  OF  THE  FEMUR. 


201 


curved  shape,  the  direction  of  fractures  in  this  region  is  apt  to  be  oblique  from 
above  downward  and  from  behind  forward.  A  few  instances  are  on  record  of 
almost  longitudinal  fracture.  Thus,  in  the  Warren  Museum,  there  i^^  a  speci- 
men^ described  as  follows  :  The  upper  portion  of  the  femur,  showing  a  recent 
and  very  oblique  fracture  at  some  distance  below  the  trochanters ;  and  from 
it  a  longitudinal  split  upwards,  and  through  the  great  trochanter.  Also  a 
fracture  of  the  neck,  just  above  the  trochanters."  A  specimen  which  is  in 
the  Lyons  Museum,  and  photographs  of  which  Mr.  Morris  showed  to  the 
Pathological  Society  of  London, ^  is  said  to  present  a  fracture  extending 
"from  the  neck  to  the  lower  third,  dividing  the  bone  into  two  almost  equal 
portions,  which  had  united  by  a  few  narrow  bands  of  bone."  A  case  of  very 
oblique,  almost  longitudinal,  fracture  in  a  lad,  which  became  the  occasion  of 
legal  proceedings,  has  been  reported  by  Dr.  Hunt.^  Spiral  fractures  have 
been  sometimes  observed,  as  well  as  fissures ;  in  either  case  the  part  affected 
is  more  apt  to  be  either  the  upper  or  the  lower  than  the  middle  portion  of 
the  bone."* 

Sometimes  the  bone  is  broken  in  two  places,  as  in  a  specimen  ^in  the 
Museum  of  the  Pennsylvania  Hospital,^  in  which  "the  upper  fracture  runs 
obliquely  from  within  outward,  and  from  below  upward,  about  two  inches 
below  the  trochanter  major;  the  lower  one  being  a  jagged,  slightly  commi- 
nuted fracture  about  three  inches  above  the  condyles."  Malgaigne  mentions 
that  in  the  Musee  Dupaytren  there  is  an  example — the  only  one  known  to 
him — of  a  triple  fracture.    He  does  not  describe  it  further. 

The  causes  of  these  fractures  are  very  various.  Direct  and  indirect  vio- 
lence, and  muscular  action,  have  all  been  observed,  the  second  perhaps  rather 
more  frequently  than  either  of  the  others. 

Cases  of  so-called  spontaneous  fracture  are  more  common  in  the  femur  than 
elsewhere,  by  reason  of  the  great  leverage  afforded  by  the  length  of  the  bone. 
One  of  the  most  remarkable  of  these  was  recently  reported  by  Rankine.^  It 
was  the  case  of  "  a  child  aged  six  years,  who,  as  the  mothei'  reported,  was 
simply  walking  across  the  floor,  wdien  its  leg  doubled  up,  the  child  falling 
instantly  to  that  side."  The  femur  was  found  to  be  fractured  in  the  middle 
third.  The  mother  declared  positively  "  that  she  was  looking  at  the  child 
walking  over  the  floor  at  the  time,  and  that  there  was  no  stumbling  or  any- 
thing, but  only  the  leg  seemed  to  double  by  the  mere  act  of  walking.  It  may 
be  mentioned  that  the  child  did  not  seem  to  be  in  the  best  of  health,  althou2:h 
nothing  very  particular  could  be  detected  about  it."  Another  case,  in"  a 
vigorous  man  aged  thirty,  is  recorded  by  Gosselin.^  I  have  treated  a  man, 
about  twenty-five  years  of  age,  who  fractured  the  shaft  of  the  femur  in  pull- 
ing on  a  boot ;  he  had  done  the  same  thing  previously  by  stepping  down  from 
a  chair ;  there  was  no  evidence  whatever'of  constitutional  taint  or  disorder.® 
Humphry^  records  a  singular  case  in  which  a  woman  aged  fifty-six  was  twice 

»  Catalogue,  p.  183,  No.  1074.  s  Lancet,  Nov.  5,  1881. 

'  American  Journal  of  the  Medical  Sciences,  Jan.  1879. 

*  These  spiral,  spiroid,  cuneiform,  helicoidal,  or  screw-like  fractures,  as  they  have  been  variously 
named  by  the  authors  who  have  treated  of  them,  are  certainly  interesting,  but  I  must  confess  I 
have  never  myself  seen  a  specimen  of  the  kind  in  the  femur.  HoUhouse  and  Morris  (Holmes's 
System  of  Surgery,  8d  ed.  vol.  i.  p.  1021)  give  a  good  description  of  them,  with  references  to  the 
somewhat  scanty  literature  of  the  subject.  From  that  source  I  derive  the  following  :  Gerdy, 
Chirurgie  pratique,  tome  iii.  ;  Fere,  Fractures  par  torsion  de  la  partie  inferieure  du"  corps  du 
Femur  ;  RauUet,  Des  Fractures  h^licoidales  (These),  1880. 

5  Catalogue,  p.  31,  No.  11355.  6  Lancet,  March  31,  1883. 

7  Clinical  Lectures  on  Surgery,  Stimson's  Translation,  p.  188.   Philadelphia,  1878. 

8  The  reader  will  find  an  interesting  paper  "On  Fractures  of  the  Femur  in  Adults,  without 
pre-existent  Osseous  Disease,"  by  Clarence  Foster,  in  the  Med.  Times  and  Gazette  for  July  17, 
1880 ;  and  another  by  Vallin,  in  the  same  journal  for  Nov.  6,  1880,  taken  from  the  Gazette  Heb- 
dom.  de  Med.  et  de  Chir.  (Paris),  10  Sept.  1880. 

*  British  Med.  Journal,  June  6,  1857. 


202 


INJURIES  OF  BONES. 


the  subject  of  apparently  spontaneous  fracture  of  the  femur ;  the  bone  on  the 
right  side  giving  way  in  May,  1855,  and  that  on  the  left  in  March,  1857.  On 
both  occasions  the  affected  part  had  previously  been  the  seat  of  sharp  pains. 
Union  had  taken  place  favorably.  But  reference  has  already  been  made  at 
sufficient  length  to  this  subject,  in  the  general  part  of  this  article. 

The  femur  has  been  the  seat  of  many  of  the  so-called  "  spontaneous"  frac- 
tures in  cases  of  cancer.  A  remarkable  instance  of  this  kind  has  lately 
been  reported  by  Mr.  Hamilton.^  It  was  that  of  a  woman  aged  Hfty-six,  who 
had  "  a  well-marked  case  of  scirrhus,"  for  which  the  right  breast  w^as  removed, 
the  wound  healing  well ;  about  three  months  afterward,  she  felt  the  right 
femur  give  w^ay,  and  fell  to  the  ground.  The  curious  fact  in  the  case  is  that 
she  ultimately  had  union,  although  with  four  inches  of  shortening — the  latter 
having  been  due  to  her  placing  herself  for  a  time  under  the  care  of  an  igno- 
rant bone-setter.  Generally,  a  fracture  produced  under  such  circumstances 
fails  to  unite. 

Fracture  seldom  occurs,  except  as  the  result  of  direct  violence,  at  any  point 
near  the  middle  of  the  femur.  The  reason  of  this  would  seem  to  be  the  fact 
that  tlie  mechanism  in  other  cases  is  leverage,  and  that  this  can  scarcely  ever 
be  applied  so  that  just  the  same  force  shall  be  exerted  on  the  two  halves  of 
the  bone.  Generally,  there  is  a  very  great  preponderance  of  force  at  one  end, 
so  that  one  arm  of  the  lever  is  virtually  much  longer  than  the  other. 

The  immense  strain  put  upon  the  femur  by  this  leverage  is  shown  by  the 
occasional  instances  in  wdiich  even  perfectly  strong  and  well-developed  bones 
are  snapped  under  it.  I  have  seen  a  case  in  which  a  man  of  remarkably 
robust  frame,  in  running,  caught  his  foot  in  a  hole  in  the  ground,  and  broke 
his  femur  in  the  middle  third.^  But  besides  the  mere  leverage,  irregularly 
exerted  as  before  said,  there  is  another  force,  a  twisting,  which  cannot  be  left 
out  of  the  account,  although  it  is  extremely  difficult  to  estimate  it  w^ith  any 
accuracy.  Thus,  in  the  last-mentioned  case,  the  foot  being  arrested  while  the 
momentum  of  the  body  carried  the  upper  part  of  the  femur  forward,  the  shaft 
of  the  bone  was  acted  upon  above  through  the  cervix,  while  below,  at  the 
knee,  the  condyles  were  held  more  or  less  exactly  transverse.  Under  ordinary 
stress,  such  a  twist  would  make  no  difference ;  but  as  the  force  applied  is  in- 
creased, the  effect  of  the  twist  is  to  augment  in  a  still  greater  ratio  the  actual 
resistance  demanded  of  the  bone. 

It  can  hardly  be  maintained  that  the  large  and  powerful  muscles  surround- 
ing the  femur,  and  acting  upon  it  either  directly  or  indirectly,  are  without 
influence  in  the  productfon  of  its  ordinary  fractures,  as  they  certainly  have 
an  effect  in  keeping  up  its  displacements  when  broken.  But  in  the  former 
case  their  action  is  accessory  only,  and  its  degree  is  not  easy  to  estimate.  It 
probably  varies  in  different  cases. 

Fracture  having  once  occurred,  the  fragments  may  act  upon  one  another 
to  produce  still  further  damage;  as  in  a  case  reported  by  Bennett,^  in  which 
the  femur  gave  way  in  its  upper  third,  and  it  seemed  clear  that  the  lower 
fragment  was  driven  into  the  upper,  splitting  and  Assuring  it.  Another  in- 
stance was  communicated  by  Bryant  to  the  Pathological  Society  of  London;* 

>  Lancet,  June  2,  1883. 

2  In  illustration  of  the  force  exerted  in  such  actions,  I  am  tempted  to  quote  from  Dr.  O.  W. 
Holmes,  the  following  passage  :  "  Walking,  then,  is  a  perpetual  falling  with  a  perpetual  self- 
recovery.  It  is  a  most  complex,  violent,  and  perilous  operation,  which  we  divest  of  its  extreme 
danger  only  by  continual  practice  from  a  very  early  period  of  life.  .  .  .  We  learn  how  vio- 
lent it  is,  when  we  walk  against  a  post,  or  a  door,  in  the  dark.  We  discover  how  dangerous  it 
is,  when  we  slip  or  trip,  and  come  down,  perhaps  breaking  or  dislocating  our  limbs,  or  over- 
look the  last  step  of  a  flight  of  stairs,  and  discover  with  what  headlong  violence  we  have  been 
hurling  ourselves  forward." — (Atlantic  Monthly,  May,  1863.) 

3  British  Med.  .Journal,  June  26,  1880.  *  Transactions,  vol.  xxix.  1878. 


FRACTURES  OF  THE  FEMUR.  203 

it  was  the  case  of  a  man  eighty -tliree  years  of  age,  who  died  on  the  twenty- 
fiftli  day  after  the  accident,  when  it  was  found  that  the  shaft  of  the  right 
femur  "had  been  clearly  fractured  at  the  junction  of  the  middle  with  the 
lower  third,  and  the  extremity  of  its  proximal  end  was  driven  to  the  extent 
of  an  inch  and  a  half  into  the  shaft  of  the  distal  portion;  this  process  of  im- 
paction splitting  the  shaft  of  the  distal  extremity  of  the  bone,  and  pi'oducing 
a  second  fracture  of  the  bone  above  the  condyles." 

The  symptoias  of  fracture  in  the  shaft  of  the  femur  are  for  the  most  part  of 
a  very  pronounced  character.  Pain  is  not  always  present,  although  it  is  in- 
duced by  any  attempt  at  movement,  whether  active  or  passive ;  but  there  is 
total  loss  of  power.  Deformity  is  apt  to  be  very  marked,  the  fragments  being 
drawn  up  at  an  angle  to  one  another,  and  the  lower  one  generally  rolled  out- 
ward, the  weight  of  the  foot  tending  to  throw  it  over  on  its  outer  side. 
Often  the  two  broken  ends  are  entirely  separated  at  the  anterior  part,  but 
posteriorly  they  are  held  together  by  the  reinforcement  of  the  periosteum  by 
the  strong  intermuscular  fibrous  tissues  attached  along  the  linea  aspera. 
This  connection  may  be  quite  close,  but  sometimes  even  here  the  periosteum 
is  stripped  away  to  a  considerable  degree,  so  as  to  allow  a  good  deal  of  play 
to  the  fragments,  and  admit  of  the  occurrence  of  decided  overlapping. 
Swelling  quickly  takes  place,  but  from  the  great  depth  of  the  bone  there  may 
be  but  slight  ecchymosis.  Preternatural  mobility  at  the  seat  of  fracture  is 
very  perceptible;  and  crepitus  is  induced,  of  course,  if  the  broken  ends  are 
rubbed  together.  Often  a  mere  glance  is  sufficient  to  show  the  nature  of  the 
injury.  The  shortening  of  the  limb,  which  strikes  the  eye  at  once  from  the 
position  of  the  foot,  may  be  verified  by  measurement  between  the  umbilicus, 
or  the  anterior  superior  spinous  process  of  the  ilium,  and  the  inner  malleolus,  as 
compared  with  that  on  the  sound  side.  However  carefully  made,  this  measure- 
ment is  very  apt  not  to  be  absolutely  correct,  partly  because  of  the  mobility 
of  the  skin,  and  partly  because  of  the  difficulty  of  getting  exactly  the  same 
bony  points  on  each  side.  But  the  matter  is  really  one  of  small  consequence, 
and  it  is  sufficient  if  the  fact  of  shortening  is  made  out.  Ordinarily  the  dif- 
ference between  the  two  limbs  strikes  the  eye  at  once,  and  may  be  from  an 
inch  to  two  or  three  inches.  In  one  case  (the  reference  to  which  has  escaped 
me),  no  treatment  having  been  instituted,  the  ultimate  loss  of  length  was  four 
inches. 

Cases  are  occasionally  met  with  in  which  both  femora  are  fractured,  and 
here  comparative  measurement  is,  of  course,  valueless.  One  such,  occurring 
to  a  sailor  at  sea,  is  reported  by  Surgeon  H.  Smith,  U.  S.  N.^  Reference  will 
be  again  made  to  this  condition  of  things  in  connection  with  the  modifications 
demanded  by  it  in  treatment.  Sometimes  the  fever  is  repeatedly  broken  at 
the  same  point,  as  in  an  instance  recorded  by  Humphry ,2  in  which  a  woman 
aged  sixty  had  in  1856  the  fourth  fracture  at  the  lower  part  of  the  bone,  the 
first  having  occurred  in  1847.  Firm  union  took  place,  but  only  after  the 
lapse  of  eighteen  weeks. 

Grosselin^  mentions  a  still  more  remarkable  case,  in  which  a  young  man  of 
twenty  had  broken  his  left  femur  six  times  in  the  course  of  twenty  months. 
Confinement  for  three  months,  with  the  use  of  phosphate  of  lime,  was  resorted 
to,  and  the  accident  did  not  again  occur. 

Fractures  of  the  shaft  of  the  femur  are  seldom  attended  with  any  serious 
complications.  Hammick^  says  that  in  simple  fracture  of  the  thigh  he  has 
never  seen  the  large  vessels  w^ounded  so  as  to  endanger  the  limb  ;  but  he  has 
once  seen  tetanus.     "  A  filament  of  the  anterior  crural  nerve  was  found 

*  Am.  Journal  of  the  Med.  Sciences,  July,  1865.  The  same  number  contains  an  account  of 
another  case,  in  a  child  aged  six,  reported  by  Dr.  A.  Peter. 

*  British  Medical  Journal,  June  6,  1857.  '  Op.  cit.,  p.  192.  4  Op.  cit.,  p.  74. 


204 


INJURIES  OF  BONES. 


stretched  through  a  cleft  in  the  bone,  so  tense  as  to  resemble  a  violin-string. 
The  patient  had  broken  his  thigh  at  sea,  seven  days  before  the  arrival  of  his 
frigate  in  the  sound." 

Burr,  however,  has  reported^  an  instance  of  occlusion  of  the  femoral  artery 
from  fracture  of  the  femur ;  gangrene  of  the  leg  ensued,  and  amputation  was 
performed.  And  Weinlechner  met  with  a  case^  in  which  the  artery  and  vein 
were  both  ruptured,  with  hemorrhage  and  consequent  gangrene ;  amputation 
Avas  submitted  to  on  the  third  day,  but  death  from  septicaemia  followed. 

Such  lesions  are  much  more  apt  to  occur  when  the  shaft  of  the  bone  is 
broken  very  low  down.  Thus,  Travers^  relates  that  "  a  man  broke  his  thigh; 
the  bone  protruded  above  the  patella ;  at  the  same  time  a  diffused  aneurism 
of  the  popliteal  artery  was  produced  by  a  spiculum  of  the  fractured  bone 
penetrating  that  vessel,  though  it  was  discovered  only  on  the  fourth  day. 
The  femoral  artery  was  immediately  tied  by  Mr.  Bransby  Cooper,  whose 
patient  he  was.  The  ligature  came  away  on  the  sixteenth  day ;  in  another 
week  the  aneurismal  swelling  had  disappeared,  and  the  fracture  was  soundly 
united  in  six  weeks."  Another  case  is  reported  by  Mr.  B.  Cooper,'*  in  which, 
the  patient  having  been  admitted  into  Guy's  Hospital  with  compound  frac- 
ture of  the  femur,  there  was  so  much  tension  of  and  injury  to  the  soft  parts, 
that  it  was  thought  unadvisable  to  put  the  limb  in  splints.  During  the  night 
spasm  came  on,  and  the  femoral  artery  was  lacerated  by  a  portion  of  the 
splintered  bone  coming  in  contact  with  it.  A  ligature  was  placed  upon  the 
vessel,  and  the  fracture  united  so  quickly  that  Mr.  Key  remarked  of  the  case, 
that  "  the  quickest  way  of  producing  union  of  fracture  of  the  femur  appeared 
to  be  by  tying  the  femoral  artery." 

Sometimes  fractures  of  the  shaft  of  the  femur  are  complicated  with  luxa- 
tion of  the  hip,  as  in  the  case  recorded  by  Murdoch,^  where  the  bone  was 
broken  in  its  upper  third,  and  its  head  lodged  upon  the  ischium ;  the  latter 
lesion  was  only  discovered  after  death,  which  resulted  from  hemorrhage  con- 
sequent upon  an  operation  for  non-union. 

Gayet  is  reported^  to  have  expressed  the  opinion  that  hydrarthrosis  of  the 
knee  was  very  apt  to  ensue  upon  fracture  of  the  femur.  Oilier  had  seen  the 
same  in  other  joints,  and  thought  it  might  be  due  to  propagation  of  irritation 
through  the  bone.  [According  to  Gosselin,  the  intra-articular  effusion  is  due 
to  irritation  of  the  outer  surface  of  the  synovial  capsule,  by  the  extra vasated 
blood  which  gradually  finds  its  way  downward  from  the  seat  of  fracture; 
hence  this  symptom  may  not  be  observed  until  some  hours  or  even  days  after 
the  reception  of  the  injury.] 

The  diagnosis  of  fractures  of  the  shaft  of  the  femur  does  not  often  present 
any  difiaculty.  Yet  a  case  was  reported,  and  the  preparation  shown  to  the 
Eighth  Congress  of  the  Deutsche  Gesellschaft  fiir  Chirurgie,^  in  1879,  of  ampu- 
tation of  the  thigh  in  its  upper  part,  by  Langenbeck,  for  supposed  malignant 
tumor,  in  a  man  aged  forty-eight.  There  was  found,  however,  only  a  simple 
fracture,  with  great  separation  of  the  broken  ends,  excessive  growth  of  cal- 
lus, and  a  distinct  false-joint,  l^o  history  of  traumatism  could  be  elicited. 
Analogous  cases  are  said  to  have  been  cited  by  Langenbeck,  Martini,  Roser, 
and  Kuster. 

Such  cases  are  certainly  rare ;  yet,  while  there  can  seldom  be  any  trouble 
in  ascertaining  the  mere  fact  of  the  existence  or  non-existence  of  fracture,  it 

>  Trans,  of  Med.  Soc.  of  State  of  New  York,  1873. 

^  Quoted  in  the  Index  Medicns  for  March,  1883,  from  the  Aertzl.  Ber.  der  k.  k.  allg.  Kranken- 
haus  zu  Wien,  1882. 

8  A  Further  Inquiry,  etc.,  p.  436.  4  Lancet,  Dec.  5,  1840. 

5  Trans,  of  Pennsylvania  State  Medical  Society,  1878. 

6  Med.  Times  and  Gazette,  Dec.  30,  1871.  '  Verhandlungen,  S.  30. 


FRACTURES  OF  THE  FEMUR. 


205 


may  be  by  no  means  easy  to  determine  the  character  of  the  lesion  or  the  di- 
rection of  the  line  of  breakage :  and  this  obscurity  is  apt  to  be  the  greater, 
the  further  the  fracture  is  seated  from  the  middle  of  the  shaft,  either  upward 
or  downward.  In  fractures  of  ancient  date  it  may  be  extreme.  A  child 
about  three  years  old  was  some  time  since  brought  to  me  on  account  of  a 
lameness  strongly  rcM^embling  that  of  hip-joint  disease  ;  but,  on  examination,  I 
found  that  there  had  been,  just  below  the  trochanters,  a  fracture  of  the  femur 
which  had  united  lirmly  with  the  fragments  at  an  angle  of  nearly  90°.  The 
child  had,  in  fact,  been\illowed  to  walk  w^hile  the  callus  was  yet  plastic,  and 
the  lower  fragment  had  tilted  up  the  distal  end  of  the  upper. 

The  course^oi  uncomplicated  cases  of  fracture  of  the  shaft  of  the  femur  is 
generally  favorable,  union  occurring  in  six  or  eight  weeks  in  adults,  and 
somewhat  earlier  in  children.  Heydenreich^  has  reported  a  case  in  which 
union  was  firm  in  thirty-five  days,  and  Henderson^  one  in  which  an  oblique 
fracture  near  the  middle,  in  a  woman  eighty-nine  years  old,  had  united  solidly 
on  the  forty-fourth  day.  Lee^  saw  a  case  of  union  of  a  broken  femur  in  a 
man  aged  ninety-eight.  False  joint  or  pseudarthrosis  has  been  met  with, 
and  is  difiicult  to  rnanage  on  account  of  the  great  mass  of  muscle,  making 
it  very  hard  to  keep  the  comparatively  small  ends  of  the  broken  bone 
together.  Operative  interference  in  these  cases  is  attended  with  peculiar 
danger ;  but  this  subject  has  been  already  spoken 
of  in  the  general  part  of  this  article. 

Williams'*  has  recorded  a  singular  case,  in  which 
a  man,  aged  seventy,  sustained  from  direct  violence 
a  fracture  in  the  upper  part  of  the  lower  third  of 
the  femur,  about  half  an  inch  above  the  point  of 
entrance  of  the  nutrient  artery.  Union  took  place 
with  overlapping  ;  the  upper  fragment  was  atro- 
phied and  conical,  the  lower  presented  a  good  deal 
of  callus,  and  was  of  full  size. 

Union  with  deformity  is  of  far  more  frequent 
occurrence,  and,  in  fact,  if  all  shortening,  of  what- 
ever degree,  be  considered  as  deformity,  it  may  be 
said  to  he  universal.  When  the  fragments  are  kept 
wholly  apart,  they  may  altogether  fail  to  unite,  but 
it  very  seldom,  indeed,  happens  that  such  is  the 
case.  A  much  more  general  event  is  tliat  part  of 
the  periosteum  remains  untorn,  and  bridges  across 
the  interval  between  the  fragments,  which  thus  be- 
come connected  by  means  of  an  intermediate  for- 
mation of  callus.  (Fig.  841.)  It  is  astonishing  how 
strong  a  bone  is  when  united  in  this  way,  and  how 
little^inconvenience  and  deformity  ensue,  provided 
only  that  there  is  a  parallelism  of  the  long  axes  of 
the  two  fragments,  and  that  there  is  no  rotary  dis- 
placement. Of  course,  how^ever,  exact  coaptation 
is  far  preferable  when  it  can  be  secured.  I  shall 
have  to  refer  to  this  matter  again  in  connection 
with  the  subject  of  treatment,  and  hence  it  need  not   ^^.^^^^^  ^^^^.^^ ^ ^^^^^^ 

be  dwelt  upon  just  now.  a  bridge  of  caUus 

1  Mem.  de  la  Soc.  de  Med.  de  Nancy,  1882.   (Index  Medicus.) 

2  London  Med.  Gazette,  Jan.  13,  1843. 

3  St.  George's  Hospital  Reports,  vol.  iv.,  1869. 
*  Dublin  Med.  Press,  April  17,  1844. 


206 


INJURIES  OF  BONES. 


From  what  has  been  said,  it  will  be  inferred  that  the  j^rognosis  will  vary 
according  to  the  circumstances  of  each  case.  It  is  certainly  better  for  the 
surgeon  to  be  very  guarded  in  making  promises  or  predictions  as  to  the 
result,  since  the  patient  or  his  friends  may  be  greatly  disappointed  at  even  a 
slight  and  unavoidable  degree  of  deformity,  A  strong  and  serviceable  limb 
is  in  the  vast  majority  of  cases  obtained,  but  occasionally  there  is  a  permanent 
halt  in  the  gait. 

The  treatment  of  fractures  of  the  shaft  of  the  femur  is  a  subject  which  has 
engaged  the  attention  of  surgeons  for  a  very  long  time,  and  upon  which 
much  ingenuity  has  been  expended.  The  end  which  has  been  most  earnestly 
sought  has  been  to  devise  means  of  making  extension  and  counter-extension, 
for  the  purpose  of  overcoming  the  shortening  which  is  the  most  obvious 
consequence  of  these  injuries.  Yet,  by  some  this  method  has  been  wholly 
discarded,  and  the  best  results  have  been  claimed  from  merely  putting  the 
limb  in  such  a  posture  as  to  relax  the  muscles.  At  the  present  day,  there 
are  very  able  advocates  for  the  use  of  lateral  compression  by  means  of 
solidifying  bandages,  to  the  exclusion  of  all  direct  extending  apparatus.  The 
adherents  of  these  various  plans  have  for  the  most  part  brought  forward 
measurements,  purporting  to  be  accurate,  of  the  limbs  treated  by  them, 
in  evidence  of  the  completeness  with  which  shortening  was  avoided.  But  I 
think  that  to  speak  of  a  shortening  of  an  eighth,  or  even  of  a  quarter,  of  an 
inch  in  the  lower  extremity,  is  a  refinement  beyond  practical  comprehension. 
I  do  not  believe  that  ten,  or  even  five,  surgeons,  examining  a  case  inde- 
pendently, and  without  bias  as  to  the  method  of  treatment  which  had  been 
pursued,  would  agree  within  an  eighth  or  a  quarter  of  an  inch  in  their 
results.  Hence  I  should  decline  to  accept  such  statements  implicitly,  re- 
garding them  as  over-precise.  Practically,  if  a  limb  is  in  good  line  and 
free  from  rotary  displacement,  a  shortening  of  half  or  three-quarters  of  an 
inch  is  a  matter  of  small  moment.  Extension  and  , counter-extension  ought, 
in  my  opinion,  to  be  carefully  and  eftectively  made,  and  the  length  of  the 
limb  maintained  as  accurately  as  possible,  attention  being  given  quite  as 
sedulously  to  the  preservation  of  its  proper  line. 

It  would  occupy  too  much  space  to  attempt  to  give  here  a  full  description 
of  all  the  forms  of  apparatus  which  have  been  at  various  times  proposed  and 
employed  in  the  treatment  of  fractures  of  the  shaft  of  the  femur,  although 
the  subject  is  really  one  of  the  most  interesting  in  the  history  of  practical 
surgery.  I  shall  first  describe  the  method  of  dressing  these  injuries  which  I 
myself  use,  and  which  is  employed  by  many  others,  and  then  some  of  the 
modifications  of  it  which  may  be  required  to  adapt  it  to  special  cases.  After- 
ward, I  shall  mention  some  other  plans  of  treatment,  and,  lastly,  will  give 
briefly  some  historical  points  in^regard  to  certain  portions  of  the"  apparatus. 

When  a  patient  with  a  broken  thigh-bone  has  to  be  transported  to  a  place 
where  he  is  to  be  treated,  whether  to  a  private  house  or  to  a  hospital,  especial 
care  should  be  taken  to  guard  against  needless  disturbance  of  the  fragments. 
A  very  good  plan  is  to  take  a  board  about  six  inches  wide,  and  long  enough 
to  reach  from  the  axilla  to  the  foot,  and  to  place  this  on  its  edge  along  the 
side  of  the  patient.  The  limb,  having  been  drawn  out  as  nearly  as  may  be  to 
its  normal  length,  may  be  surrounded  with  a  bundle  of  straw,  or  with  a  folded 
auilt  or  blanket,  and  then  bound  to  the  board  with  a  number  of  broad  strips 
of  muslin  or  linen,  the  body  being  also  confined  in  the  same  way.  If  another 
board  is  now  slipped  under  the  pelvis  and  lower  extremities,  the  patient  can 
be  carried  very  comfortably. 

Arrived  at  the  place  of  destination,  a  bed  is  prepared  with  a  firm,  hard 
mattress,  perforated  or  not,i  and  the  patient's  clothes  are  removed.    As  far 


See  page  56, 


FRACTURES  OF  THE  FEMUR. 


207 


a.6  possible,  the  exact  seat  of  fracture  is  now  determined,  and  the  amount  of 
shortening  is  ascertained  by  measurement.  A  strip  of  good  adhesive  plaster, 
about  three  inches  wide,  and  long  enough  to  reach  from  the  seat  of  fracture 
down  one  side  of  the  limb  to  four  inches  below  the  heel,  and  up  along  the  other 
side  of  the  limb  to  the  point  of  fracture  again,  is  well  warmed  and  applied, 
leaving  a  loop  of  eight  inches  below  the  sole  of  the  foot.  In  this  loop  is  placed 
a  piece  of  thin  board  three  inches  square,  and  close  to  it,  at  either  side,  a  small 
slit  is  cut  in  the  plaster,  thi-ough  which  a  cord  or  strip  of  bandage  may  be 
passed.  Three  or  four  transverse  strips  of  adhesive  plaster,  or  a  roller,  may  be 
applied  to  keep  the  longitudinal  strips  in  exact  contact  with  the  skin.  A  pul- 
ley is  now  placed  at  the  foot  of  the  bed,  either  on  a  tripod  with  one  long  foot, 
extending  under  the  bed,  and  two  at  right  angles  to  it,  or  on  a  rod  attached  to 
the  bedstead  frame  witli  a  clamp.  An  ingenious  apparatus  for  attaching  the 
pulley  has  been  devised  by  Dr.  Sheppard.^  One  fok-ni  of  it  is  intended  for 
cribs  or  beds  with  high  foot  pieces,  the  other  for  the  ordinary  iron  bedstead 
in  use  in  hospitals.  I  have  sometimes  screwed  the  pulley  into  the  foot-board 
when  the  bedstead  was  so  made.  In  the  case  of  some  iron  bedsteads,  a 
pulley  may  be  made  with  a  spool  and  a  piece  of  wire,  the  latter  being  run 
through  the  former,  and  then  bent  up  and  curved  into  two  hooks  to  catch 
on  to  the  bar  of  the  bed-frame. 

The  patient  is  now  to  be  placed  in  the  bed,  the  foot  of  which  is  elevated  a 
few  inches  by  means  of  a  couple  of  bricks  ;  the  cord  is  passed  over  the  pulley, 
and  the  surgeon  proceeds  to  make  extension  and  to  adjust  the  fragments. 
Sometimes  the  services  of  assistants  are  required  in  doing  this,  and  occasion- 
ally anaesthesia  must  be  induced.  If  the  limb  be  a  very  muscular  one,  and 
the  displacement  great,  one  assistant  may  grasp  the  foot  and  another  the 
upper  part  of  the  thigh ;  the  force  used  must  be  very  gentle  and  gradual, 
and,  while  it  is  exerted,  the  surgeon  carefully  handles  the  fractured  part,  and 
coaxes  the  broken  ends  into  their  normal  relation.  Sometimes,  in  old  people, 
or  in  persons  of  no  great  muscular  development,  the  adjustment  is  readily 
made,  and  as  easily  kept  up  by  moderate  traction.  But  in  the  strong,  or  in 
those  whose  nervous  systems  are  excitable,  a  good  deal  of  power  has  to  be 
exerted.  The  weight  to  be  used  depends  greatly  upon  these  circumstances  ; 
sometimes  it  is  but  small — perhaps  two  or  three  pounds — and  again  it  may 
require  ten  or  tw^elve  pounds  to  overcome  the  muscular  resistance.  One,  two, 
three,  or  four  bricks  may  be  thus  used,  or  bottles  of  sand,  or  regular  weights 
placed  in  a  frame ;  the  latter  device  is  adopted  in  some  hospitals. 

Sand-bags,  to  give  lateral  support  to  the  limb,  are  of  great  service ;  they 
are  made  of  muslin,  are  long  enough  to  reach,  one  from  the  heel  to  the  peri- 
neum, the  other  from  the  heel  to  above  the  crista  ilii,  and  should  be  ten  or 
twelve  inches  in  circumference.  They  ought  not  to  be  too  tightly  stuffed, 
hut  should  be  capable  of  adaptation  to  the  outline  of  the  limb. 

Whenever  the  patient  is  restless,  or  if  there  is  a  tendency  to  angulation 
of  the  thigh  forward  or  outward,  or  both  (it  very  seldom  bends  inward  or 
backward),  one  or  more  ^' coaptation-splints"  maybe  employed.  Binder's 
board  or  felt  answers  best  for  this  purpose,  a  piece  of  suitable  size  being  soft- 
ened hi  hot  or  cold  water,  and  moulded  to  the  normal  shape  of  the  thigh ; 
after  which  it  is  to  be  carefully  padded,  and  applied  with  a  roller,  or  with 
three  or  four  w^ide  adhesive  strips.^  If  the  foot  shows  any  tendency  to  dis- 
placement, whether  outward  or  inward,  this  must  be  carefully  corrected,  as 
it  indicates  rotation  of  the  lower  fragment ;  and  the  proper  position  must 

1  Medical  News,  Jan.  7,  1882. 

*  The  plaster  should  always  be  cut  for  this  purpose  in  the  length  of  the  piece,  and  not  across 
it,  lest  it  should  yield  and  stretch. 


208 


INJURIES  OF  BONES. 


he  secured  by  a  loop  of  bandage  around  the  foot,  fastened  to  the  sand-baff  or 
the  side  opposite  to  that  toward  which  the  foot  inclines. 

Certain  details  must  be  attended  to  in  making  all  these  arrangements,  in 
order  to  the  effective  working  of  the  plan.  The  adhesive  strips  must  be 
smoothly  fitted,  and  not  allowed  to  wrinkle,  lest  the  skin  should  be  irritated  ; 
the  circular  pressure  should  not  be  tight  enough  to  obstruct  the  return  of 
venous  blood  along  the  limb;  the  pulley  must  be  placed  at  the  proper 
height,  and  exactly  in  the  line  of  the  long  axis  of  the  limb.  Should  the  con- 
stant pressure  on  the  heel  give  rise  to  any  soreness,  a  mass  of  carded  wool  or 
cotton  may  be  placed  a  little  above,  so  that  the  limb  may  rest  on  a  different 
point ;  it  is  better,  however,  to  guard  against  any  such  trouble  by  protectino- 
the  skin  with  a  patch  of  soft  kid  spread  with  soap  plaster.  The  proper  adap- 
tation of  the  w^eight  to  the  necessities  of  each  case  is  a  matter  of  much  conse- 
quence. 

It  will  be  perceived  that  in  this  plan  of  treatment  the  counter-extension  is 
exerted  by  the  weight  of  the  body,  by  reason  of  the  elevation  of  the  foot  of 
the  bed,  a  device  credited  by  Hamilton  to  Dr.  Van  Ingen,  of  Schenectady. 
The  w^eight  and  pulley,  distinctly  described  by  Gui  de  Chauliac  in  the  four- 
teenth century,  was  brought  forward  in  modern  times  by  John  Bell,  in  1801, 
and  in  this  country,  in  1824,  by  Dr.  Luke  Howe,  and  again  in  1829,  by  Dr.' 
Daniell,  of  Georgia.^  Its  most  prominent  advocate,  however,  was  the  late 
Dr.  Gurdon  Buck,  of  ^ew  York,  whose  name  has  been  generally  attached  to 
the  method  since  he  revived  it  in  1861.^  To  show  how  thoroughly  developed 
it  had  formerly  been,  however,  I  may  perhaps  quote  the  following  passage 
from  Le  Clerc  : — ^ 

"  To  hinder  the  Patient  from  turning  cross  and  sliding  down  toward  the  Feet  of  the 
Bed,  you  must  plant  a  Stake  into  the  Floor,  underneath  the  Bed,  and  pass  it  through  the 
Matting  and  Bedclothes,  so  that  it  may  be  between  the  Patient's  Legs.  This  ought  to  be 
as  thick  as  the  small  of  the  Arm,  and  covered  with  some  Stuff  or  other,  that  it  may  not 
hurt  the  Patient.  And  for  greater  security,  let  it  be  ty'd  with  an  equal  Girth  to  the 
Patient's  Thigh  above  the  Knee  ;  and  let  each  Branch  or  Tail  of  the  Girth  pass  on  each 
side  the  Knee,  exactly  on  the  middle,  and  over  two  Bullies  (fastened  at  the  end  of  the 
Bed's  Feet),  and  at  the  end  of  them  let  there  be  two  Weights  suspended  to  draw  the  Thigh, 
and  keep  it  in  a  streight  Posture.  The  Thigh  must  be  wrapt  round  with  a  Bolster'^in 
the  Place  where  the  Girth  is,  that  it  may  not  hurt  it." 

When  the  fracture  is  very  high  up,  just  below  the  trochanters,  there  is  apt 
to  be  not  only  the  drawing  upward  of  the  lower  fragment,  but  a  tilting  up- 
ward and  forward  of  the  upper  one,  by  contraction  of  the  psoas  and  iliacus'mus- 
cles.  Perhaps  this  fragment  is  also  rotated  outward  by  the  glutei  and  other 
rotator  muscles  at  the  back  of  the  hip  ;  but  I  have  never  seen  this  distinctly. 
Under  such  circumstances  there  is  so  little  purchase  upon  the  upper  fragment, 
that  it  is  apt  to  remain  in  its  abnormal  position  in  spite  of  every  effort  to 
bring  it  down ;  and  the  result  is  that  when  union  takes  place  the  limb  is  not 
only  permanently  shortened,  but  deformed  and  seriously  disabled.  I  believe 
that  in  such  a  case  the  only  resource  is  to  make  the  lower  fragment  follow 
the  upper,  by  raising  the  knee  and  flexing  the  whole  thigh  upon  the  pelvis. 
This  may  be  done  by  means  of  the  double-inclined  plane  in  some  form,  or 
perhaps  even  by  the  single  inclined  plane,  as  the  latter  would  produce  no 
tension  upon  the  muscles  of  the  front  of  the  thigh.  The  double-inclined 
plane  is  merely  a  framework,  generally  hinged  so  that  the  angle  can  be 

1  The  reader  will  find  an  excellent  article  on  the  history  of  this  subject,  by  Dr.  E.  Hartshorne, 
in  the  American  Journal  of  the  Medical  Sciences  for  April  and  July,  1869 

2  Arn(!rican  Medical  Times,  March  30,  1861. 

3  The  Compleat  burgeon,  etc.    London,  1727. 


FRACTURES  OF  THE  FEMUR. 


209 


changed  at  will ;  one  part  of  it  is  intended  to  support  the  thigh,  while  the 
leg  rests  upon  the  other,  the  angle  occupying  the  bend  of  the  kiiee.  Exten- 
sion may  be  made  by  means  of  a  pulley  attached  either  to  the  apparatus 
itself,  a  frame  being  added  for  the  purpose,  or  to  a  standard  lixed  at  the  foot 
of  the  bed. 

The  single  inclined  plane,  as  its  name  imports,  is  a  board  inclined  at  an 
angle,  upon  whicli,  properly  padded,  one  or  both  of  the  patient's  lower  limbs 
may  rest.  Extension  may  be  made  by  means  of  a  pulley  fixed  at  the  upper 
end  of  the  board.  One  objection  holds  against  both  these  forms  of  apparatus  ; 
there  is  much  difficulty  in  preventing  the  patient  from  w^orking  his  body  up 
on  to  the  inclined  plane,  so  as  to  neutralize  its  effect  more  or  less  completely. 
Possibly  this  object  might  be  accomplished  by  having  a  perineal  block,  or  a 
well-rounded  upright  arranged  at  a  suitable  point.  But  it  would  perhaps  be 
better  to  have  recourse  to  one  or  other  of  the  suspensory  splints  to  be  pre- 
sently described. 

Dr.  Swinburne,  of  Albany,  advocates^  the  treatment  of  fractures  of  the 
shaft  of  the  femur  by  simple  extension,  using  a  perineal  band  attached  to 
the  head  of  the  bed,  and  fastening,  the  lower  part  of  the  limb  to  the  foot  of 
the  bed,  by  means  of  adhesive  plaster  and  a  cord.  Without  disputing  Dr. 
Swinburne's  statements  as  to  the  results  obtained  by  him  in  this  Avay,  I  can- 
not but  think  that  the  less  rigid  methods  are  at  the  same  time  more  com- 
fortable to  the  patient,  more  adaptable  to  the  varying  circumstances  under 
which  fractures  occur,  and  more  likely  to  be  satisfactory  in  the  hands  of 
most  practitioners. 

Plastcr-of-Paris  bandages  were  strongly  recommended  a  few  years  ago  by 
Dr.  Sands,2  of  I^ew  York.  They  were  applied  during  complete  extension, 
and  sometimes  under  anaesthesia.  Whether  acknowledged  or  not,  the  efficacy 
of  this  method  must  have  largely  depended  upon  the  extension  made  against 
the  swell  of  the  leg  below  the  knee,  and  the  counter-extension  against  the 
upper  portion  of  the  thigh  ;  and  the  lateral  compression  must  have  been  at 
once  lost  if  the  thigh. itself  diminished  in  size,  as  it  naturally  would  do  fron:k 
total  inaction.  My  own  experience  of  this  plan  is  limited  to  a  very  few  cases 
in  children,  in  which  it  afforded  good  results.  It  seems  to  me  that  here, 
where  there  is  but  slight  muscular  power  to  be  counteracted,  and  the  small 
size  of  the  bone  makes  the  leverage  on  the  fragments  but  trifling,  the  plaster- 
of-Paris  or  other  solidifying  dressing,  especially  the  silicate-V-potassium, 
is  much  less  objectionable  than  in  the  case  of  adults.  Hamilton,  however, 
holds  the  opposite  view.  He  says  :  "  If  I  have  been  unable  to  give  my  ap- 
proval to  the  treatment  of  fracture  of  the  shaft  of  the  femur  in  adults  with 
plaster  of  Paris,  or  to  any  other  form  of  immovable  dressing,  I  am  still  less 
able  to  give  it  my  approval  in  fracture  of  the  same  bone  in  children."  He 
then  relates  a  case  of  gangrene  in  a  boy  four  years  old,  treated  on  this  plan  ; 
but,  according  to  the  account,  there  was  unpardonable  neglect  on  the  part  of 
the  surgeon,  and  nothing  is  proved  against  the  treatment" if  carried  out  with 
ordinary  skill  and  judgment. 

The  method  devised  by  Dr.  Nathan  Smith,  and  improved  upon  by  his  son, 
the  late  Dr.  i^athan  R.  Smith,  of  Baltimore,  has  had  a  wide  popularity  in 
this  country,  especially  in  the  Southern  States.  As  at  first  made,  the  appa- 
ratus consisted  of  a  wooden  splint,  cut  so  as  to  fit  along  the  front  of  the  entire 
limb,  from  the  groin  to  the  toes,  the  hip  and  knee  being  each  flexed  to 
about  135°.  To  the  under  side  of  this  splint  the  limb  was  carefully  band- 
aged, and  then  slung  by  means  of  two  staples  driven  into  its  upper  face,  one 

^  Treatment  of  Fractures  of  Long  Bones  by  Simple  Extension.    Albany,  1861. 
2  New  York  Medical  Journal,  June,  1871. 
VOL.  IV. — 14 


210 


INJURIES  OF  BONES. 


above  and  the  other  below  the  knee.  By  changing  the  point  of  suspension, 
a  more  or  less  considerable  degree  of  extending  force  was  applied  to  the  limb, 
the  weight  of  the  body  upon  the  bed  giving  the  counter-extension. 

Afterwards,  this  splint  was  modified  by  substituting  for  the  wooden  splint 
a  wire  frame,  suspended  by  means  of  wire  loops.  One  advantage  of  this  is 
that  it  may  be  bent  so  as  to  suit  limbs  of  various  lengths.  The  cord  attached 
to  the  splint  runs  through  the  loop  of  another  cord,  which  passes  over  a 
pulley  fastened  in  the  ceiling,  or  in  a  frame  over  the  bed ;  and  this  latter 
cord  is  passed  through  what  is  known  as  a  tent-block,  by  means  of  which 
it  may  be  tightened  up  or  let  out,  so  as  to  raise  or  lower  the  limb  at  pleasure. 
(Fig.  842.) 

.     Fig.  842. 


Smith's  anterior  splint  for  treatment  of  fractured  thigh. 

By  the  late  Dr.  Hodgen,  of  St.  Louis,  a  somewhat  similar  splint  was  used, 
but,  instead  of  being  bandaged  to  it,  the  limb  was  suspended  in  it  by  means 
of  strips  of  muslin,  so  that  it  formed  a  sort  of  cradle.    (Fig.  843.) 

With  both  these  forms  of  apparatus  good  results  have  been  obtained  in  a 
very  large  number  of  cases.  Yet  in  one  instance  seen  by  me,  that  of  a  man 
treated  by  an  experienced  surgeon,  and  an  enthusiastic  advocate  of  Smith's 
method,  the  fragments  had  united  at  an  angle  backward,  and  such  pressure 
had  been  made  upon  the  sciatic  nerve  as  to  give  rise  to  very  serious  symp- 
toms, only  partially  relieved  by  an  operation. 

1  may  mention  that  Dr.  J.  R.  Taylor,  of  'New  York,  has  recently^  published 
an  account  of  a  "  saddle"  attached  to  an  iron  brace,  and  fitting  into  the  peri- 
neum, for  the  purpose  of  making  counter-extension,  extension  being  made 
by  means  of  a  coiled  spring.  Dr.  Brownrigg,  of  Tennessee,  has  described^  an 
apparatus  of  his  own,  in  which  counter-extension  is  made  by  means  of  a 

^  .lounial  of  Am.  Med.  Association,  Sept.  1,  1883. 

2  Trans,  of  Mississippi  State  Med.  Association  for  1881,  quoted  iu  the  College  and  Clinical 
Record  for  August  15,  1883. 


FRACTURES  OF  THE  FEMUR. 


211 


jacket  of  stout  muslin.  Neither  of  these  plans  seems  to  me  to  possess  any 
advantages  over  other  methods  more  generally  known. 


Fig.  843. 


Hodgen's  suspension  splint  for  treatment  of  fractured  thigh. 


Mention  has  already  been  made,  in  a  previous  part  of  this  article,  of  certain 
forms  of  apparatus  known  as  fracture-beds.  These  contrivances,  of  which  the 
best  known  perhaps  were  Earle's,  Amesbury's,  Crosby's,  and  Burge's,  were 
mostly  on  the  principle  of  the  double-inclined  plane,  but  some  of  them  were 
arranged  for  making  extension  with  the  limb  straight.  They  were  all  com- 
plicated and  expensive,  and  liable,  when  used  in  hospitals,  to  become  iniested 
with  bugs.  At  the  present  day,  I  think  that  they  may  be  said  to  have  been 
abandoned. 

Vertical  extension  has  been  recommended  in  cases  of  children,  by  Klimmel,^ 
who  applies  adhesive  plaster  in  the  manner  before  described,  and  keeps  the  leg 
in  the  vertical  position,  with  the  corresponding  side  of  the  pelvis  suspended 
by  means  of  a  cord  fixed  to  the  loop  of  plaster,  and  either  attached  above  to 
some  object  over  the  bed,  or  slung  over  a  pulley,  with  its  free  end  support- 
ing a  weight.  A  curious  eftect  of  this  treatment,  in  female  children,  is  the 
occurrence  of  vaginal  catarrh,  which,  however,  soon  yields  to  appropriate 
measures  when  the  extension  is  no  longer  kept  up.  Bryant  recommends  ver- 
tical extension  of  both  the  sound  and  the  injured  limb. 

A  few  words  may  now  be  said  as  to  the  development  of  the  present  methods 
of  treating  fractures  of  the  shaft  of  the  femur,  and  especially  in  regard  to 
certain  points. 

Benjamin  BelP  describes  an  apparatus,  invented,  he  says,  by  Gooch,  and 
improved  by  Aitken, which  promises  to  be  of  the  greatest  utility  in  oblique 
fracture  of  the  thigh."  It  consists  of  two  leather  straps,  one  buckled  around 
the  upper  part  ot  the  thigh,  the  other  around  the  lower  part ;  two  or  three 
steel  splints,  connected  with  the  straps,  pass  from  one  to  the  other  in  such  a 
manner,  that  by  means  of  them  the  straps  can  be  forced  asunder,"  thus 
making  extension  and  counter-extension.  If  such  an  apparatus  could  be 
borne  by  the  patient,  it  would  seem  that  there  would  be  great  danger  of 
undue  pressure,  Avith  serious  consequences. 

Besault's  splint  extended  from  the  crista  ilii  to  the  sole  of  the  foot.   It  was 

'  Am.  Journal  of  the  Med.  Sciences,  July,  1882 ;  from  Berl.  kliu.  Wochenschrift,  No.  4,  1882. 
*  System  of  Surgery,  vol.  vi.    London,  1788. 


212 


INJURIES  OF  BONES. 


notched  at  either  end,  and  the  upper  and  lower  turns  of  the  bandage  con- 
fining the  limb  to  it  were  cast  through  these  notches,  so  as  to  make  an  im- 
perfect and  inefficient  extension  and  counter-extension.  Phjsick  lengthened 
this  splint  both  ways,  extending  it  up  into  the  axilla,  and  downward  beyond 
the  foot ;  he  also  contrived  a  gaiter  to  be  placed  over  the  ankle,  in  place  of 
the  figure-of-8  bandage  previously  employed,  and  introduced  the  perineal 
band,  afterward  padded  by  Coates,  for  counter-extension. 

Hutchinson  added  a  block  on  the  inner  side  of  the  long  splint,  below  the 
foot,  over  which  the  extending 'band  passed,  thus  bringing  the  force  into  line 
with  the  axis  of  the  limb. 

The  iiitroduction  of  adhesive  plaster  for  securing  the  extending  band  to 
the  limb,  an  invention  the  paternity,  of  which  has  never  been  satisfactorily 
established,  but  which  is  certainly  of  American  origin,  was  a  great  step  in 
advance.  By  Gilbert^  the  use  of  the  same  material  for  counter-extension  was 
strongly  advocated. 

Yet  the  extension  and  counter-extension,  however  carefully  made,  were 
apt  to  become  relaxed,  and  various  means  were  tried  with  the  view^  to  make 
them  constant.  I  myself  employed  an  India-rubber  accumulator  f  and  the 
same  idea  was  subsequently  brought  forward  by  Buckstone  Brown^  and 
others  in  England.  It  was  not,  however,  until  the  revival  of  the  old  weight- 
and-pulley  extension  that  the  problem  was  solved  ;  although,  indeed,  the  sus- 
pension splint  of  Dr.  i^athan  Smith,  before  mentioned,  may  be  regarded  as 
capable  of  answering  the  same  end. 

In  the  foregoing  slight  sketch,  many  things  have  been  omitted  which  would 
deserve  description  in  a  history  of  the  developmicnt  of  the  treatment  of  these 
fractures.  Such  are,  for  example,  the  inside  splint  of  Physick's  apparatus, 
and  the  splint-cloth  by  which  it  and  the  other  splint  were  connected ;  the 
various  forms  of  apparatus  in  which  it  was  attempted  to  "  make  the  sound 
limb  act  as  a  splint  for  the  injured  one;"  the  different  arrangements  of  screws 
for  making  extension;  and  the  perineal  block  for  counter-extension.  All 
these  devices  have  been  so  completely  superseded  that  it  seems  to  me  need- 
less to  enter  into  detail  with  regard  to  them. 

After  the  descriptions  now  given  of  elaborate  contrivances  for  the  treat- 
ment of  fractures  of  the  shaft  of  the  femur,  and  the  importance  evidently 
assigned  by  surgeons  to  the  prevention  of  shortening,  the  reader  may  well  be 
surprised  to  know  that  there  have  been  advocates  of  the  use  of  a  simple 
roller  bandage  in  these  cases.  This  plan,  which  is  a  good  deal  more  than  a  step 
beyond  that  with  the  plaster-of-Paris  or  starched  bandage,  was  first  proposed 
by  an  English  surgeon  named  Eadley.  Dr.  Dudley,^  of  Kentucky,  claimed 
great  merit  for  it,  but  without  succeeding  in  gaining  for  it  the  favor  of  the 
profession  at  large.  It  would  certainly  be  a  difiacult  matter  to  convince  a 
jury,  if  a  dissatisfied  patient  should  seek  for  damages  in  a  case  so  treated, 
that  due  care  had  been  exercised  to  obtain  the  best  possible  result. 

Bryant,  however,  tells  us  that,  in  St.  Bartholomew's  Hospital,  both  Paget 
and  Callender  were  in  the  habit  of  treating  all  cases  of  fracture  of  the  shaft 
of  the  femur,  in  children,  without  splints  or  other  apparatus ;  "  the  child 
being  laid  on  a  firm  bed,  with  the  broken  limb,  after  setting  it,  bent  at  the 
hip  and  knee,  and  laid  on  its  outer  side."  Bloxam^  makes  a  similar  statement. 

It  may  serve  as  an  additional  illustration  of  the  diversity  of  views  that 
may  be  held  on  practical  subjects,  if  in  contrast  with  those  given  on  the  fore- 

1  Am.  Journal  of  the  Med.  Sciences,  Jan.  1858,  and  April,  1859. 

2  Ibid.,  July,  18G2.  »  Lancet,  Oct.  10,  1874. 

4  Am.  Journal  of  the  Med.  Sciences,  Nov.  1836  ;  from  Transylvania  Journal  of  Medicine,  etc., 
April,  1836. 

6  St.  Bartholomew's  Hospital  Reports,  1867. 


FRACTURES  OF  THE  FEMUR. 


213 


going  pages,  as  to  the  necessity  of  extension  and  counter-extension  in  the 
cases  in  question,!  quote  the  following:  Winchester'  lias  advanced  the  opinion 
that  muscular  contraction  "is,  if  rightly  understood,  a  natural  power  of  in- 
estimable value,  supplying  the  exact  amount  of  forcible  contact  between  the 
broken  surfaces  necessary  to  excite  healthy  reparative  action  in  the  most 
speedy  and  perfect  manner,  accurately  adjusted  to  the  functional  capacity  of 
each  individual  case." 

When  union  has  taken  place  with  the  fragments  in  had  jposition^  in  fractures 
of  the  shaft  of  the  femur,  the  correction  of  the  deformity  is  highly  desirable, 
since,  if  left  to  itself,  it  entails  upon  the  patient  a  lameness  which  not  only  is 
unsightly  and  mortifying,  but  may  be  a  very  serious  hindrance  to  his  gainilig 
a  livelihood.  Generally,  the  best  procedure  in  such  cases  is  forcible  refracture 
under  anaesthesia.  Numerous  instances  of  this  kind  have  been  recorded. 
Xorris^  gives  references,  asid  more  or  less  of  detail,  in  regard  to  some  twenty- 
five  cases,  all  but  three  of  which  were  successful.  One,  operated  on  by  Bon- 
tecou,  is  recorded  among  the  experiences  of  our  late  war.^  Fayrer^  gives 
two,  in  one  of  which  the  bone  was  broken  at  two  points — at  the  middle  and 
in  the  lower  third.  The  patient,  an  English  boy  fourteen  years  of  age,  had. 
met  with  his  accident  at  sea.  Both  cases  did  well.  Buck*  has  recorded  five. 
A  very  remarkable  case  of  multiple  fractures,  one  of  which,  in  the  femur, 
united  with  deformity  and  was  corrected  by  re-fracture,  is  recorded  by 
Tifiany.®  I  myself  had  occasion,  some  years  since,  to  rectify  a  fractured 
femur  in  a  boy  nine  years  old,  which  had  been  badly  treated  in  the  country, 
and  had  united  with  marked  overlapping  as  well  as  slight  angle  outward ; 
the  callus  gave  way  readily  under  ether,  and  the  little  fellow  recovered  so  as 
to  walk  without  any  perceptible  limp.  It  is  well  to  bear  in  mind  that  in 
conducting  a  procedure  of  this  kind  a  good  deal  of  force  may  be  saved,  by 
not  only  bending  the  bone,  but  giving  it  a  slight  twist  also.  Extension 
should  be  cautiously  made  in  these  cases,  lest  if  it  be  suddenly  and  too 
strongly  efi:ected,  damage  should  result  to  tliQ  soft  parts,  and  especially  to  the 
vessels.    I  have  seen  death  caused  in  this  manner. 

Subcutaneous  osteotomy  may  sometimes  be  resorted  to  witli  advantage,  as 
in  a  case  reported  by  Verneuil,^  this  plan  being  preferable  when  the  bone 
is  afiected  near  a  joint,  or  when  the  injury  is  of  such  ancient  date  that  union 
is  probably  very  firm.  The  details  of  the  operation  are  much  the  same  as 
when  it  is  practised  in  other  cases,  and  the  after-treatment  does  not  difter 
materially  from  that  of  accidental  fractures.  Resection  through  an  open 
wound,  a  procedure  attended  with  much  greater  risk,  was  many  times  prac- 
tised, and  with  a  considerable  degree  of  success,  by  the  older  surgeons.^  It 
is  now  almost  wholly  abandoned  in  favor  of  the  improved  method  just 
mentioned. 

Occasionally,  when  the  callus  has  not  yet  become  thoroughly  solidified,  it 
may  be  bent  into  proper  shape  by  firm  but  gentle  pressure  applied  by  means 
of  well-padded  splints  and  compresses,  or  by  bands  attached  to  the  bedstead. 
A  case  so  treated  with  success  at  the  tenth  week,  extension  and  counter-ex- 
tension being  also  used,  has  been  reported  by  Michener.^ 

>  Lancet,  Aug.  22,  1863.  2  Contributions  to  Practical  Surgery,  pp.  112  et  seq, 

*  Med.  and  Surg.  Hist,  of  the  War  of  the  RebeUion,  Part  III.,  Surgical  Volume,  p.  651. 

*  Indian  Medical  Gazette,  March  1,  1872. 

*  Transactions  of  N.  Y.  Acad,  of  Medicine,  1855. 

6  Trans,  of  Medical  and  Chirurgical  Faculty  of  Maryland,  1874. 
1  Bull,  de  la  Societe  de  Chirurgie,  5  Dec.  1882. 

«  See  Norris,  op.  cit.  9  Am.  Journal  of  the  Med.  Sciences,  Jan.  1848. 


214 


INJURIES  OF  BONES. 


Com.'pound  fractures  of  the  femur  are  always  of  serious  importance,  involving 
a  good  deal  of  shock,  and  presenting  sometimes  great  difficulties  in  their 
treatment.  When  amputation  is  not  indicated,  the  surgeon  has  to  choose, 
among  the  various  plans  already  described,  the  one  which  seems  best  adapted 
to  the  circumstances  of  the  case.  Often  the  plaster-of-Paris  bandage,  fene- 
strated so  as  to  give  access  to  the  wound  for  the  purpose  of  dressing  it,  and 
combined  with  suspension,  presents  great  advantages.  But  in  the  majority  of 
cases,  the  ordinary  arrangement  for  extension,  by  the  weight  and  pulley,  will 
answer  quite  as  well,  allowing  the  wound  to  be  dressed  and  the  limb  com- 
pletely supported.  I  believe  this  method,  carefully  carried  out  and  properly 
watched,  to  be  the  best,  except  in  cases  of  very  restless  patients,  as  for  exam- 
ple those  who  have  delirium  tremens;  for  such  the  plasrer  of  Paris,  with 
moulded  splints,  may  be  temporarily  employed  with  great  benefit.  Much 
depends  upon  the  situation,  size,  and  depth  of  the  wound ;  and  no  general 
rules  can  be  laid  down  which  shall  cover  the  various  conditions  presented  by 
even  a  small  number  of  cases. 

Fractures  of  the  lower  'portion  of  the  shaft  of  the  femur  are  by  no  means 
as  frequently  met  with  as  those  higher  up  in  the  bone.  They  have,  in  most 
of  the  recorded  cases,  affected  adult  males.  Opinions  have  varied  as  to  their 
causes;  Sir  A.  Cooper  says^  that  they  happen  "  when  a  person  falls  from  a 
considerable  height  upon  his  feet,  or  is  thrown  upon  the  condyles  of  the  os 
femoris  with  the  knee  bent."  Hamilton  concurs  with  him  ;  but  Malgaigne 
says,  "  These  fractures  seem  to  me  to  be  chiefly  produced  by  direct  causes." 
Probably  the  experience  of  different  surgeons,  or  of  the  ?ame  surgeon  at  dif- 
ferent times,  may  differ  in  regard  to  this  point  as  upon  many  others.  Mal- 
gaigne had  seen  only  two  cases  from  indirect  causes,  but  seven  from  direct. 
Among  the  former  cases  is  perhaps  included  one  previously  published  by 
him,2  to  which,  however,  he  makes  no  reference  in  his  work ;  the  fracture 
was  due  to  rotation  of  the  knee  in  an  attempt  to  reduce  a  luxation  of  the 
hip-joint. 

How^ever  produced,  these  injuries  present  very  various  conditions,  differing 
materially  from  those  of  other  portions  of  the  bone.  At  its  lower  portion, 
the  femur  broadens  toward  the  knee,  and  just  above  the  condyles  swells  out 
quite  abruptly.  Its  cancellous  structure  resembles  that  of  the  lower  portion 
of  the  radius,  except  that  the  downw^ard  direction  of  the  lamellae  is  more  dis- 
tinctly marked ;  and  I  think  that  sometimes  the  "  cross-breaking  strain" 
must  be  admitted  as  the  true  mechanism  of  its  fractures  also. 

Generally,  the  principal  direction  of  the  fracture  is  obliquely  downward  and 
forward ;  but  Hamilton  mentions  an  instance  in  which  it  ran  dow^nward  and 
backward,  and  in  which  gangrene  of  the  foot  occurred,  apparently  from  pres- 
sure of  the  lower  end  of  the  upper  fragment  upon  the  vessels. 

In  one  case,  recorded  by  the  same  author,  both  femora  were  broken  just 
above  the  condyles,  by  a  fall  from  a  fourth-story  window,  the  patient  alight- 
ing upon  his  feet. 

A  very  singular  specimen,  in  the  Museum  of  the  Pennsylvania  Hospital,  is 
thus  described  :^  "  An  oblique  fracture,  which  commences  at  the  linea  aspera, 
about  six  inches  above  the  condyles,  and  extends  spirally  inward  and  down- 
ward, completely  circling  the  bone  until  it  reaches  within  an  inch  of  the  con- 
dyle. The  beginning  and  end  of  this  line  of  fracture  are  united  by  two  other 
lines  of  fracture  extending  upward  from  the  lowest  point  until  they  reach  the 
upper  end  of  the  spiral  fracture.    These  have  separated  a  bony  fragment  of  the 

>  Dislocations  and  Fractures  of  the  Joints,  p.  244. 

2  Gazette  des  Hopitaux,  15  Fev.  1838. 

3  Catalogue  (Supplement),  p.  37,  No.  114116. 


FRACTURES  OF  THE  FEMUR. 


215 


outer  part  of  the  shaft  from  the  remainder,  and  thus  completely  severed  the 
condyle-portion  from  the  upper  part  of  the  bone."  The  patient,  a  man  aged 
iifty-nine,  had  fallen  from  the  height  of  a  ladder.  Another  specmien  in  the 
Hanie  museum,^  taken  from  a  man  aged  thirty-five,  who  had  also  fallen  from 
a  beio-ht,  shows  a  fracture  about  two  inches  below  the  trochanter  major, 
Lesides  "  a  jagged,  slightly  comminuted  fracture  about  three  inches  above 
the  condyles." 

Sometimes,  as  in  two  cases  recorded  by  Ilamdton,^  the  long  anterior  point 
of  the  upper  fra2:ment  projects  so  as  to  give  trouble;  in  one  of  Hamilton's  case& 
resection  was  required  in  order  to  effect  reduction.  Spence^  has  published 
an  account  of  a  very  similar  ca^^e,  the  sharp  point  of  the  upper  fragment  pro- 
jectino-,  covered  merely  by  the  skin,  and  with  the  patella  apparently  locked 
between  it  and  the  condyles.  Reduction  was  attempted  in  vain,  and  the 
patient  died  on  the  fourth  day,  having  sustained  other  grave  injuries.  It 
was  then  found  that  the  bone  had  penetrated  through  the  vastus  externus 
and  crureus  muscles,  and  the  edge  of  the  tendon  of  the  rectus,  on  dividing 
which  transversely,  reduction  became  possible.  The  condyles  were  found  to 
be  separated  and  comminuted. 

Occasionally ,  the  lower  fragment  is  tilted  down  backward,  as  mentioned  by 
Boyer,  and  observed  much  more  recently  by  Erichsen,  Bryant,  and  others ; 
the  displacement  is  ascribed  by  these  surgeons  to  the  traction  exercised  by 
the  o;astrocnemius  muscle,  which,  it  has  been  proposed,  should  be  relaxed  by 
division  of  the  tendo  Achillis.  Three  cases  so  treated  have  recently  been 
placed  upon  record  by  Treves.-*  I  believe  the  cause  of  this  rare  displacement 
to  be  the  upward  pull  of  the  muscles  at  the  back  of  the  thigh,  forcing  the 
lower  fragment  against  the  upper,  by  which  it  is  again  pressed  backward. 

I  have  "cited  from  Hamilton  a  case  in  which  the  circulation  was  interfered 
with  by  the  pressure  of  one  fragment  upon  the  vessels ;  Laurent^  quotes  a 
case  in  wdiich  a  popliteal  aneurism  was  thus  developed,  necessitating  ligature 
of  the  femoral  artery.  Injury  to  the  peroneal  nerve  from  like  cause  has 
lately  been  reported  by  Lauenstein.^ 

The  symptoms  and  diagnosis  of  fractures  of  the  lower  part  of  the  shaft  of 
the  femur  need  hardly  be  dwelt  upon  at  much  length.  Pain,  helplessness  of 
the  limb,  swelling^  deformity,  and  crepitus  may  be  looked  for.  The  main 
difficulty  will  be  to  determine  the  exact  extent  and  direction  of  the  lesion 
of  the  bone,  and  whether  or. not  it  involves  the  joint.  For  it  must  be 
remembered  that  even  if  an  arthritis  be  not  set  up,  there  will  still  very 
probably  be  some  effusion,  and  that  this,  along  with  the  rapid  swelling  of  the 
neighboring  soft  parts,  will  obscure  the  precise  condition  of  the  bone.  I 
think  that  the  degree  of  lateral  mobility  of  the  leg  upon  the  thigh  (the  real 
point  of  motion  being,  however,  above  the  knee)*  may  be,  to  some  extent, 
relied  upon  as  indicating  the  state  of  the  condyles  ;  if  it  is  very  free,  they 
have  probably  suffered.  Anaesthesia  should  always  be  induced  for  the  pur- 
pose of  making  this  examination,  which  should  be  cautiously  and  gently 
conducted  ;  and  if  the  question  is  not  readily  settled,  it  is  far  better  not  to  be 

1  Catalogue,  p.  31,  No.  1133*.  «  Op.  cit.,  p.  489. 

8  Am.  Journal  of  the  Med.  Sciences,  July,  1848,  from  Monthly  Journal  and  Retrospect  of  Medi- 
cal Sciences  (Edinburgh),  May,  1848. 

4  British  Med.  Journal,  Feb.  17,  188a.  ^  Op.  cit.,  Obs.  XXI.  p.  36. 

6  The  quotation  is  thus  given  in  the  Index  Medicus  for  February,  1883  ;  Bruch  des  Obersch- 
enkels  oberhalb  der  Condylen,  Dislokation  des  unteren  Fragmentes  nach  der  Knie-kehle,  mit  Ver- 
letzung  des  N.  peroneus  ;  Befreiung  des  Nerven  durch  Resektion  des  vorspringenden  Knochen- 
fragmentes  (Fracture  of  thigh  just  above  the  condyles,  displacement  of  the  lower  fragment  toward 
the°ham,  with  injury  to  the  peroneal  nerve  ;  freeing  of  the  nerve  by  resection  of  the  projecting 
portion  of  the  bone.)  Centralblatt  fiir  Chirurgie,  Leipzig,  1882.  I  have  not  had  access  to  the 
original  account  of  this  case. 


216 


INJURIES  OF  BONES. 


too  curious,  but  to  assume  that  the  condyles  are  involved,  and  to  act  accord- 
ingly. 

The  ireatmeMt  of  these  injuries  consists,  first,  in  allaying  inflammation  by 
the  ordinary  means,  keeping  the  joint  immovable  .by  placing  it  on  a  well- 
padded  back-splint,  and  employing  extension  by  the  weight  and  pulley  from 
the  very  outset.  After  all  swelling  has  subsided,  and  the  parts  are  again  in 
a  healthy  condition,  the  limb  may  be  laid  on  a  pillow,  and  the  extension  kept 
up  until  the  fourth  or  fifth  w^eek,  when  passive  motion  may  be  veiy  care- 
fully tried.  Union  generally  occurs  favorably,  and,  in  many  cases,  a  perfect 
recovery  has  ensued.  Yet  it  must  not  be  forgotten  that  there  are  chances 
of  grave  constitutional  disturbance,  and  that  in  all  injuries  of  large  bones, 
especially  in  the  neighborhood  of  joints,  there  are  risks  which  cannot  safely 
be  ignored. 

Separation  of  the  lower  epiphysis  of  the  femur  is  a  rare  accident, 
although  perhaps  it  sometimes  occurs  without  being  recognized.  It  belongs, 
of  course,  to  the  period  of  life  in  which  consolidation  with  the  shaft  has  not 
yet  occurred,  that  is  to  say,  before  the  twentieth  year  (sometimes  as  late  as 
the  twenty-fifth).  As  far  as  I  know,  in  all  the  recorded  instances  the  patients 
have  been  males,  and  none  of  them  have  been  over  sixteen  years  of  age. 

The  epiphyseal  line  is  just  above  the  boundary  of  the  knee-joint,  and  when 
a  separation  takes  place  exactly  through  it,  that  cavity  will  not  be  involved, 
although  it  may  become  so  secondarily.  Holmes  says:^  "A  reference  to 
such  of  the  published  cases  of  'separation  of  epiphysis'  as  are  accompanied 
by  anatomical  examination,  will  satisfy  the  reader  that  most  of  them  have 
been  of  this  nature,  viz.,  injuries  in  which  the  line  of  fracture  has  been  close 
to  the  epiphyseal  line,  and  generally,  in  all  probability,  corresponding  with 
it  in  more  or  less  of  its  extent ;  but  accompanied  with  fracture  in  almost  all 
cases,  and,  therefore,  as  IvTelaton  has  truly  observed,  presenting  identical 
symptoms  with  those  of  fracture."  Sometimes,  as  in  a  specimen  figured  in 
the  work  just  quoted  (Fig.  43,  p.  261),  another  line  of  breakage  extends  down 
between  the  condyles. 

The  cause  of  this  injury  has  been  in  almost  every  case,  I  believe,  indirect 
violence.  Madame  Lacliapelle  is  quoted  by  Malgaigne  as  having  seen  the 
lower  epiphysis  of  the  femur  and  the  upper  one  of  the  tibia  separated  at 
once  by  traction  on  the  foot  in  aiding  delivery.  CouraP  has  observed  in  a 
boy  of  eleven  years,  whose  leg  was  buried  in  a  hole  up  to  the  knee,  while 
his  body  was  thrown  forward,  a  separation  of  the  femoral  epiphysis ;  the 
upper  fragment  was  carried  backward,  and  on  proceeding  to  amputation,  which 
became  necessary,  the  condyles  were  found  in  front  of  the  shaft,  and  so  tilted 
that  the  articular  surface  was  directed  forward.  In  several^  cases  the  injury 
was  the  result  of  entanglement  of  the  leg  in  the  spokes  of  a  wheel.  Eobson* 
has  reported  three  cases.  In  one,  in  a  boy  of  fifteen,  hurt  in  a  colliery  acci- 
dent, the  lower  end  of  the  diaphysis  projected  into  the  popliteal  space,  tightly 
stretching  the  large  vessels  and  nerve ;  in  another,  in  a  boy  of  six,  the  same 
deformity  w^as  observed ;  and  in  both,  amputation  was  necessary.  In  the 
third,  in  a  boy  of  fifteen,  caught  in  a  belt  and  carried  around  a  shaft,  there 
was  the  same  displacement;  union  occurred,  and  excision  of  the  knee  was  ulti- 
mately performed  with  success.  In  the  Museum  of  the  Pennsylvania  Hospital, 

*  Surgical  Treatment  of  Children's  Diseases,  first  ed.,  p.  259. 

2  Fontenelle,  Archives  Gen6rales,  Oct.  1825. 

3  One  seen  by  Hamilton,  and  two  quoted  by  him.  Callender  published  another  in  the  St. 
Bartholomew's  Hospital  Reports  for  1873. 

*  Liverpool  Medico-Chirurg.  Journal,  July,  1883. 


FRACTURES  OF  THE  FEMUR. 


217 


there  is  a  specimen*  of  separation  of  the  condyloid  epiphysis,  along  with 
transverse  fracture  in  the  middle  third  of  the  hone,  in  a  boy  run  over  by  a 
railroad  car;  also  another  of  the  former  lesion  only,  without  history. 

Even  in  this  small  list  of  cases,  the  course  and  results  presented  a  marked 
variety.  Sometimes  amputation  became  necessary,  once  excision  ;  in  Hamil- 
ton's case  there  was  anchylosis  of  the  knee-joint,  and  some  shortening  of  the 
limb.  Callender's  patient  did  much  better ;  union  took  place  in  six  weeks, 
and  sixteen  months  later  there  was  no  sign  of  atrophy.  Another  very  favor- 
able result  occurred  in  a  case  treated  by  Puzey.^  A  boy  aged  sixteen  was 
playing  leapfrog,  and  alighted  with  his  legs  farther  apart  than  usual ;  he  fell, 
and  was  taken  to  the  hospital  with  one  leg  at  an  ande  of  about  130°  with 
the  femur — looking,  it  is  said,  like  genu  valgum.  Under  ether,  the  joint 
was  found  all  right.  "The  lower  end  of  the  thigh  was  now  steadied,  and 
by  gently  pushing  the  leg  toward  the  middle  line,  the  limb  was  straightened, 
and  in  so  doing  there  was  clearly  felt  the  soft  crunch  and  crepitus  which  is 
generally  noticed  in  straightening  out  a  greenstick  fracture  ;  further  exami- 
nation made  it  evident  that  what  had  occurred  was  a  separation  of  the  con- 
dyloid epiphysis,  not  quite  complete  at  its  upper  aspect."  Eight  months 
after  the  accident,  this  patient  w^as  seen  again,  with  a  good  straight  limb  and 
perfect  movement  of  the  knee-joint. 

As  to  the  diagnosis  in  these  cases,  very  little  can  be  said.  The  age  of  the 
patient,  and  the  characters  of  the  fracture — its  want  of  obliquity,  its  nearness 
to  the  joint,  and  the  smoothness  of  the  fragments — will  be  the  chief  points  to 
be  relied  upon  in  distinguishing  this  lesion  from  ordinary  supra-condyloid 
fracture. 

The  treatment  must  consist  in  thorough  reduction,  and  then  in  placing  the 
limb  at  complete  rest  in  an  easy  position,  especial  care  being  taken  to  pre- 
vent eversion  or  inversion  of  the  foot.  Extension  may  be  called  for  if  syno- 
vitis of  the  knee  should  ensue,  but  need  not  be  as  energetically  made  as  in 
fracture  of  the  shaft.  Minute  directions  need  hardly  be  given  as  to  the 
means  of  following  out  this  course,  as  they  do  not  ditfer  from  those  employed 
in  other  cases. 

Fractures  of  the  condyles  of  the  femur  are  not  very  seldom  rnet  with  as 
the  result  either  of  direct  violence,  as  from  railroad  or  machinery  accidents,  or 
of  indirect,  as  from  falls  on  the  knees.  They  generally  occur  in  male  adults, 
and  present  numerous  varieties  according  to  the  seat  and  direction  of  the 
fracture,  the  amount  of  bone  involved,  the  degree  of  comminution,  and  the 
severity  of  the  damage  done  to  the  soft  parts. 

The  majority  of  these  injuries  atfect  hoth  condyles,  and  many  of  them  are 
T-fi'actures,  the  bone  being  broken  across  transversely,  and  the  lower  fras;- 
ment  split  down  into  the  joint.-  I  shall  speak  first  of  fractures  of  this  kind, 
and  afterward  of  those  which  concern  one  condyle  only. 

Sometimes  the  transverse  fracture  is  quite  low  down,  sometimes  much 
higher.  Thus  in  the  pathological  cabinet  of  the  IN'ew  York  Hospital  there 
is  a  specimen^ "  from  a  man  who  had  had  his  right  knee  jammed  betw^een  the 
side  of  a  ship  and  a  box  of  two  tons'  weight,  a'few  days  previous  to  the  am- 
putation of  the  thigh.  The  shaft  was  fractured  very  obliquely  a  couple  of 
inches  above  the  condyles,  the  inner  one  of  which,  moreover,  had  been  crushed 
inward  toward  its  fellow,  and  was  traversed  by  several  gaping;  fissures,  which 
incompletely  separated  it  into  several  fragments."  Another*  is  described  as 
follows :  "  Fracture  of  the  femur,  four  inches  above  the  knee,  accompanied 


^  Catalogue,  p.  31,  No.  1132. 
a  Catalogue,  p.  97,  No.  177. 


2  British  Med.  Journal,  Oct.  21,  1882. 
*  Ibid.,  p.  98,  No.  181. 


218 


INJURIES  OF  BONES. 


by  a  separation  of  the  two  condyles  from  each  other  by  a  line  of  fracture  up 
at  right  angles  into  the  one  first  named.  The  condyles  have  united  by 
porous  bone  situated  between  their  opposed  surfaces,  while  the  fracture  of 
the  shaft  has  not  united  at  all,  owing,  as  was  found  on  dissection,  to  the 
interposition  of  a  portion  of  muscle  between  the  fragments." 

In  the  Museum  of  the  Pennsylvania  Hospital,  there  is  a  specimen^  showing 
a  transverse  fracture  an  inch  and  a  half  above  the  joint,  and  a  longitudinal 
fracture  completely  separating  the  condyles  from  each  other.  In  this  case  the 
patient,  a  man,  aged  nineteen,  was  caught  between  two  railroad  cars ;  there 
w^as  great  contusion  about  the  knee,  and  the  popliteal  artery  was  ruptured, 
necessitating  amputation. 

Again,  in  the  Warren  Museum,  there  is  a  specimen^  with  the  following 
description:  "  An  oblique  fracture  just  above  the  condyles;  and  a  second 
between  these  two  into  the  knee-joint.  The  upper  fragment  is  drawn  down- 
ward in  front  of,  and  two  inches  below,  the  knee-joint ;  its  pointed  ex- 
tremity being  far  advanced  in  the  process  of  separation,  and  showing  finely 
the  contrast  between  the  living  and  dead  bone.  A  considerable  quantity  of 
new  and  soft  bone  connects  this  upper  fragment  with  the  shaft  above  the 
inner  condyle.  From  an  intemperate  man,  aged  thirty-seven  years,  who 
slipped  and  fell  with  the  whole  weight  of  his  body  upon  this  limb.  On 
entrance  into  the  hospital  (December  20,  1844),  there  was  a  shortening  of 
two  or  three  inches.  Considerable  swelling  and  emphysema  about  the  knee,, 
and  a  protrusion  of  the  upper  fragment  nearly  an  inch,  with  great  pain  and, 
considerable  bleeding.  The  fracture  was  reduced,  but  the  bones  could  hardly 
be  kept  in  place  ;  and  on  the  third  day,  the  extension  being  discontinued  on 
account  of  the  pain  and  sw^elling,  the  limb  was  simply  laid  in  a  fracture-box. 
Suppuration  and  sloughing  followed.  February  5,  the  limb  was  much 
shortened,  and  the  upper  fragment  seemed  to  have  penetrated  the  knee-joint 
beneath  the  patella.  On  the  11th  of  March  it  protruded  below  this  bone, 
and  on  the  11th  of  April  the  man  died." 

Occasionally  there  is  scarcely  a  distinct  transverse  separation,  but  rather  a 
double  oblique  one,  the  upper  fragment  being  obtusely  pointed  in  front,  and 
seeming  as  if  it  might  have  acted" as  a  w^edge  in  bursting  apart  the  condyloid 
portion  of  the  bone  ;  and  I  think  that  this  may  sometimes  be  accepted  as  the 
true  explanation  of  the  mechanism  of  the  lesion.  Or,  possibly,  first  one  con- 
dyle and  then  the  other  may  have  been  detached,  the  end  of  the  shaft  being 
thus,  as  it  were,  denuded  ;  such  it  seems  to  me  was  the  rationale  of  Bichat's 
case,  quoted  by  Malgaigne,  in  which  a  man  broke  the  condyles  by  lighting 
on  his  feet. 

It  will  readily  be  seen  that  whether  the  force  producing  the  fracture  be 
direct  or  indirect,  it  is  scarcely  possible  for  it  to  act  alike  on  both  sides  of  the 
bone.  Hence,  as  in  some  of  the  instances  above  cited,  one  or  the  other  con- 
dyle must  suffer  more  severely  ;  and  hence  there  must  result  a  change  in  the 
position  of  the  limb,  so  that  an  angle  will  be  presented  between  the  shaft  of 
the  femur  above,  and  the  leg  below.  Sometimes  this  angle  will  be  open  out- 
wardly, sometimes  at  the  inner  side  of  the  limb  ;  and,  slight  as  it  may  be,  it 
will  be  so  far  indicative  of  the  character  of  the  lesion. 

In  two  cases  recorded  by  Callender,^  the  patella  had  sunk  into  the  space 
between  the  fractured  condyles,  and  was  so  wedged  there  that  its  extrication 
was  impossible ;  the  patients  recovered  slowly,  and  in  each  case  the  knee 
was  rendered  permanently  stiff. 

The  symptoms  are  pain,  loss  of  power,  deformity,  often  rendered  very  ob- 

1  Catalogue,  p.  33,  No.  11381°.  2  Catalogue,  p.  197,  No.  1118. 

3  St.  Bartholomew's  Hospital  Reports,  vol.  vi.  1870. 


FRACTURES  OF  THE  FEMUR. 


219 


scure  by  the  swelling  from  effusion  into  the  periarticular  bursfe  as  well  as  into 
the  joint  itself,  lateral  mobility  just  above  the  joint,  and  crepitus. 

When  the  case  is  seen  very  early,  the  diagnosis  may  present  no  great  diffi- 
culty ;  but  from  the  extreme  rapidity  with  which  swelling  comes  on,  and  the 
complexity  of  the  parts  involved,  the  surgeon  is  rarely  able  to  pronounce  upon 
the  nature  of  the  injury  without  reserve. 

The  gravity  of  these  cases  may  be  at  once  perceived.  The  knee-joint  is  of 
necessity  involved,  and  must  become  the  seat  of  inHammation,  so  that  there 
is  a  great  risk  of  anchylosis  if  the  immediate  dangers  to  life  arc  surmounted. 
Hence  a  carefully  guarded  prognosis  only  should  be  given. 

The  treatment  must  be  directed  in  the  first  place  to  the  rectification  of  any 
obvious  distortion,  and  then  to  subduing  inliammatory  action.  During  the 
few  hours  succeeding  the  accident,  indeed,  there  may  be  a  very  marked  col- 
lapse, and  this  must  be  met  as  in  any  other  case,  bearing  in  mind  the  proba- 
bility of  the  occurrence  of  severe  reaction  in  a  succeeding  stage. 

Complete  immobilization  of  the  joint,  with  moderate  extension  and  coun- 
ter-extension, will  I  think  commend  themselves  to  the  judgment  of  every  one 
as  the  cardinal  principles  of  the  local  treatment  in  these  cases.  As  to  the 
exact  means  to  be  employed,  there  may  be  room  for  the  exercise  of  choice. 
My  own  preference  would  be  for  a  well -fitted  back-splint,  and  suspension  in 
either  Smith's  or  Hodgen's  wire-frame ;  but  I  cannot  speak  from  experience, 
having  never  treated  a  case  of  this  kind  except  complicated  with  other  inju- 
ries which  proved  speedily  fatal.  Theoretically,  I  should  think  that  the  corn- 
fort  of  the  patient,  as  well  as  the  retention  of  the  fragments,  would  be  pro- 
moted by  a  slightly  flexed  posture  of  the  knee,  while  in  the  event  of  anchy- 
losis this  would  insure  a  better  gait  than  could  be  obtained  with  the  limb 
entirely  straight.  Should  suppuration  unfortunately  occur,  it  would  be  neces- 
sary to  decide  between  evacuating  the  pus  and  washing  out  the  joint  with 
carbolized  water,  and  amputation ;  or  in  young  subjects  the  propriety  of  ex- 
cision might  be  considered. 

Fracture  of  one  condyle,  although  more  rare  than  that  of  both,  has  been 
repeatedly  observed.  All  the  cases  have  been  in  males,  and  the  result  of 
direct  violence. 

Malgaigne  says  that  this  lesion  "consists  in  a  nearly  vertical  division  of 
the  bone,  striking  the  articular  face  near  one  or  the  other  of  the  condyles,  and 
directed  from  before  backward,  which  goes  up  along  the  bone,  deviating 
inward  or  outward,  according  to  the  condyle  affected,  and  terminating  two, 
three,  or  even  four  inches  above  the  joint;  the  detached  fragment  forming  a 
sort  of  pyramid,  with  the  condyle  for  its  base." 

The  external  condyle  was  broken  off*  in  two  cases  recorded  by  Sir  A.  Cooper  ;^ 
in  both,  however,  the  shaft  of  the  bone  was  also  fractured  across.  In  another 
instance,  reported  by  Crosby,*  the  separation  of  the  condyle  was  due  to  a  twist 
of  the  leg,  and  the  fragment  Avas  removed  by  incision  some  months  afterward. 
Here  there  may  be,  perhaps,  a  question  as  to  the  correctness  of  regarding  the 
force  as  direct,  but  I  am  inclined  to  think  that  it  was  so.  Hamilton  mentions 
the  case  of  a  man  aged  forty,  seen  by  him  three  months  after  the  receipt  of 
the  injury;  the  fragment  was  then  distinctly  movable,  and  he  was  in  doul)t 
whether  the  fracture  had  involved  the  joint.  Such  a  lesion  would  be  analo- 
gous to  fracture  of  the  epicondyle  of  the  humerus.  Kirkbride^  saw  the  ex- 
ternal condyle  separated  by  the  kick  of  a  horse. 

1  Dislocations  and  Fractures  of  the  Joints,  pp.  241,  242. 
*  New  Hampshire  Journal  of  Medicine,  1857. 
'  Am.  Journal  of  the  Med.  Sciences,  May,  1835. 


/ 


220 


INJURIES  OF  BONES. 


Brookes^  has  published  an  account  of  a  boy,  aged  eleven  and  a  half  years, 
"  who  had  his  leg  entangled  in  a  wheel,  and  sustained  a  compound  fracture  of 
the  femur,  extending  obliquely  downward  through  the  external  condyle, 
which  was  movable  with  the  lower  portion,  projecting  through  a  wound  in 
the  popliteal  space.  The  leg  was  twisted  inward,  much  hemorrhage  had 
taken  place,  and  the  patient  was  in  a  state  of  collapse.  On  further  examina- 
tion, the  capsular  ligament  was  found  to  be  lacerated,  and  synovia  escaped — the 
wound  in  the  popliteal  space  being  as  large  as  a  five-shilling  piece.  There 
w^as  also  a  simple  fracture  of  the  lower  third  of  the  same  thigh-bone.  Ampu- 
tation having  been  refused,  the  limb  was  put  up  in  the  straight  position,  with 
a  splint  extending  from  the  hip  to  the  ankle  on  the  outer  side,  and  a  concave 
one  on  the  inner  side  of  the  thigh.  Complete  union  had  occurred  by  the  end 
of  the  sixth  week."  At  the  time  of  the  report  the  knee  could  be  bent  to  a 
right  angle,  and  the  entire  use  of  the  limb  had  been  recovered ;  there  v^^as  no 
shortening  perceptible. 

Three  other  cases  are  cited  by  Malgaigne:^  one  seen  by  himself,  another 
published  by  Gerdy,  and  a  third,  the  specimen  from  which,  without  history, 
is  found  in  the  Musee  Dupuytren. 

The  inner  condyle  has  been  observed  to  be  fractured  in  the  following  in- 
stances :  Wells^  saw  a  thick  scale  of  bone  detached  from  the  inner  part  of 
the  condyle,  the  tibia  being  at  the  same  time  luxated  outward  and  backward; 
the  patient  could  only  state  that  he  had  fallen.  Malgaigne  quotes  from  Boyer* 
a  case  the  account  of  w^hich  is  too  meagre  to  be  of  much  interest.  The  internal 
condyle  w^as  separated,  the  line  of  fracture  running  only  a  short  distance  up- 
w^ard ;  there  was  no  displacement,  but  manifest  mobility  of  the  fragment. 
Consolidation  took  place  without  difficulty,  and  without  apparent  deformity. 
The  patient  could  not  walk  for  three  months,  and  two  months  afterwards  he 
still  limped.  Two  other  cases  are  cited  in  the  same  article,^  one  seen  by  Mal- 
gaigne himself,  and  the  other  by  Lisfranc.  Curtis^  has  published  an  account 
of  a  case  seen  by  him,  in  which,  from  the  statement  made  by  the  surgeon 
first  called,  the  fragment  was  displaced  backward,  the  outer  side  of  the  limb 
appearing  normal ;  the  joint  could  not  be  flexed  by  reason  of  the  pain  caused  by 
bending  it.  Reduction  was  easily  accomplished,  and  a  good  recovery  ensued, 
the  joint,  however,  remaining  enlarged.  Hamilton  quotes  a  case  reported  to 
him  by  Dr.  Eiggs,  in  which,  by  the  kick  of  a  horse,  "  the  internal  condyle  of 
the  right  femur  was  broken  ofi^",  carrying  away  more  than  half  the  articulating 
surface  of  the  joint ;  the  tibia  and  fibula  were  at  the  same  time  dislocated  in- 
w^ard  and  upward,  carrying  w^ith  them  the  broken  condyle  and  the  patella. 
The  displacement  upward  was  about  two  inches,  and  the  sharp  point  of  the 
inner  fragment  had  nearly  penetrated  the  skin.  There  was  no  external 
wound."  Great  difficulty  w^as  experienced  in  the  reduction,  but  the  case 
ultimately  did  well. 

Two  instances  are  cited  by  Morris,^  as  follows :  "  M.  Dubue  has  reported 
the  case  of  a  man  aged  sixty,  who  fell  while  ascending  a  ladder,  and  broke  off 
very  obliquely  the  whole  of  the  internal  condyle  of  the  femur,  and  the  supe- 
rior external  angle  of  the  patella.  Prof.  Yerneuil  had  a  case  in  which  a  large 
cube  of  bone,  consisting  of  the  inner  condyle,  w^as  broken  off  by  the  falling  of 
a  quantity  of  earth  upon  a  man  aged  twenty-eight." 

»  London  Med.  Gazette,  March  10,  1848. 
2  Revue  Med.-Chirurgicale,  April,  1847. 
'*  Am.  Journal  of  the  Med.  Sciences,  May,  1832. 

*  Traito  des  Maladies  Chirurgicales,  tome  iii.  Paris,  1845.  This  case  does  not  appear  in  the 
earlier  editions  of  Boyer's  Treatise. 

6  Revue  Med.-Chirurgicale,  April,  1847. 

8  Am.  Journal  of  the  Medical  Sciences,  Oct.  1866. 

'  Holmes's  System  of  Surgery,  3d  ed.,  vol,  i.  p.  1023. 


FRACTURES  OF  THE  PATELLA. 


221 


The  symptoms  of  these  cases  would  seem,  as  far  as  they  have  been  recorded, 
to  resemble  in  many  respects  those  of  fractures  of  both  condyles ;  there  is  the 
same  pain,  loss  of  power,  swelling,  and  crepitus,  and  in  some  cases,  especially 
where  the  bone  has  been  broken'higher  up  also,  there  would  seem  to  be  like 
deformity.  But  if  one  condyle  alone  is  separated,  and  the  case  is  seen  before 
the  parts  have  been  masked  by  swelling,  it  may  be  possible  to  grasp  the  frag- 
ment by  itself,  and  to  move  it  upon  the  rest  of  the  bone,  so  as  to  gain  some 
idea  in  regard  to  it. 

The  diagnosis,  however,  is  extremely  difficult  in  injuries  of  this  portion  of 
the  femur ;  and  for  my  own  part,  I  should  be  unwilling  to  make  a  positive 
assertion  as  to  any  case  in  which  the  examination  w^as  made  after  swelling 
had  taken  place,  unless  either  the  detached  fragment  was  thrown  off,  or  an 
opportunity  for  dissection  had  occurred.  I  may  say  that  I  have  seen  several 
cases  in  which  there  was  reason  to  believe  that  one  or  other  condyle  had 
been  separated,  but  it  was  impossible  to  arrive  at  anything  approaching  to 
certainty.  Theoretically,  it  is  easy  to  point  out  what  it  seems  ought  to  be 
the  signs  of  one  or  other  lesion ;  but  in  practice  the  matter  is  far  more  per- 
plexing. 

The  course  of  these  cases  varies  very  much;  sometimes  excellent  results 
have  been  obtained,  but  in  other  cases,  either  from  the  previous  bad  habits  of 
the  patients,  or  from  the  severity  of  other  injuries,  the  loss  of  the  limb,  or 
even  of  life,  has  ensued.  When  recovery  has  taken  place,  the  use  of  the  limb 
has  generally  been  in  very  great  measure  restored,  and  sometimes  the  cure 
may  be  said  to  have  been  perfect. 

As  to  the  treatment,  no  precise  directions  can  be  given,  but  the  general 
course  to  be  followed  is  the  same  as  that  advised  for  fractures  involving  both 
condyles. 

Fractures  of  the  Patella. 

According  to  most  observers  who  have  furnished  statistics,  the  patella  is 
affected  in  s'omething  less  than  2  per  cent,  of  all  the  cases  of  fracture.  Gurlt,^ 
in  the  tables  before  quoted,  cites  from  the  record  of  the  Klinik  and  Poly- 
klinik  at  Halle,  given  by  Blasius,  the  statement  that  out  of  778  cases  there 
were  20,  or  over  2 J  per  cent.,  of  the  patella.  On  the  other  hand,  at  the 
AUerheiligen  Hospital  at  Breslau,  Midcleldorpf  reported  but  3  fractures  of 
the  patella  out  of  325  cases,  being  less  than  1  per  cent. 

By  far  the  larger  number  of  the  subjects  of  fractured  patella  arc  adult  males. 
Agnew^  says  that,  in  the  Pennsylvania  Hospital,  out  of  106  cases  96  were  in 
men  and  only  10  in  women  ;  only  one  case  was  seen  under  twenty  years  of  age, 
the  largest  number,  36,  occurring  between  twenty  and  thirty.  Fractures  of  the 
patella  do  not  appear  at  all  in  the  seven  years'  tables  of  the  Children's  Hos- 
pital in  Philadelphia,  already  several  times  cited.  Malgaigne's  figures  are 
not  quite  as  striking  as  the  above ;  out  of  45  cases,  37  were  in  men  to  8  in 
women.  Of  20  cases  observed  by  himself,  only  4  w^ere  in  women.  But  1  of 
the  45  w^as  in  a  person  under  seventeen  years  of  age ;  one  of  his  own  cases, 
however,  was  that  of  a  boy  of  eleven.  He  calls  attention  to  the  fact  that  in 
women,  from  the  seventeenth  year  to  the  fifty-fifth,  there  were  but  3  fractures 
of  the  patella;  there  were  5  beyond  this  period. 

Rare  as  this  injury  is  in  children,  it  has  been  observed  in  them.  Haniilton 
mentions  the  case  of  a  boy  of  five,  in  whom,  by  a  direct  blow,  a  small  piece  of 
the  mai'gin  of  the  bone  was  broken  oft'.  Dr.  Samuel  Ashhurst  has  reported 
to  the  Academy  of  Surgery,  in  Philadelphia,  the  case  of  a  child  four  years  old, 


J  Op.  cit.,  Bd.  i.  S.  6  und  7. 


«  Op.  cit.,  voL  i.  p.  971. 


222 


INJURIES  OF  BONES. 


who,  by  a  fall,  striking  the  knee  against  a  glass  "marble,"  sustained  a  frac- 
ture of  the  patella  downward  and  inward. 

The  patella  may  be  broken  either  by  direct  force  or  by  muscular  action,  or 
by  both  these  causes  combined.  The  mechanism  by  which  the  bone  is  made 
to  yield  in  the  first  case,  is  plain  enough,  as  its  spongy  and  easily  crushed 
texture  would  ill  lit  it  to  resist  a  sudden  blow — such,  for  example,  as  the  kick 
of  a  horse.  Muscular  action  does  not  produce  the  effect  by  tearing  the  bone 
apart,  but  by  the  pull  exerted  upon  the  upper  portion  of  the  bone,  v/hile  its 
lower  part  is  fixed  by  the  ligamentum  patellae,  and  the  resulting  leverage 
over  the  lower  end  of  the  femur.  According  to  this  theory,  which  has  re- 
ceived the  sanction  of  most  of  the  leading  authorities,  this  fracture  is  due,  like 
so  many  others,  to  "  cross-breaking  strain."  Malgaigne  suggests  that  in  some 
of  these  cases  the  bone  has  been  weakened  by  previous  injury,  and  that  in 
some  there  have  been  pains,  or  other  indications  of  pathological  change ;  but 
there  have  certainly  been  many  instances  in  which  nothing  of  the  kind  has 
been  known  to  have  occurred.  Perhaps  it  is  too  obvious  to  need  argument, 
that  in  many  cases  the  muscles  are  in  a  state  of  tension  when  direct  violence 
is  applied  to  the  bone,  and  that  this  condition  aids  materially  in  overcoming 
the  resistance  of  its  structure. 

Desault^  relates  the  case  of  a  patient  who  was  cut  for  stone,  and  who,  in  a 
consequent  convulsion,  broke  both  patellae  at  once.  Marcy^  reports  that  a 
woman,  aged  thirty-eight,  in  an  effort  to  save  herself  from  falling,  met  with 
the  same  misfortune.  Sir  A.  Cooper^  mentions  another  case,  and  Johnston* 
another.  Callender^  has  recorded  one,  to  be  again  referred  to,  and  one  was 
seen  by  Beauvais.^  Callender  has  recorded^  two  cases  in  wdiich  a  different 
mechanism  was  thought  to  have  obtained : — 

"  I.  M.,  aged  45,  laborer,  fell  20  feet,  from  a  ladder,  on  his  knees.  There  was  great 
effusion  into  the  right  knee-joint,  with  fracture  extending  througli  the  condyles  of  the 
femur,  and  comminuted  fracture  of  the  patella,  without  mu6h  displacement  of  its  pieces. 
The  injury  was  treated  on  a  double-inclined  plane,  and  the  patient  was  discharged  with 
a  useful  knee-joint.  We  had  no  doubt  but  that  this  patella  was  broken  after  ^fracture 
of  the  femur,  by  displaced  fragments  being  driven  against  the  articular  surface  of  the 
bone.  In  the  museum  of  St.  George's  Hospital  is  a  transverse  fracture  of  the  patella, 
without  laceration  of  the  fibrous  covering  of  the  bone,  produced  by  violence  acting  from 
within,  in  a  case  of  compound  fracture  of  the  lower  end  of  the  femur,  one  of  the  fraf^- 
ments  of  the  femur  being  driven  against  the  deep  surface  of  the  sesamoid  bone." 

The  line  of  fracture  may  be  almost  exactly  transverse,  or  it  may  be  more 
or  less  oblique,  and  in  a  few  instances  it  has  been  seen  to  be  longitudinal. 
One  specimen,  without  history,  in  the  Musee  Dupuytren,  has  been  accepted 
as  an  example  of  incomplete  fracture,  involving  only  the  articular  cartila2:e 
and  a  small  portion  of  the  underlying  bony  structure,  and  not  extending  to 
the  lateral  edges  of  the  bone.^  It  does  not  seem  to  me  to  be  unquestionably 
of  the  character  claimed  for  it.  Sometimes  the  bone  gives  way  at  more  than 
one  point.  Bryant  mentions  a  specimen,  in  Guy's  Hospital  Museum,  in  which 
there  were  four  fragments,  united  by  ligamentous  bands.  There  is  one  in  the 
museum  of  the  Pennsylvania  Hospital,^  described  as  follows :  "  The  bone  has 
been  fractured  into  five  fragments,  which  are  all  bound  together  by  a  thin, 

'  Treatise  on  Fractures,  Luxations,  etc.  Edited  by  Bichat.  Caldwell's  translation,  p.  299. 
Philadelphia,  1817. 

2  Boston  Med.  and  Surg.  Journal,  October  8,  1874. 

I  Op.  cit.,  p.  230.  4  Lancet,  November  8,  1873. 

5  St.  Bartholomew's  Hospital  Reports,  1870. 

6  Medical  Times  and  Gazette,  Oct.  9,  1880  ;  from  L'Union  Medicate. 
'  St.  Bartholomew's  Hospital  Reports,  1870. 

8  Holmes's  System  of  Surgery,  3d  ed.,  vol.  i.  p.  1028. 

9  Catalogue,  p.  35  ;  No.  1146. 


FRACTURES  OF  THE  PATELLA. 


223 


broad  layer  of  fibrous  tissue.  The  distance  between  the  upper  and  lower 
frao-ments  is  fully  ^  inches,  the  three  other  fragments  occupying  interme- 
diate positions.  The  surfaces  of  the  fragments  have  been  a  good  deal  rounded 
off,  but  are  still  quite  irregular."  The  patient  in  this  case  v  as  known  to  have 
twice  fractured  the  bone.  Gross'  figures  a  specimen  in  the  museum  of  Prof. 
Joseph  Paucoast,  in  which  there  are  three  fragments,  with  intermediate  bands. 
Xo  history  of  double  fracture  or  of  re-fracture  is  given. 

Lonsdale  speaks  of  having  seen  a  man  who  "fell  and  struck  his  knee 
ao*ainst  the  edge  of  a  curb-stone ;  the  fracture  took  a  direction  so  as  to  leave 
the  lower  portTon  projecting  angularly  upwards,  fitting  into  the  upper."  In 
comminuted  fractures,  there  is  not  unfrequently  a  line  of  separation  more  or 
less  transverse,  and  the  lower  fragment  is  again  divided  by  one  or  two  splits 
running  downward  from  this  main  fracture. 

An  anatomical  point  of  importance  is  well  set  forth  by  Tillaux^  in  regard 
to  the  connections  of  the  patella.  He  describes  the  "lateral  ligaments"  of 
the  bone  as  continuous  with  and  arising  from  the  ligamentum  patellae. 
Strongly  attached  to  the  lateral  borders  of  the  patella,  where  they  (the  liga- 
ments^  are  very  thick,  they  pass  backward,  surround  the  condyles,  and  are 
inserted  into  the  fibro-cartilaginous  capsule  with  which  the  gastrocnemii  are 
connected.  These  lateral  ligaments,  be  says,  "constitute  a  powerful  protec- 
tion for  the  front  of  the  knee,  and  play  an  important  part  in  fractures  of  the 
patella,  according  as  they  are  more  or  less  torn.  When  they  are  but  slightly 
torn,  or  not  at  all,  as  happens  in  fractures  by  direct  violence,  which,  indeed, 
are  the  rarest,  they  hold  the  fragments  together ;  if,  on  the  other  hand,  they 
are  much  lacerated,  the  unopposed  quadriceps  muscle  drags  the  upper  frag-^ 
ment  upward,  until  it  may  be  separated  from  the  lower  by  several  fingers' 
breadths.  This  ^toint  must  be  taken  into  the  account  in  estimating  the  value 
of  different  methods  of  treating  these  fractures,  since  in  the  one  c-ase  the  frag- 
ments remain  in  contact,  of  themselves,  while  in  the  other  it  is  difficult  to 
control  them  even  with  the  best  contrived  means." 

When  transverse  fracture  of  the  patella  occurs,  the  lower  fragment  remain.s 
in  place,  being  attached  to  the  tibia  by  the  very  strong  and  unyielding 
ligamentum  patelke.  But  there  are  two  agencies  by  which  the  upper 
fragment  may  be  separated  from  it,  so  that  there  exists  a  perceptible^  gap 
between  them.  One,  already  alluded  to,  is  the  contraction  of  the  quadriceps 
muscle ;  the  other  is  effusion  of  serum,  and  sometimes  of  blood  also,  into 
the  knee-joint.  Both  of  these,  it  must  be  obvious,  will  be  limited  in 
their  action  by  the  lateral  ligaments  of  which  I  have  just  quoted  Tillaux's 
description ;  but  the  muscle'may  be  powerful  enough  to  tear  the  ligaments, 
and  thus  to  produce  the  displacement.  Indeed,  it  may  well  be  doubted 
whether  it  is  not  in  this  way  that  laceration  of  the  ligaments  always 
occurs,  since  they  can  seldom  be  directly  ruptured  by  the  fracturing  force 
except  just  at  the  edges  of  the  bone ;  yet  having  given  way  here,  thei«r 
further  tearing  can  scarcely  require  any  very  great  force.  Once  torn,  how- 
ever, the  greatest  obstacle  both  to  muscular  action  and  to  effusion  into  the 
joint  is  removed ;  and  separation  of  the  fragments  will  very  soon  take  place. 

It  must  not  be  forgotten  that  the  strength  of  these  ligaments  varies  in 
different  individuals ;  and  it  is  doubtless  for  this  reason,  as  well  as  because 
of  the  varying  degree  of  the  violence  sustained,  that  in  some  cases  there  is  at 
once  a  wide  gap  between  the  portions  of  the  bone,  while  in  others  the  frag- 
ments remain  almost  in  contact  until  inflammatory  effusion  occurs  in  the  joint. 

Mr.  Jonathan  Hutchinson^  maintains  that  the  quadriceps  extensor  muscle 


^  System  of  Surgery,  vol.  i.  p.  1000. 

'  Med.-Chir.  Transactions,  vol.  lii.  1869. 


^  Anatomie  Topographique,  p.  1103. 


224 


INJURIES  OF  BONES. 


is  singularly  inactive  in  cases  of  transverse  fracture  of  the  patella,  and  that 
the  separation  of  the  fragments  is  due  largely  to  fluid  pressure  from  within 
the  joint.  He  says  that  the  muscle  occasionally  undergoes  marked  and  per- 
manent atrophy. 

Vertical  or  longitudinal  fractures  of  the  patella  are  always  due  to  direct 
violence,  and  differ  from  the  transverse  in  the  much  less  separation  of  the 
fragments.  Dupuytren^  gives  four  cases  of  this  kind,  in  one  of  which  it  is 
stated  that  the  bone  was  divided  into  two  nearly  equal  portions.  He  speaks 
of  having  treated  several  other  cases  at  the  Hotel  Dieu,  and  thinks  them  less 
rare  than  they  have  been  generally  supposed  to  be.  Lonsdale,  Cooper,  and 
others,  have  met  with  them  in  the  dead  subject.  The  literature  of  the  sub- 
ject is  very  scanty,  and  I  know  of  no  recent  reports  of  such  cases. 

Rupture  of  the  prepatellar  bursa  is  very  apt  to  occur,  whether  the  bone 
gives  way  to  direct  violence  or  to  muscular  action;  in  the  former  case  it  is  by 
bursting,  in  the  latter  by  tearing  of  its  posterior  wall.  It  is  not  of  any  im- 
portance as  compared  with  the  lesion  of  the  bone. 

The  symftoms  of  this  fracture  are  generally  well  marked ;  the  patient  falls — 
and  sometimes  it  is  difficult  to  say  whether  the  fall  is  the  cause  or  the  result 
of  the  injury  to  the  bone  ;  there  is  pain,  aggravated  by  the  strain  upon  the 
fibrous  structures  surrounding  the  bone  which  must  attend  any  attempt  at 
movement;  there  are  swelling  and  deformity,  and,  unless  the  upper  fragment 
has  been  dragged  away  entirely  from  the  lower,  crepitus  is  very  easily  elicited. 

These  syniptoms  are  by  no  means  always  equally  clear.  Tresoret^  has  pub- 
lished an  account  of  a  robust  man  of  forty -five,  who  struck  his  left  knee  in 
a  fall.  He  kept  at  work  for  three  weeks,  and  then,  examining  his  knee  on 
accoun\  of  its  being  swollen,  he  thought  that  the  bone  was  broken.  Two 
months  after  the  accident,  he  applied  for  advice,  when  a  transverse  fracture 
between  the  middle  and  lower  thirds  of  the  bone  was  easily  detected.  A 
cyst  (?)  had  formed  at  this  point ;  iodine  was  injected,  and  a  month  after- 
ward the  patient  was  considered  as  cured.  Morris^  mentions  the  case  of  a 
young  woman  who  struck  her  knee  forcibly  against  a  chair:  ''for  part  of  two 
days  she  got  about  the  house  and  up  and  down  stairs,  moving,  hoM^ever,  with 
great  difficulty  and  much  pain,"  w^hen  an  oblique  fracture  of  the  patella  was 
detected. 

Tillaux*  mentions  a  source  of  error  in  the  diagnosis  of  fracture  of  the 
patella,  which,  he  says,  he  has  several  times  witnessed:  "An  efitision  of 
blood  in  the  prepatellar  bursa  may  give  rise  to  crepitation,  and  the  clots  may 
even  cause  a  sensation  exactly  like  that  of  separation  of  the  fragments."  He 
is  of  opinion  that  this  may  have  been  the  real  state  of  things  in  some  cases 
in  which  fracture  has  been  supposed  to  exist,  and  in  which  it  has  been  claimed 
that  a  perfect  cure  with  bony  union  was  effected.  When  there  is  doubt  as 
to  the  existence  of  fracture,  Mr.  H.  Morris  recommends*  "  fixing  the  bone 
between  the  finger  and  thumb  of  one  hand,  and  then  pressing  all  around  the 
circuinference  of  it  with  the  index  finger  of  the  other."  Hupuytren^  cites  a 
case  seen  by  Breschet,  in  which  it  was  very  difficult  to  determine  the  nature 
of  an  injury,  sustained  by  a  patella  which  had  been  fractured  twelve  years 
previously  ;  the  joint  had  become  almost  entirely  anchylosed,  and  the  conclu- 
sion arrived  at  was  that  the  union  had  given  way. 

The  course  of  these  cases  is  very  various,  but  that  which  is  most  usually 
observed  is  a  gradual  subsidence  of  the  inflammation  in  and  about  the  joint, 
and  the  formation  of  a  ligamentous  connection  between  the  fragments.  If 

1  Diseases  and  Injuries  of  Bones,  Syd.  Soc,  TransL,  p.  225. 

2  Gaz.  des  Hopitaux,  11  Aout,  1881. 

^  Holmes's  System  of  Surgery,  3d  ed.,  vol.  i.  p.  1029. 
"  Op.  cit.,  p.  1124.  6  Lqc.  cit. 

6  Op.  cit.,  p.  228. 


FRACTURES  OF  THE  PATELLA. 


225 


there  is  no  displacement,  as  occasionally  happens  by  reason  of  the  fibrous 
envelop  and  hiteral  lii^anients  remaining  intact,  this  fibrous  band  may  be 
exceedingly  short,  so  that  the  fragments  are  very  close  together.  But  cases 
are  upon  record  in  which  the  separation,  at  first  only  slight,  has  been  in- 
creased upon  the  use  of  the  limb  being  resumed ;  and  it  is,  I  think,  the  rule 
that  in  every  case  some  such  increase  takes  place,  unless  tiie  fragments  have 
been  united  by  bone.  For  bony  union  does  sometimes  occur;  there  are 
several  specimens  of  it  in  the  Miitter  Museum  of  the  ( 'ollege  of  riiysicians  of 
Philadcl[>hia,and  one  is  figured  by  Malgaigne;  several  are  mentioned  by  Mr. 
11.  Morris.'  In  such  cases  the  usual  rule  obtains,  that  on  the  articular  face 
of  the  bone  thei'e  is  rather  a  loss  of  substance  than  a  deposit  of  callus,  so  that 
the  line  of  fracture  is  marked  by  a  shallow  groove.  T.  C.  Smith  has  re- 
corded* a  case  of  fracture  of  the  patella  by  a  fall  on  the  knee,  the  outer  con- 
dyle of  the  femur  being  also  broken  off.  There  was  no  separation  ;  firm 
osseous  union  ensued  in  about  six  weeks,  and  no  observable  deformity  was 
left  from  either  fracture. 

Sometimes,  as  in  a  specimen  figured  by  Morris,^  it  seems  unquestionable 
that  there  has  been  a  new  formation  of  fibrous  tissue,  developed  from  a 
plasma,  just  as  in  some  instances  of  like  union  between  other  bones;  but  this 
is  not  always  the  case,  for  there  may  be  only  an  expansion  of  pre-existing 
liii'an lentous  substance.  When  the  fragments  have  been  tilted,  the  attach- 
ment of  these  fibres  may  be  somewhat  changed,  as  in  another  example  given 
l;y  Morris.*  Kirkbride*  has  reported  a  case  in  which  the  fragments  had  be- 
come united  at  their  inner  part  by  a  round  fibrous  cord,  the  remainder  of 
their  extent  being  unconnected  ;  with  the  knee  in  the  straight  position,  they 
were  two  inches  apart  at  the  outer  side  and  one  and  a  half  at  the  inner,  while 
on  flexion  of  the  knee  the  distances  were  increased  to  three  and  three-fourths 
and  two  and  a  half  inches.  The  patient  had  good  use  of  the  limb,  and 
walked  without  any  perceptible  limp. 

Irregular  i)ressure  by  apparatus,  or  perhaps  the  unequal  yielding  of  dif- 
ferent [)ortions  of  the  ligamentous  structures,  may  give  rise  to  lateral  tilting 
of  the  fragments,  so  that  the  gap  between  the  latter  is  wider  on  one  side 
than  on  the  other.  And  sometimes  there  are  irregular  deposits  of  bone  in 
the  uniting  medium,  showing  an  effort  at  the  establishment  of  bony  union, 
lioth  these  points  are  illustrated  in  a  preparation  in  the  museum  of  the  Pem>- 
sylvania  Hospital:^  ''The  fracture  has  been  transverse,  about  the  middle  of 
the  bone ;  the  fragments  are  covered  by  a  thick  membrane ;  a  broad,  fibrous 
layer,  an  inch  and  a  quarter  w^ide,  unites  the  two  fragments,  being  attached 
to  their  anterior  surface.  There  is  also  a  strong  but  thin  band  passing 
between  their  posterior  surfaces.  At  the  outer  side  of  the  patella  there  are 
two  bony  nodules  springing  from  each  fractured  surfiice ;  these  are  evidently 
new-formed  bone,  and  are  almost  in  contact  with  each  other,  though  no  bony 
union  has  occurred  between  them;  they  were,  however,  firmly  bound  together 
by  ligament.  The  degree  of  separation  at  the  outside  of  the  joint  is  not  more 
than  half  an  inch ;  at  the  inside  it  amounts  to  fully  an  inch."  This  speci- 
men was  taken  from  the  body  of  an  old  negro,  who  had  sustained  the  fracture 
eleven  years  previously. 

Hamilton^  makes  the  extraordinary  statement  that  in  the  case  of  a  young 
man  of  nineteen,  with  a  transverse  fracture  caused  apparently  by  a  direct 

'  Loc.  cit.  2  Am.  Journal  of  the  Med.  Sciences,  April,  1873. 

»  Loc.  cit.,  p.  1031  ;  fig.  175.  *  Ibid.,  fig.  176. 

*  Amer.  Journal  of  the  Medical  Sciences,  May;  1835. 
6  Catalogue,  p.  35  ;  No.  1145. 
^  Treatise  on  Fractures,  etc.,  6th  edition,  p.  502. 
VOL.  IV. — 15 


226 


INJURIES  OF  BONES. 


blow,  '  the  ligament  subsequently  gave  way  completely  on  the  outside,  and 
u  new  patella  formed  in  the  very  ng.uch  elongated  ligament  on  the  inner  side." 

It  must  be  clear  that  in  so  far  as  the  separation  "of  the  fragments  is  due  to 
eftusion  within  the  joint,  it  must  lessen  as  the  fluid  is  absorbed;  and  this 
phenomenon  has  been  strikingly  described  by  Malgaigne,  as  noted  by  him  in 
two  of  his  own  cases.  But  the  contraction  of  the  quadriceps  muscle  can  only 
induce  a  progressive  increase  of  the  interval,  and  may  thus  act,  if  unopposed, 
for  a  long  time. 

Malgaigne  says  that  the  greatest  separation  within  his  knowledge  was  one 
observed  by  Sir  A.  Cooper,  which  amounted  to  four  inches  ;  but  Cooper  him- 
self says,i"the  bone  may  be  drawn  five  inches  upward,  the  capsular  ligament 
and  tendinous  aponeurosis  covering  it  being  then  greatly  lacerated;  and 
this,  with  one  exception,  is  the  greatest  extent  of  separation  which  I  have 
seen."  And  Mol-ris^  says  that  "in  St.  Thomas's  Hospital  Museum  are  two 
specimens  in  which  the  ligamentous  union  is  six  inches  or  more  in  length." 

A  curious  shortening  of  the  ligamentum  patellae  sometimes  occurs ;  and 
though  it  is  not  generally  of  great  extent,  yet  it  contributes  somewhat  to  the 
ultimate  amount  of  separation  between  the  fragments.  Perhaps  this  is  due 
in  some  degree  to  pressure  by  apparatus,  which  certainly  often  has  the  effect 
of  causing  the  gap  to  be  greater  at  the  anterior  surface  than  at  the  posterior. 
Callender^  has  noted  the  occasional  occurrence  of  hypertrophy  of  the  fras;- 
ments,  as  well  as  the  fact  that  the  opposite  condition  has  been  met  with,  the 
broken  portions  becoming  atrophied.  He  also  mentions  a  specimen,  in  the 
museum  of  the  Middlesex  Hospital,  in  which  the  lower  fragment  has  become 
united  by  bone  to  the  tibia,  so  that  the  fibrous  band  between  the  fragments 
had  come  to  represent  the  ligamentum  patellae. 

^  In  one  or  two  recorded  instances,  the  upper  fragment  has  contracted  adhe- 
sions to  the  femoral  condyles,  but  without  any  direct  influence  in  impairing 
the  usefulness  of  the  limb. 

Refracture  of  the  patella  is  not  a  very  unfrequent  occurrence.  Sometimes, 
but  rarely,  the  bond  of  union  gives  way.  More  frequently  the  bone  separates 
at  another  point ;  and  this,  I  think,  is  to  be  accounted  for  on  the  ground  that 
as  the  use  of  the  limb  is  acquired,  one  or  other  of  the  fragments  comes  to 
bear,  as  the  original  bone  did,  over  the  lower  extremity  of  the  femur,  this 
portion  then  giving  way  under  a  "cross-breaking  strain."  I  have  myself 
reported'  a  case  in  which,  under  the  use  of  Malgaigne's  hooks,  I  had  succeeded 
in  getting  extremely  close  union  of  a  transverse  tracture,  and  the  bone  gave 
way,  apparently  at  the  same  point,  four  months  afterward,  under  a  sudden 
slight  strain.  But  instances  of  this  kind  are  not  common.  Little^  has  re- 
corded a  case  in  which,  ligamentous  union  having  occurred,  a  second  fracture, 
half  an  inch  higher  up,  took  place  niue  months  afterward  ;  so  that  when  the 
patient  finally  recovered,  there  were  three  fragments  and  two  clearly  defined 
fibrous  bands.  Parson^  published  an  account  of  a  case  in  which  (in  Decerii- 
ber,  1874)  the  left  patella  was  fractured  at  the  junction  of  the  middle  and 
upper  third  ;  io  October,  1880,  the  same  bone  gave  way  at  the  junction  of 
the  middle  and  lower  thirds,  and  in  August,  1882,  it  was  again  broken  at  the 
same  point.  Lloyd^  saw  a  patella  broken  by  direct  violence,  which  gave  way 
again  twice  at  intervals  of  twelve  months.  Bryant  mentions  a  case  seen  by 
him,  in  which  one  patella  had  been  broken  tw^ice,  and  the  other  three  times. 

It  is  not  very  diflicult  to  see  why  fracture  of  one  patella  should  occasion 

1  Dislocations  and  Fractures  of  the  Joints,  p.  224. 

2  Loc.  cit.,  p.  1030.  3  St.  Bartholomew's  Hospital  Reports,  1870,  p.  49. 
*  Am.  Journal  of  the  Med.  Sciences,  Oct.  1861.  -f      '         ^  ^ 

6  Med.  Record,  March  4,  1882.  6  Lancet,  May  19,  1883. 

'  liirmingliam  Medical  Review,  March,  1883. 


FRACTURES  OF  THE  PATELLA. 


227 


ally  be  followed  by  a  like  misfortune  to  the  other.  The  patient  will  natu- 
rally spare  the  limb  which  has  already  suffered,  and  in  case  of  a  slip,  or  any 
demand  for  effort,  will  be  likely  to  put  a  severe  stress  upon  the  better  one, 
which  yields  as  its  fellow  did.  The  interval  between  the  fractures  is  some- 
times a  long  one.  I  have  now  under  treatment  at  the  Episcopal  Hospital  a 
robust  and  healthy  man  with  fracture  of  the  right  patella,  in  whom  the  bone 
of  the  left  side  was  broken  about  two  years  ago,  and  is  united  by  a  short 
fibrous  bond.  He  was  not  aware  of  any  lameness  or  weakness  of  either  limb. 

When  re  fracture  occurs,  the  damao:e  done  is  sometimes  far  more  serious 
than  that  of  the  original  accident.  Thus  King^  met  witli  a  case  in  which, 
five  months  after  a  fracture  of  the  patella,  union  having  taken  place  with 
the  fragments  about  half  an  inch  apart,  the  whole  knee  was  burst  open, 
a  wound  seven  inches  long  being  produced,  and  the  fragments  separated 
an  inch  and  a  quarter.  Suppuration  ensued,  but  the  patient  made  a  good 
recovery  ;  the  amount  of  motion  in  the  knee,  if  any,  is  not  stated. 

Charles  Bell^  mentions  a  very  similar  instance.  The  bone  had  united  by 
ligament,  and  this  ligament  had  incorporated  with  the  skin  in  such  a  manner 
that  it  lost  much  of  its  pliancy.  The  poor  man  w^as  carrying  a  burden  and 
fell  backward,  the  knee  sank  under  him,  and  the  whole  fore})art  of  the  joint 
was  laid  open  by  laceration.  The  case  terminated  in  amputation  of  the  limb." 
^falgaigne,  after  referring  to  this  case,  says :  "  I  have  seen  a  nearly  similar 
instance  ;  the  rupture  of  the  fibrous  band  was  attended  with  enormous  ecchy- 
mosis,  gangrene  ensued  at  about  the  fifth  day,  and  death  closed  the  scene. 
M.  Seutin  quite  recently  sought  in  vain  to  save  a  limb  thus  affected ;  after 
four  months  of  suftering,  am[)utation  of  the  thigh  became  the  only  resource." 

Thomson^  reported  to  the  surgical  section  of  the  British  Medical  Associa- 
tion, a  case  of  old  fracture  of  the  patella,  in  which  suture  of  the  fras^ments 
liad  been  practised;  a  year  later,  the  knee  being  stiff',  the  patient  tripped, 
and  burst  open  the  whole  joint.  Resection  was  performed,  with  a  good 
result.  lie  refers  to  other  like  cases  seen  by  Bell,  Poland,  and  Pelletan,  in 
all  of  which  amputation  was  deemed  necessary.  A  very  similar  instance  has 
been  placed  on  record  by  Mason,*  and  another,  but  with  a  far  more  fortunate 
issue,  by  Roberts.* 

Necrosis  of  a  portion  of  the  fractured  bone  has  been  observed  in  a  very  few 
instances.  One  of  these  is  given  by  Erichsen,^  as  follows:  "The  patient,  a 
middle-aged  man,  had  met  with  an  ordinary  transverse  fracture  of  the  patella, 
which  united  by  ligament  two  years  after  the  accident;  and  without  any 
fresh  injury  he  came  to  the  hospital,  with  necrosis  of  the  outer  half  of  the 
upper  fragment,  which  was  completely  detached,  and  lying  in  a  cavity 
bounded  and  shut  off'  from  the  joint  by  plastic  matter.  1  cut  down  upon 
and  removed  the  necrosed  fragment,  which  appeared  to  constitute  about  one- 
quarter  of  the  patella.  Xo  cause  could  be  assigned  for  the  necrosis,  except 
defective  vascular  supply  to  this  part  of  the  bone."  Another  instance  is 
briefly  referred  to  by  Lawson,^  "  in  which  a  portion  of  the  patella  was  chipped 
off",  necrosed,  and  fell  into  the  joint,  there  setting  up  inflammation,  which 
caused  death."  Hulke^  says  that  a  partially  detached  portion  of  one  of  the 
fragments  may  die  and  be  gradually  exfoliated,  as  in  Liston's  patient,  a  sailor, 
aged  twenty-four,  who  died  seven  weeks  after  the  injury  from  hectic  fever 
following  extensive  suppuration  in  and  around  the  knee-joint. 

'  Dublin  Med.  Press,  Dec.  8,  1847. 

*  A  System  of  Operative  Surgery,  2d  Am,  ed.,  vol.  ii.  p.  361.  1816. 

»  British  Med.  Journal,  Aug.  26,  1882.  ♦  Med.  Record,  March  20,  1875. 

6  Bryant's  Surgery,  3d  Am.  ed. 

6  Science  and  Art  of  Surgery,  Am.  ed.,  vol.  1.  p.  381.  1873. 
'  British  Med.  Journal,  June  9,  1877. 

•  Holmes's  System  of  Surgery,  3d  ed.,  vol.  i.  p.  1028. 


228 


INJURIES  OF  BONES. 


A  fact  of  much  importance,  as  will  be  seen  when  the  subject  of  treatment 
comes  under  discussion,  is  that  the  usefulness  of  the  limb  after  recovery  from 
fracture  of  the  patella  is  not  necessarily  in  proportion  to  the  closeness  of 
apposition  of  the  fragments.  I  have  seen  a  number  of  persons  who  had  had 
this  injury,  and  in  whom  very  great  separation  remained,  who  yet  were  able 
to  walk,  to  go  up  and  down  stairs,  and  even  to  mount,  as  for  instance  into 
a  chair,  as  well  apparently  as  ever.  One  very  large  and  portly  man,  well 
known  for  years  in  Philadelphia,  had  had  fracture  of  both  patellae  at  different 
times,  with  very  lengthy  ligamentous  union,  and  yet  he  walked  about  freely, 
and  showed  no  peculiarity  of  gait  beyond  what  might  have  been  perfectly 
natural  to  him. 

Such,  however,  is  not  always  the  case.  Callender^  says :  I  note  in  April , 
1866,  the  case  of  a  poor  fellow  who  had  fractured  either  patella  some  years 
previously,  and  who  was  admitted  for  some  other  trouble.  He  had  lost  all 
power  of  recovering  himself  when  the  body  was  bent  back  from  the  knees^ 
and  thus  he  constantly  fell  whilst  moving  about.  In  his  case  the  interval 
between  the  two  fragments  of  bone  on  each  side  was  less  than  two  inches  and 
a  half,  but  then  both  knees  were  damaged."  My  belief  is  that  much  depends 
upon  the  confidence  felt  by  the  patient ;  and  it  is  very  probable  that  in  a 
case  of  simultaneous  fracture  of  both  bones,  the  loss  of  power  would  be  apt 
to  be  greater  and  more  persistent  than  if  the  injury  should  be  sustained  first 
in  one  limb,  and  at  some  later  period  in  the  other. 

When  fracture  of  one  patella  has  taken  place,  and  even  when,  as  in  an 
instance  recorded  by  Hamilton, ^  the  fragments  are  separated  to  a  distance  of 
four  and  a  half  inches,  and  no  bond  of  union  can  be  detected,  the  rule  is  that 
in  a  greater  or  less  length  of  time,  with  judicious  management,  the  strength 
and  usefulness  of  the  limb  are  in  a  very  complete  measure  regained.  Hence 
it  seems  to  me  that  the  i^'^ogiiosis  of  these  cases  rnay  be  favorable,  so  far  as 
the  ultimate  result  is  concerned ;  but  the  patient  should  not  be  led  to  think 
that  his  recovery  will  be  speedy,  not  only  lest  he  should  be  disappointed,  but 
also  lest  he  should  by  imprudence  sustain  further  damage. 

As  to  the  treatment^  a  great  deal  of  ingenuity  has  been  expended  in  the 
endeavor  to  devise  means  of  holding  the  fragments  in  apposition,  or  as  nearly 
so  as  possible ;  and  a  vast  number  of  appliances  for  this  purpose,  many  of 
them  very  similar  in  principle,  and  varying  only  in  trifling  details,  have  been 
described,  each  with  its  inventor's  name.  I  shall  not  attempt  to  give  a  com- 
plete list  of  these,  but  propose  to  state  the  objects  to  be  aimed  at,  and  the 
chief  methods  by  which  they  may  be  attained  ;  not  omitting  any  practical 
suggestions,  but  not  being  careful  to  mention  all  the  curious  and  complicated 
mechanisms  which  have  been  from  time  to  time  recommended,  without 
acquiring  more  than  a  transient  and  local  reputation. 

Surgeons  have  difiered  as  to  the  best  position  in  which  to  place  the  limb, 
some  advocating  the  flexion  of  the  hip-joint,  others  deeming  it  of  little  im- 
portance. Callender^  says :  "  I  hope  the  old  fashioned  plan  of  raising  the 
limb  on  an  inclined  plane  for  the  treatment  of  fracture  of  the  patella  is  quite 
obsolete.  Fractures  of  this  sesamoid  bone  are  now  treated  in  St.  Bartholo- 
mew's by  rest  simply,  the  limb  lying  in  the  horizontal  position."  On  the 
other  hand,  Mr.  Croly,  of  Dublin,  is  said^  to  be  ''content  to  obtain  good 
fibrous  union  by  simply  elevating  the  limb,  so  that  a  line  drawn  from  the  toe 
wall  pass  on  a  level  with  the  patient's  nose,  the  chest  and  shoulders  being 
raised  by  a  bed-rest,  and  subduing  all  inflammation  by  ice  and  evaporating 
lotions." 


'  Loc.  cit.,  p.  49. 
3  Loc.  cit.,  p.  46. 


2  Op.  cit.,  6tli  ed.,  p.  527.  1880. 
<  Lancet  (editorial),  March  31,  1883. 


FRACTURES  OF  THE  PATELLA. 


229 


While  it  is  very  probable  that  the  importance  of  flexing  the  limb  strongly 
upon  the  body  may  have  been  overstated  by  some  writers,  it  seems  to  me 
that  surgeons  generally  would  be  unwilling  to  forego  the  advantage  gained 
by  complete  relaxation  of  the  muscles  on  the  front  of  the  thigh.  I3ut  in 
order  to  secure  this,  it  is  not  necessary  to  place  the  limb  at  an  angle  of  less 
than  about  130°  with  the  axis  of  the  body.  It  is,  however,  essential  that  the 
knee  should  be  kept  in  the  extended  position,  and  this  becomes  very  irksome 
from  stretching  of  the  posterior  muscles,  if  the  hip-joint  is  strongly  flexed. 
So  o-enerally  has  the  propriety  of  this  posture  of  the  knee  been  recognized, 
that  almost  all  suro-eons  have  included  a  back-splint  in  their  appliances  for 
dealniii-  with  fractures  of  the  patella.  By  some  the  ordinary  single-inclined 
plane  "is  used,  so  arranged  that  the  degree  of  elevation  of  the  foot  may  be 
altered  at  the  will  of  the  attendant.  Others  have  employed  a  trough  of  tin, 
iCutta  percha,  binders'  board,  or  some  like  material ;  while  many  prefer  a 
board,  either  sloped  ofi:'  above  and  below,  or  padded,  so  as  to  All  up  the  hol- 
low of  the  ham.  If  such  a  board  is  used,  it  should  be  of  suitable  width  for 
each  portion  of  the  limb,  very  slightly  hollowed  out  along  the  middle,  and  at 
its  ends  the  edges  should  be  carefully  bevelled  oft'  so  as  to  make  no  pressure 
upon  the  skin. 

Plaster-of-Paris  bandages  have  been  used  by  some  surgeons,  and  the  starched 
bandage  is  highly  recommended  by  Erichsen;  but  neither  of  these  can,  in  my 
opinion,  be  safely  employed,  except  in  the  later  period,  when  the  patient  is 
beginning  to  weary  of  confinement,  and  union  has  so  far  progressed  as  to  be 
inli  measure  assured.  Hamilton  quotes  several  cases  in  which  the  injudi- 
cious use  of  plaster  of  Paris,  or  of  a  silicate  bandage,  seemed  to  be  the  clearly 
assignable  cause  of  very  imperfect  results,  and  one  has  been  recorded^  in 
which  gangrene  ensued,  and  amputation  had  to  be  performed. 

I  will  merely  mention  that  some  surgeons  on  the  Continent  of  Europe  have 
resorted  to  what  must,  I  think,  be  regarded  as  an  unjustifiable  practice— the 
aspiration  of  the  knee-joint  for  the  removal  of  the  eftused  liquid,  by  which  it 
is  ai)t  to  be  distended  for  a  few  days  after  the  accident.  Such  interference  is 
not  only  theoretically  attended  with  risk,  but  it  has  been  actually  proved  so. 
I  do  not  refer  to  the  rare  cases  in  which  a  formidable  arthritis  has  already 
been  set  up,  and  in  which  there  is  an  existing  danger  from  the  products  of 
inflammation  within  the  joint,  although  as  to  even  these  there  are  conserva- 
tive surgeons  who  would  hesitate  to  adopt  such  measures ;  but  to  those  cases 
in  which  the  eftiision  is  a  mere  temporary  inconvenience,  and  in  which  nature 
will,  do  the  work  of  relief  as  surely  and  much  more  safely,  if  not  as  promptly, 
as  any  surgical  instrument. 

For  a  few  days,  then,  until  the  swelling  of  the  joint  has  subsided,  the  best 
course  is  to  place  the  limb  at  rest  on  a  back-splint,  and  to  employ  suitable 
means  for  allaying  the  local  irritation.  Evaporating  lotions,  lead-water  and 
laudanum,  or  hot  water-dressing,  may  be  made  use  of,  the  choice  being 
determined  according  to  the  age  and  strength  of  the  j^atient,  the  season  of  the 
year,  and  perhaps  other  circumstances. 

Upon  the  disappearance  of  the  eftusion  into  the  joint,  means  must  be 
adopted  for  approximating  the  fragments.  Should  the  tendency  to  separa- 
tion be  very  great,  an  attempt  should  be  made  to  control  it  even  from  the 
outset;  for  although  the  bringing  of  the  fragments  together  may  be  impos- 
sible, and  even  inadvisable  for  fear  of  injury  to  the  joint,  yet  the  subsequent 
coaptation  may  be  rendered  easier.  The  best  way  of  doing  this  is  by  means 
of  a  compress  of  folded  lint,  having  around  it  an  envelope  of  adhesive  plaster, 
the  adhesive  surface  outside ;  this  being  placed  on  the  skin  just  above  the 


•  Am.  Journal  of  the  Med.  Sciences,  Feb.  1840;  from  the  Gaz.  Medicale,  1839,  No.  28. 


230 


INJURIES  OF  BONES. 


upper  fragment,  and  the  middle  of  a  strip  of  bandage  laid  over  it,  the  ends  of 
the  bandage  may  be  gently  drawn  upon,  and  secured  to  pegs  or  nails  at  either 
side  of  the  splint,  at  such  points  that  the  tension  shall  be  exactly  in  the  direc- 
tion desired. 

The  aim  of  most  of  the  inventors  of  appliances  for  the  treatment  of  these 
fractures  has  been  to  act  on  both  fragments,  forcing  them  together.  But,  in 
fact,  the  lower  one  is  not  displaced,  unless  by  the  shortening  of  the  ligamen- 
tum  patellse,  before  spoken  of;  and  it  is  very  doubtful  whether  this  is  not 
actually  promoted  by  pressure  brought  to  bear  upon  it  in  some  methods. 

Various  devices  for  circular  pressure  were  used  at  a  very  early  date ;  Mal- 
gaigne  speaks  of  splints  perforated  in  the  centre,  and  kept  in  place  by  a  ban- 
dage (the  patella  being  received  into  the  opening,  by  the  edges  of  which  the 
fragments  were  held  together),  as  known  to  Albucasis,  Guy  de  Chauliac,  and 
others.  This  plan,  he  says,  was  still  employed  at  the  Hotel  Dieu  in  the  latter 
part  of  the  last  century. 

Another  development  of  the  same  idea  w^as  the  rino-  or  cap,  Avhich  has  been 
revived  in  modern  times  by  Knight,^  Gibson,^  Eve,^  Blackma'n,''  and  perhaps 
others.  Its  simplicity  is  its  only  recommendation,  and  although  it  may 
answer  well  where  there  is  little  or  no  gap  between  the  fragments,  and  where 
mere  support  is  required,  it  is  not  likely  to  take  the  place  of  appliances 
which  admit  of  greater  adaptation  to  the  circumstances  of  each  case.  A 
positive  objection  may  be  made  to  it  on  the  ground  of  its  interfering  with 
the  nutrition  of  the  bone.  Gross^  quotes  Manning  as  having  "  observed  by 
dissection  that  the  vascular  arch  of  the  upper  fragment  is  situated  at  the 
precise  spot  where  the  greatest  amomit  of  pressure  is  nsually  made  by  the 
retentive  apparatus ;  and  that  the  lower  fragment  experiences  a  similar  fate 
when,  as  not  unfrequently  happens,  the  internal  superior  and  inferior  arteries 
arise  from  a  common  trunk."  By  Thomas,^  also,  the  importance  of  non- 
interference with  the  circulation  of  the  patella  is  urged. 

By  a  great  many  surgeons,  the  use  of  pressure  by  bands,  with  or  without 
compresses,  and  arranged  in  various  ways,  has  been  relied  upon.  Thus  Dor- 
sey  used  a  Dack-splint,  with  tapes  fastened  to  it,  which  were  brought  up  above 
and  below  the  broken  bone,  so  that  they  should  draw  the  fragments  into 
place  ;  the  lower  one  passing  above,  and  the  upper  one  below,  crossing  one 
another  at  each  side.  A  somewhat  similar  arrangement,  but  with  pegs  for 
tightening  the  bands,  is  recommended  by  Agnew.^  ""Perhaps  it  need  hardly  be 
pointed  out  that  by  changing  the  points  of  attachment  of  the  tapes  or  bands, 
the  traction  may  be  brought  more  or  less  parallel  with  the  long  axis  of  the  limb ; 
and  that  the  further  apart  they  are,  the  more  directly  will  the  fragments  be 
drawn  together.  Hamilton  uses  a  moulded  trough,  and  figure-of-S  turns  of  a 
roller.  Sir  A.  Cooper  laid  tapes  along  the  limb  on  either  side  of  the  fractured 
patella,  and  then  applied  a  roller,  leaving  the  patella  uncovered.  By  drawing 
up  the  ends  of  the  tapes,  and  tying  the  corresponding  ones  together,  the  turns 
of  the  roller  above  and  below  the  knee  were  approximated,  and  with  them  the 
fragments.  The  obvious  objection  to  this  plan  is  the  circular  constriction 
which  it  of  necessity  involves.  Gerdy's  method  was  somewhat  similar  to  this. 
A  much  better  device,  but  still  subject  to  the  same  inconvenience,  was  afterward 
used  by  Cooper  f  it  was  a  leathern  band  buckled  round  the  thigh  just  above 

'  Am.  Journal  of  the  Med.  Sciences,  July,  1860. 

2  St.  Louis  Med.  and  Surg.  Journal,  Oct.  1866.  This  author  claims  to  have  obtained  bony- 
union  by  means  of  the  ring. 

3  Nashville  Journal  of  Medicine  and  Surgery,  Feb.  1867. 
*  Western  Journal  of  Medicine,  May,  1868. 

5  Op.  cit.,  vol.  i.  p.  999.  6  Med.  Press,  and  Circular,  Oct.  11,  1882. 

'  Op.  cit.,  vol.  i.  p.  974.  »  Op.  cit.,  p.  229. 


FRACTURES  OF  THE  PATELLA. 


231 


the  patella,  and  drawn  down  by  another  strap  passing  down  from  it,  around 
the  sole  of  the  foot,  and  then  up  along  the  other  side  of  the  leg.  An  appa- 
ratus, very  similar  in  principle,  has  lately  been  proposed  by  Levis,  of  Phila- 
delphia.^ 

A  plan  Avhieh  has  in  my  hands  proved  very  satisfactory,  is  known  as  ban- 
born 's.  Its  peculiarity  consists  in  the  use  of  a  strip  of  adhesive  plaster  along 
the  upper  surface  of  the  limb,  leaving  a  free  loop  just  over  the  patella.  Com- 
presses having  been  applied,  and  the  ends  of  the  strip  secured  by  transverse 
strips  and  a  roller,  the  loop  is  twisted  up  by  means  of  a  bit  of  stick  passed 
til  rough  it,  until  the  compresses  are  so  drawn  together  as  to  bring  the  frac- 
tured ^surfaces  as  nearly  as  possible  into  contact.  The  stick  is  then  secured 
by  tyino-  its  ends  with  a  strip  of  bandage  passed  round  under  the  back-splint. 
Of  course  the  pressure  can  be  increased  at  any  time  by  twisting  the  loop  up 
tio:hter,  and  can  be  lessened  by  untwisting  it. 

"a  number  of  appliances  have  been  proposed,  and  a  few  of  them  have  been 
extensively  used,  with  semicircular  or  crescentic  plates  of  metal,  arranged  to 
press  ai>:ainst  the  upper  and  lower  edges  of  the  fragments,  and  to  push  them 
togethei'.  Of  these,  Lonsdale's^  was  the  lirst ;  his  plates  were  carried  on 
arms  attached  to  the  back-splint,  and  by  means  of  screws  and  nuts  could  be 
adjusted  so  as  to  produce  the  desired  effect.  I  need  hardly  enumerate  the 
other  forms  of  apparatus  based  upon  this  idea,  as  they  can  be  found  described 
in  readily  accessible  works,  and  have  mostly  had  but  an  extremely  limited 
use.    Some  of  them  are  complicated,  and  others  inefficient. 

Perhaps  I  may  be  permitted  here  to  digress  for  a  moment,  and  to  say  that 
this  subject  of  the  treatment  of  fractures  of  the  patella  affords  a  striking  illus- 
tration of  the  fact  that  in  surgical  appliances  and  methods  what  is  wanted  is 
not  power,  not  mere  brute  force,  but  exact  adaptation.  Much  ingenuity  has 
been  expended  upon  the  invention  of  apparatus  to  overcome  resistance  which 
it  is  far  better  to  evade  than  to  oppose,  to  coax  than  to  compel. 

An  apparatus  employed  at  the  ^liddlesex  Hospital,^  in  London,  seems  to 
me  to  possess  very  great  advantages,  and  I  will  quote  the  description  of  it  in 
full  :— 

"  A  broad  piece  of  moleskin  plaster,  cut  out  at  one  border,  somewhat  horseshoe- 
shaped,  but  with  the  ends  oV  the  curve  prolonged,  is  fixed  to  the  thigh,  so  that  the 
curved  edge  is  level  witli  the  normal  position  of  the  patella,  and  is  retained  by  means  of 
a  few  turns  of  roller.  Next  the  limb  is  fixed  upon  a  well-padded  Mclntyre  or  simple 
wooden  back-splint  having  a  foot-piece.  Then  the  lower  fragment  of  tlie  patella  is 
fixed  by  means  of  a  pad  of  lint  and  broad  strip  of  adhesive  plaster  applied  figure-of-8 
fashion  around  limb  and  splint  ;  and  the  bandage  which  confines  the  foot  and  leg  to  the 
splint  is  continued  upward  as  far  as  this  pad,  which  it  assists  in  fixing.  To  the  pro- 
longed ends  of  the  moleskin  plaster  are  sewn  pieces  of  bandage  (pieces  of  moleskin 
plaster  of  different  sizes  cut  to  the  right  shape,  and  having  the  pieces  of  bandage  fas- 
tened on,  are  always  kept  ready)  which  are  attached  in  turn  to  India-rubber  accumu- 
lators, one  on  each  side  of  the  leg  ;  eacli  of  the  accumulators  at  its  lower  end  is  fastened 
to  a  piece  of  bandage,  and  these  are  tied  togetlier  below  the  foot-board  of  the  splint. 
With  a  pad  of  lint  at  tlie  upper  border  of  the  superior  fragment  of  the  patella  beneath 
the  free  edge  of  the  moleskin,  the  requisite  amount  of  tension  is  obtained  by  tightening 
the  tied  pieces  of  bandage." 

I  am  at  present  using  this  plan  in  two  cases  in  my  wards  at  the  Episcopal 
Hospital,  and  find  it  satisfactory. 

A  very  elegant,  but  very  complicated  arrangement  for  the  use  of  weights 
and  pulleys  in  coaptating  the  fragments  of  the  broken  patella,  the  invention 


'  Agnew,  op.  cit.,  vol.  i.  980.  •  Treatise  on  Fraetures,  p.  427. 

*  Holmes's  System  of  Surgery,  3d  ed.,  vol.  i.  p.  1032. 


232 


INJURIES  OF  BONES. 


of  which  is  ascribed  to  Dr.  Burge,  of  Brooklyn,  is  figured  by  Agnew.  Callen- 
der/  Hornibrook,^  and  Grant^  have  suggested  simpler  devices  for  merely 
drawing  down  the  upper  fragment  by  means  of  a  weight  and  pulley.  I  think 
that  instruments  of  this  kind  would  scarcely  be  available  in  practice,  unless 
with  extremely  tractable  patients. 

Malgaigne's  hooks,  intended  to  act  directly  upon  the  bone  itself,  and  to 
keep  the  fragments  in  exact  apposition,  have  been  by  some  surgeons  regarded 
with  great  favor,  while  by  others  they  have  been  strongly  condemned.  The 
instrument,  as  used  by  its  inventor  and  by  others,  myself  among  the  number, 
consisted  of  a  pair  of  steel  plates,  each  carrying  a  pair  of  strong  recurved 
hooks,  and  having  on  its  upper  face  a  block  perforated  with  a  female  screw ; 
the  hooks  having  been  inserted  through  the  skin  so  as  to  catch,  one  the  upper 
edge  of  the  upper  fragment,  the  other  the  lower  border  of  the  lower  one,  were 
brought  toward  one  another  by  turning  a  male  screw  through  the  blocks,  and 
the  fractured  surfaces  were  thus  forced  together.  Within  a  few  years,  Mor- 
ton and  Levis*  have  employed  these  hooks,  detaching  them  so  as  to  make 
them  into  two  independent  pairs,  or  into  a  set  of  four  movable  hooks.  The 
question  with  regard  to  them,  however,  is  not  of  their  efficiency,  which  is 
obvious,  the  modifications  suggested  being  merely  for  convenience  in  appli- 
cation ;  it  is  whether  their  use  is  or  is  not  attended  with  danger.  On  this 
point  Agnew^  says : — 

"  Once  have  I  seen  death  follow  the  use  of  this  infernal  machine,  from  an  erysipe- 
latous inflammation  exteiiding  into  the  joint,  and  giving  rise  to  abscesses,  both  within 
and  without  the  articulation.  No  advantage  whatever  results  from  the  close  contact  of 
the  fragments  accomplished  by  the  instrument ;  it  is  rather  a  disadvantage,  as  the  ten- 
dency to  refracture  is  increased  by  the  very  closeness  of  the  union,  the  intermediate 
bond  not  being  as  strong  as  the  ordinary  fibrous  tissue  which  fills  the  gap  when  the 
pieces  of  the  bone  are  a  short  distance  apart.  Three  times  have  I  seen  the  union  broken 
a  few  weeks  after  the  patients  treated  by  this  method  had  been  discharged  from  the  hos- 
pital." 

Hamilton^  quotes  from  Volkmann:  "  That  Malgaigne's  hooks  have  caused 
ulceration  of  the  joint  and  death  of  the  patient  in  a  number  of  cases,  is  only 
too  true ;  I,  myself,  know  of  two  which  occurred  in  the  practice  of  friends, 
and  which  were  never  published,  and  another  sad  experience  was  met  with 
in  my  own  clinic  a  number  of  years  since."  On  the  other  hand,  De  Morgan,^ 
speaking  from  his  experience  with  the  hooks  in  the  Middlesex  Hospital,  says 
"  there  is  no  method  of  treatment  which,  with  so  little  trouble  to  the  surgeon 
or  irksomeness  to  the  patient,  will  produce  such  satisfactory  results." 

Hamilton,  while  he  says  that  "  several  cases  have  been  reported  of  danger- 
ous or  disastrous  inflammation  induced  by  the  hooks,"  thinks  that  "  in  cases 
in  which  the  original  separation  exceeds  one  or  one  and  a  half  inches,  and 
especiallj^  in  cases  of  a  refracture  or  rupture  of  the  fibrous  band,  accompanied 
with  great  separation,"  the  plan  is  entitled  to  a  further  trial. 

In  "the  case  recorded  by  me,^  in  which  the  hooks  were  used,  they  caused 
no  inflammation  of  any  moment,  and  by  experiment  on  the  dead  subject  I 
afterwards  satisfied  myself  that  there  could  be  no  risk,  with  ordinary  care 
and  skill,  of  wounding  the  knee-joint  in  their  application.  With  the  excep- 
tion of  the  cases  referred  to  by  Agnew  and  Volkmann,  and  one  reported  by 

»  Practitioner,  March,  1875.  '  Canada  Lancet,  Jan.  1876. 

3  Edinburgh  Med.  Journal,  Oct.  1876. 

4  Medical  News,  Jan.  7,  1882.    See,  also,  Surgery  in  the  Pennsylvania  Hospital,  p.  274. 
6  Op.  cit.,  vol.  i.  p.  980. 

6  Clinical  Lecture,  Med.  News  and  Abstract,  April,  1881. 
1  British  Med.  Journal,  May  24,  1842. 

^  American  Journal  of  the  Medical  Sciences,  April  and  October,  1861, 


FRACTURES  OF  THE  PATELLA. 


233 


Mr.  Royes  Bell,^  I  do  not  know  of  any  distinct  statement  of  damage  done  by 
this  plan  of  treatment;  and  if  the  obtaining  of  very  close  apposition  of  the  frag- 
ments were  the  only  condition  of  restoring  the  usefulness  of  the  limb,  I  should 
reo-ard  the  employment  of  the  hooks  as  not  only  justifiable,  but  an  imperative 
diUy.  Such,  however,  is  not  the  case  ;  very  many  patients,  as  has  been  before 
stated,  are  able  to  walk,  climb,  and  run,  with  the  fragments  connected  by 
tibrous  bands  of  considerable  length  ;  and  it  seems  to  me  that  the  question  is, 
therefore,  one  which  may  be  left  to  the  individual  judgment  of  each  surgeon. 
Those  who  use  the  instrument  are  not  to  be  adjudged  foolhardy,  and  those 
who  al)stain  from  employing  it  are  not  necessarily  timid  or  over-cautious. 

Trelat  is  said  by  Stimson^  to  have  applied  the  hooks  through  the  medium 
of  plates  of  cratta-percha,  moulded  to  the  anterior  aspect  of  the  limb  above  and 
below  the  knee ;  thus  avoiding  the  wounding  of  the  skin,  and,  of  course, 
placing  the  joint  beyond  all  risk  of  harm.  Similar  plans  have  been  advo- 
cated by  Spence^  and  by  Gant.*  But  whether  the  instrument  is  not  deprived 
of  its  efficiency  by  this  change,  may  be  seriously  questioned.  ^ 

Of  late  years,  even  bolder  procedures  have  been  advocated  and  practised, 
with  a  view  to  securing  apposition  of  the  fragments  in  transverse  fi'actures 
of  the  patella.  Operations  similar  to  those  mentioned  in  the  early  part  of 
this  article^  as  performed  in  cases  of  non-union  of  other  bones,  the  exposure 
and  wiring  together  of  the  broken  portions,  have  been  resorted  to,  and  in 
many  cases  with  success,  notwithstanding  the  unavoidable  risks  from  the 
neighborhood  of  so  large  a  joint  as  that  of  the  knee.  The  idea  is  not 
altogether  a  new  one.  Hamilton^  says:  "  Severinus,  an  Italian,  proposed  to 
make  an  incision  into  the  joint,  exposing  the  fragments,  and  then  to  freshen 
the  broken  surfaces  and  bring  them  together.  This  was  nearly  three  hun- 
dred years  ago,  when  surgeons  did  not  pretend  to  have  any  specific  for  pre- 
ventiiig  infiammation  after  wounds  of  large  joints,  such  as  Mr.  Lister  thinks 
we  possess  to-day."  Malgaigne  also  refers  to  this  proposal,  but  only  to  con- 
demn it.  According  to  Byrd,^  Dr.  George  McClellan,  of  Philadelphia,  adopted 
such  a  course  many  years  ago,  in  one  instance,  and  as  an  experiment,  which 
is  said  to  have  proved  successful ;  but  no  account  of  this  case  was  ever  pub- 
lished, and  it  certainly  seems  as  if  more  would  have  been  known  of  so  bold 
a  procedure,  and  as  if  the  surgeon  would  have  had  imitators,  if  the  result  had 
been  favorable.  It  was  also  among  the  achievements  of  Prof.  Cooper,^  of  San 
Prancisco. 

As  has  been  before  remarked,  the  gravity  of  fractures  of  the  patella  depends 
in  no  small  degree  upon  the  involvement  of  the  knee-joint ;  and  the  same  may 
be  said  of  these  operations.    By  the  advocates  of  Listerism,  it  is  claimed  that 
antiseptic  precautions"  diminish  the  risk  of  opening  the  joint-cavity.^  Rose^° 
reported  to  the  Medical  Society  of  London,  two  cases  of  fracture  of  the  patella 

»  Lancet,  April  29,  1882.  2  Op.  cit.,  p.  561. 

'  Practitioner,  March,  1875  ;  Med.  Times  and  Gazette,  Aug.  21,  1875. 

<  Lancet,  April  29,  1882.  6  See  pp.  62  et  seq. 

6  Clinical  Lecture  in  the  Med.  News  and  Abstract,  April,  1881. 

'  New  York  Medical  .Journal,  May,  1876. 

•  As  claimed  in  a  letter  from  him,  quoted  in  the  Medical  Times  and  Gazette,  Nov.  2,  1861. 
The  original  report  I  have  been  unable  to  find. 

9  Lister  himself  is  reported  (Lancet,  Nov.  22,  1879)  to  have  said  that  "the  risk  a  patient 
incurs  in  having  his  knee-joint  opened  antiseptically  is  not  greater  or  so  great  as  that  attending 
the  removal  of  an  ordinary  fatty  tumor  without  antiseptic  treatment."  I  have  no  hesitation  in 
saying  that  such  a  claim  is  unsupported  by  the  experience  of  the  profession  at  large.  Perhaps 
I  may  say  here  that  there  is  often  a  confusion  between  safety  and  impunity.  The  fact  that  an 
operation  has  been  done  with  success,  does  not  by  any  means  show  that  it  did  not  involve  great 
risk.  Persons  have  fallen  from  great  heights,  sustainiug  only  slight  injuries  ;  but  they  certainly 
were  in  most  imminent  danger. 

w  Lancet,  Jan.  22,  1879. 


234 


INJURIES  OF  BONES- 


in  which  he  opened  the  knee-joint,  drilled  the  fragments,  and  fastened  them 
together  with  silver  wire.  The  operations  were  done  with  antiseptic  precau- 
tions ;  no  bad  symptoms  ensued,  and  the  final  result  in  each  case  was  satisfac- 
tory. 

Cameron^  gives  the  case  of  a  man,  aged  thirty-five,  in  whom  the  broken 
patella  had  formed  a  wide  ligamentous  union,  the  fragments  being,  in  exten- 
sion of  the  knee,  three  inches  apart,  and  in  flexion  admitting  the  breadth  of 
the  hand  between  them  ;  he  sutured  them  with  thick  silver  wire,  under  anti- 
septic precautions,  leaving  a  drainage  tube  in  the  joint.  The  result  was 
satisfactory ;  eight  months  afterward  the  man  had  difiiculty  in  flexing  the 
knee,  owing  to  the  shortening  of  the  parts  in  front.^ 

Other  instances  have  been  recorded,  , without  a  distinct  statement  as  to  the 
fact  of  interference  with  the  joint.  Thus  Barling^  showed  to  the  Midland 
Medical  Society  an  adult  patient  who  by  a  fall  had  torn  the  ligamentous 
union  of  an  old  fractured  patella.  By  a  longitudinal  incision  over  the  bone, 
the  fragments  had  been  laid  bare,  refreshed,  and  then  approximated  by  a  sin- 
gle silver  wire  suture,  which  was  cut  ofl:"  short  and  left.  The  operation  had 
been  performed  some  weeks  before,  and  the  fragments  were  in  good  position. 
In  course  of  time.  Dr.  Barling  hoped  that  solid  osseous  union  would  take 
place."  Holmes*  records  the  history  of  an  attempt  to  obtain  bony  union  in 
a  case  in  which  the  fragments  were  connected  by  fibrous  tissue ;  an  incision 
w^as  made  with  antiseptic  precautions,  and  a  suture  applied  ;  the  patient's  life 
was  seriously  endangered  by  suppurative  inflammation. 

Other  cases  have  been  reported  in  various  journals.^  One  instance  in  which 
very  little  good  seems  to  have  been  accomplished  is  recorded  by  Lloyd.®  The 
fracture  was  caused  by  direct  violence  ;  the  knee  gave  way  about  twelve 
months  afterward,  and  again  twelve  months  after  that.  Malgaigne's  hooks 
were  then  used,  but  without  success,  arid  incision^  resection,  and  suture  were 
employed,  with  division  of  the  quadriceps  tendon,  of  the  tissues  at  either 
side  of  the  bone,  and  of  the  ligamentum  patellae.  The  suture  was  allowed  to 
remain  ;  the  fracture,  however,  w^as  still  ununited. 

Lund^  has  proposed  a  plan  of  treatment  combining  the  idea  of  Malgaigne's 
hooks  and  that  of  suture  of  the  fragments.  He  advocates  keeping  the  limb 
extended,  on  a  back-splint  with  a  foot-piece,  and  slightly  raised ;  a  cold  evap- 
orating lotion,  or  ice,  is  applied  to  the  knee  until  nearly  all  eflusion  has  sub- 
sided.   Then,  under  anaesthesia,  a  strong  screw-pin  is  driven  into  each  frag- 

'  Glasgow  Medical  Journal,  April,  1883. 

2  In  the  Index  Medicus  for  August,  1883,  I  find  the  following  title  :  Henzelt,  Ueber  die  Behand- 
lung  der  subcutanen  Querfracturen  der  Patella  mit  besonderer  Beriicksichtigung  der  Function  des 
Gelenkes  und  der  Knochennaht.  Dorpat,  1883.  (On  the  treatment  of  simple  transverse  fractures 
of  the  patella,  with  reference  especially  to  puncture  of  the  joint  and  suture  of  the  bone.)  The 
work  itself  I  have  not  seen. 

8  British  Med.  Journal,  April  14,  1883.  *  St.  George's  Hospital  Reports,  1879. 

6  Ward  (British  Med.  Journal,  June  9,  1883)  records  five  operated  on  in  the  Leeds  Infirmary, 
three  having  been  cases  of  simple  and  two  of  compound  fracture.  I  find  also  in  the  Index  Medicus 
the  following  : — 

Weinlechner,  Eine  durch  Verschiittetwerden  erzeugte  Fraktur  der  Fatella,  welche  das  Gehen 
wegen  weiten  Abstandes  der  Bruchstiicke  und  unwollstilndiger  Streckung  des  Unterschenkels 
behinderte,  kam  nach  sechsmonatlichem  Bestande  durch  Resection  und  Naht  der  Bruchstiicke 
zur  Heilungmit  normaler  Function.  (A  fracture  of  the  patella  by  direct  violence  which  hindered 
walking  by  reason  of  the  wide  separation  of  the  fragments  and  inability  to  extend  the  leg  ;  after 
six  months  the  normal  function  was  restored  by  resection  and  suture  of  the  fragments.)  Aertzl. 
Bericht  der  k.  k.  allgem.  Krankenh.  zu  Wien,  1882. 

Sacre,  Fracture  ancienne  de  la  rotule  droite  ;  avivement ;  suture  osseuse  ;  guerison  avec  anky- 
lose.  (Old  fracture  of  the  right  patella ;  freshening  of  edges  ;  suture  of  the  bone  ;  cure  with 
anchylosis.)    Journal  de  Medecine,  Chirurgie  et  Pharmacie,  Bruxelles,  1883. 

Wahl,  Naht  einer  Patella-fraktur.  (Suture  of  a  fracture  of  the  patella.)  Deutsche  med. 
Wochenschrift,  Berlin,  1883. 

6  Birmingham  Medical  Review,  March,  1883.  ^  Lancet,  April  29,1882. 


FRACTURES  OF  THE  PATELLA. 


235 


meiit  so  as  not  to  injure  the  articular  face,  and  a  double-acting  screw-instru- 
ment is  ap[)lied  so  as  to  bring  the  fragments  together.  Then  a  coil  of  very 
thin  copper  wire  is  firmly  wound  around  the  pins,  and  the  screw-instrument 
is  removed. 

Occasionally,  very  bad  results  have  followed  these  heroic  measures.  Wyeth^ 
relates  a  case  of  long  standing  in  which  the  fragments  were  sutured  ;  the  joint 
suppurated,  and  amputation  became  necessary. 

It  has  been  proposed  by  Oilier,  VV^yeth,^  and  others,  to  insert  fresh  marrow 
cells  between  the  fragments  ;  and  the  [)lan  has  been  adopted  in  a  few  instances, 
but  I  believe  with  only  negative  results.  The  theory  of  such  a  procedure  is 
difficult  to  understand ;  it  would  seem  to  be  needless  if  the  fragments  were 
close  together,  and  useless  if  they  were  widely  separated,  to  say  nothing  of 
the  want  of  a  physiological  ground  for  expecting  any  advantage  from  it  in 
the  way  of  bone-formation. 

Dietfenbach^  made  a  subcutaneous  section  of  the  ligamentum  patelh^,  and 
of  the  rectus  femoris  about  three  inches  above  the  patella ;  he  then  rubbed 
the  fragments  together,  and  kept  them  in  contact  by  means  of  an  apparatus 
for  i)arallel  pressure ;  it  is  said  that  there  was  "  complete  hardening  of  the 
interposed  substance,"  and  that  the  patient's  condition  was  markedly  im- 
proved. One  cannot  help  asking,  however,  whether  the  mere  solidification  of 
the  patella  would  not  be  somewhat  dearly  bought  at  the  expense  of  a  length- 
ened and  weakened  ligament,  and  a  muscle  impaired  by  the  substitution  of 
a  cicatrix  for  a  portion  of  its  substance. 

It  will  now  be  necessary,  in  order  that  the  reader  may  not  be  only  embar- 
rassed by  the  foregoing  enumeration  of  methods  and  appliances  for  the  treat- 
ment of  fractures  of  the  patella,^  that  I  should  give  a  brief  and  practical 
summary  of  the  subject.  Here,  as  elsewhere,  the  great  aim  of  the  surgeon 
is,  and  ought  to  be,  to  restore,  as  nearly  as  possible,  the  normal  state  of  things  ; 
and  it  has,  therefore,  been  thought  desirable  to  obtain  bony  union  betw^een 
the  fragments.  But  that  this  is  not  essential  to  a  good  cure  has  been  shown 
in  the  facts  stated  as  to  the  value  of  limbs  in  which  the  fragments  were  con- 
nected only  by  a  fibrous  band  of  considerable  length.  Hence  it  may  well  be 
questioned  whether  it  is  not  a  mistake  to  concentrate  all  our  attention  upon 
merely  forcing  the  fragments  together,  and  especially  to  run  any  risk  of  doing 
greater  mischief  by  the  very  means  employed  to  this  end. 

Whenever  the  fragments  have  already  been  forced  apart,  a  tearing  of  the 
fibrous  tissues  surrounding^  the  bone,  and  in  the  neighborhood,  must  have 
occurred.  To  prevent  any  increase  of  this  rending,  by  properly  securino-  the 
upper  portion  of  the  bone,  is  manifestly  indicated  ;  and  in  doing  this^it  is 
equally  clear  that  interference  with  the  nutrition  of  the  bone  and  of  the  limb 
should  be  avoided.  I  think  that  it  is  sound  surgery  to  use  mild  means  first ; 
and  hence  should  advise  the  relaxation  of  the  quadriceps  muscle  by  extend- 
ing the  knee,  and  fiexing  the  hip-joint  by  elevating  the  foot.  As  soon  as  the 
inflammatory  symptoms  of  the  first  few  days  have  been  subdued,  the  upper 
fragment  should  be  brought  down,  but  not  with  any  great  force,  and  a  com- 
press applied  above  it,  with  pressure  in  such  a  direction  as  to  oppose  the 
upward  pull  of  the  quadriceps  muscle.  For  this  purpose  any  of  the  simpler 
means  above  described  will  answer  ;  I  think  that  the  elastic  traction  of  the  Mid- 
dlesex-Hospital plan  is  perhaps  the  best,  but  it  should  not  be  too  vigorously 
applied.    At  the  end  of  six  or  seven  weeks,  it  will  be  found  that  the  tendency 

>  Med.  Record,  June  22,  1882.  2  ibid.,  May  11  1878 

»  Casper's  Wochenschrift,  Oct.  2,  1841.  ' 

*  The  list  might  have  been  still  further  extended,  but  I  have  not  thought  it  worth  while  to 
include  a  number  of  contrivances,  which,  although  published  as  new,  are  really  only  modifi- 
cations, and  often  very  trifling  ones,  of  existing  plans  or  instruments. 


236 


INJURIES  OF  BONES. 


to  separation  of  the  fragments  no  longer  exists,  and  the  patient  may  be 
allowed  to  lie  in  bed  with  merely  a  back  splint  on  the  knee,  and  with  the 
limb  otherwise  unconfined.  A  week  later  he  may  be  permitted  to  sit  up, 
and  to  move  about  in  a  wheel-chair ;  after  which  the  use  of  the  limb  may  be 
graduall}^  resumed,  the  back  splint  being  left  off.  It  may  very  probably  be 
that  the  uniting  medium  will  be  found  to  stretch,  and  the  gap  between  the 
fragments  to  be  thus  widened  ;  but  in  time  the  parts  will  acquire  firmness, 
and  the  result  will  be  satisfactory. 

In  the  rare  instances  in  which  this  does  not  happen,  but  the  limb  remains 
weak  and  useless,  the  propriety  of  resorting  to  more  energetic  means  may 
be  considered.  I  do  not  myself  think  that  any  great  risk  is  run  in  using 
Malgaigne's  hooks,  but  I  do  not  think  that  any  great  gain  is  effected  by 
them.  And,  although  much  is  claimed  for  the  graver  procedures,  the  resection 
and  suture  of  the  fragments,  I  think  that  a  faithful  trial  should  first  be  made 
of  the  reparative  powers  of  nature,  aided  by  frictions,  shampooing,  and  well- 
regulated  exercise,  before  the  patient  is  subjected  to  the  hazards  which  they 
cannot  but  involve.  Everything  else  failing,  and  it  being  clear  that  the 
want  of  union  between  the  fragments  is  the  sole  cause  of  the  disability, 
extreme  measures  may  be  taken ;  but  the  patient  should  be  made  fully  aware 
of  the  extent  of  the  dangers  attending  them,  and  of  the  chances  of  anchylosis, 
or  of  still  worse  evils. 

As  to  section  of  the  quadriceps  or  its  tendon,  it  seems  to  me  to  be  merely 
the  substitution  of  one  evil  for  another.  If  incomplete,  it  is  useless,  while, 
if  complete,  it  must  almost  of  necessity  involve  the  w^ounding  of  the  knee- 
joint. 

Compound  fractures  of  the  patella  are  always  of  grave  importance,  largely 
increased  if  the  knee-joint  be  directly  involved.  .  These  injuries  are  always 
due  to  direct  violence,  and  the  bone  is  often  comminuted.  The  arthritis 
which  is  so  apt  to  ensue  upon  simple  fractures  may  be  looked  for  in  even  a 
higher  degree  in  the  cases  in  question,  and  is  much  more  likely  to  assume 
the  suppurative  character,  as  it  will  almost  certainly  do  if  the  synovial  cavity 
is  laid  open  to  any  extent.  Gross^  mentions  a  case  followed  by  abscess, 
necrosis,  and  removal  of  the  patella,  the  knee-joint  becoming  partially  anchy- 
losed.  Levergood^  records  an  instance  in  which,  the  patient  having  been 
inefiaciently  treated,  and  having  left  his  bed  four  weeks  after  the  accident, 
suppurative  arthritis  ensued,  and  the  joint  was  emptied  by  incision  ;  ampu- 
tation was  proposed  but  refused ;  recovery  took  place,  and  the  patient  was 
dismissed  with  "  slight  anchylosis."  Poland,^  among  85  recorded  cases,  found 
that  20  proved  fatal ;  suppuration  occurred  in  63,  and  anchylosis  more  or  less 
complete  resulted  in  31  out  of  the  65  in  which  recovery  took  place. 

The  symptoms  are  generally  sufficiently  clear.  The  diagnosis  is  only  obscure, 
in  some  instances,  in  regard  to  the  involvement  of  the  knee-joint,  which  may 
be  but  slightly  punctured ;  sometimes  the  opening  is  large  enough  for  the 
finger  to  be  readily  passed  in,  and  in  any  case  the  escape  of  synovia,  if  abun- 
dant enough  to  be  distinctly  perceived,  is  conclusive. 

The  progn.osis^  it  need  hardly  be  said,  is  to  be  carefully  guarded.  If  the 
immediate  danger  of  shock  is  surmounted,  there  remain  too  many  chances 
against  both  the  limb  and  the  life  of  the  patient  to  warrant  the  surgeon  in 
presuming  upon  success.  Yet  it  does  sometimes  happen  that  complete 
recovery  takes  place,  even  under  apparently  adverse  circumstances. 

The  treatment  is  not  materially  different  from  that  of  ordinary  simple  frac- 

»  Op.  cit.,  vol.  i.  p.  1004.  2  Am.  Journal  of  the  Med.  Sciences,  Jan.  1860. 

*  Med.-Cliir.  Transactions,  vol.  liii. 


FRACTURES  OF  THE  BONES  OF  THE  LEG. 


237 


tures,  except  that  the  wound  must  be  dressed.  If  small,  an  attempt  may  be 
made  to  close  it ;  but  if  large,  and  if  the  joint-cavity  be  opened,  I  think  that 
thorouo;!!  washing  out  with  carbolized  water  should  always  be  resorted  to. 
Afterv\^ird,  the  closure  of  the  wound  ought  again  to  be  aimed  at,  as  it  may 
be  obtained  unless  suppuration  ensue,  in  Avhicli  case  experience  teaches  that 
effective  drainage  gives  the  best  results  ;  this  may  be  accomplished  either  with 
a  tine  rubber-tu1[)e,"with  horse-hair,  or  with  a  few  strands  of  carbolized  silk. 

As  dressing's,  lead-water  and  laudanum,  carbolized  water,  or  an  ice-bag 
(in  hot  weather  especially)  may  be  employed.  Irrigation  has.  been  preferred 
by  some  surgeons,  but  cannot  always  be  conveniently  arranged  so  as  not  to 
wet  the  clothing  and  bed,  on  account  of  the  position  of  the  limb. 

The  question" of  amputation  or  of  excision  of  the  joint  must  sometimes 
come  up  when  the  patient  is  young,  and  the  local  injury  very  severe,  but  it 
can  hardly  be  appropriately  discussed  here. 

Perha[)s  it  is  in  these  cases  that  the  use  of  Malgaigne's  hooks,  or  the  resort 
to  the  suture,  is  most  available;  yet  I  cannot  but  think  that  other  means 
should  lirst  be  tried,  and  that  they  will  often  be  found  efficient. 

Very  generally,  after  the  tirst  stage  of  the  case,  and  especially  if  suppura- 
tion is  established,  a  stimulant  and  supporting  treatment  is  obviously  demanded, 
and  must  be  kept  up  during  a  long  and  tedious  convalescence. 

Fractures  of  the  Bones  of  the  Leg. 

All  authors  agree  that  these  injuries  are  of  very  common  occurrence ;  but 
there  are  some  curious  differences  noticeable  between  the  statistics  derived 
from  different  sources,  as  will  appear  from  the  following  data,  chiefly  ob- 
tained from  Gurlt : — 

Lonsdale,  out  of  1901  cases,  gives  289,  or  about  15  per  cent,  of  the  leg. 
Gurlt,  among  1631,  found  283,  or  over  17  per  cent. 
Blasius,  out  of  778,  found  139,  or  nearly  18  per  cent. 
Middeldorpf,  out  of  325,  gives  59,  or  a  little  over  18  per  cent. 
Matiejowsky,  among  1086,  gives  293,  or  nearly  27  per  cent. 
Agnevv,  among  8667,  found  2315,  or  nearly  27  per  cent. 
Malgaigne,  out  of  2328,  found  652,  or  28  per  cent. 
Lente,  among  1722,  gives  579,  or  nearly  34  per  cent. 

If  the  reader  will  take  the  trouble  to  compare  these  statements  with  those 
quoted  on  page  186  from  the  same  sources,  but  in  reference  to  fractures  of  the 
femur,  he  will  see  that  the  figures  given  by  the  different  institutions,  for  the 
latter  bone,  are  not  in  the  same  ratio  to  one  another  as  those  above  quoted  for 
the  leg.  But  these  discrepancies  can  only  be  stated  as  facts,  difficult,  it  seems 
to  me,  of  explanation. 

Fractures  of  the  leg  are  divided  into  those  which  affect  both  bones,  those 
of  the  tibia  alone,  and  those  of  the  fibula  alone.  These  again  are  found  to 
differ  in  frequency  ;  both  bones  being  involved  far  oftener  than  either  bone 
singly.  These  differences  are  marked  enough  to  warrant  their  presentation 
in  a  table  as  follows  — 


1  The  percentages  in  this  table  have  reference  to  the  fractures  of  the  leg  only,  and  in  stating 
them  they  are  given  approximately,  neglecting  fractions. 


238 


INJURIES  OF  BONES. 


Lonsdale 
Gurlti  . 
Blasius  . 
Middeldorpf 
Matiejowsky 
Agnew  . 
Malgaigue 
Lente  . 


Both  bones.  Tibia  alone.  Fibula  alone. 

197  or  68  per  cent.     41  or  14  per  cent.      51  or  17  per  cent. 

173  "  61  "  36  "  13       "  42  "  15 

94  "  67  "  30      21  15  "  11 

40  "  68  "  8  "  14       "  9  15 

230  "  78  "  33  "  11  30  "  10 

1441  "  61  437  "  19       "  437  "  19 

515  "  79  "  29  "    4       "  108  "  15 

442  "  73  "  45  "    8       "  92  "  16 


Among  the  316  cases  derived  by  me  from  the  records  of  seven  years  at  the 
Children's  Hospital,  there  are  stated  to  have  been  7,  or  a  little  over  2  per  cent., 
of  the  leg;  they  are  not  classed  as  above,  but  fractures  of  either  bone  by 
itself  are  of  extreme  rarity  during  childhood,  as,  indeed,  may  almost  be  said 
of  fractures  in  this  region  in  general.  Probably  the  reason  of  this  may  be 
found  in  the  very  slight  leverage  afforded  by  the  bones  of  the  leg  at  this 
period  of  life,  whereas  the  femur,  which  is  so  often  broken  in  children,  yields 
by  reason  of  its  slenderness.  I  have,  however,  myself  repeatedly  had  occa- 
sion to  treat  fractures  of  the  leg  in  children  in  private  practice. 

It  may  easily  be  seen  why  the  proportion  of  fractures  of  both  bones  should 
be  so  large.  Any  force  applied  to  the  part,  sufficient  to  break  one  bone,  will 
l3e  likely  to  act  on  both;  and  if  one  of  the  bones  gives  way,  the  other,  losing 
its  support,  will  be  very  apt  to  give  way  also. 

Fracture  of  the  leg  may  occur  at  any  age,  and  in  either  sex;  but  the 
great  majority  of  its  subjects  are  adult  males,  simply  because  these  are  espe- 
cially exposed  to  the  violence  by  which  the  injury  is  produced.  Agnew  says 
that  he  has  twice  seen  intra-uterine  fracture  of  both  bones ;  and  two  other 
cases  have  been  referred  to  elsewhere.^  On  the  other  hand,  Meachem^  has 
reported  the  case  of  a  woman  aged  ninety  years,  who  broke  her  leg  in  the 
lower  third  ;  union  had  occurred  by  the  twenty-eighth  day. 
_  For  greater  convenience,  fractures  of  both  bones  of  the  leg;  will  first  be  con- 
sidered, then  those  of  the  tibia,  and  lastly  those  of  the  fibula. 

Feactures  of  both  bones  of  the  leg  may  be  produced  either  by  direct  vio- 
lence, as  by  blows,  kicks,  or  falls— the  leg  striking  against  resisting  objects— 
or  by  indirect,  as  when  a  man  falls  from  a  height,  alighting  on  his  feet,  or 
when  the  foot  is  caught,  and  the  impetus  of  the  body  is  exerted  upon  the 
upper  part  of  the  leg.  It  is  not  always  easy  to  explain  the  mechanism  of 
these  injuries  with  exactness,  although  the  general  principles  of  their  produc- 
tion can  be  readily  understood.  The  whole  limb  constitutes  a  mechanical 
system  ;  and  if  force  be  brought  to  bear  upon  it  in  such  a  way  that  the  lever- 
age is  through  the  lower  part,  for  example,  of  the  leg,  the  foot  being  fixed, 
and  especially  if  there  be  any  twist  impressed  upon  the  bones  at  the  same 
time,  the  bones  will  give  way  either  where  the  stress  is  greatest,  or  at  the 
weakest  point  of  their  structure. 

Muscular  action  has  in  a  very  few  instances  been  assigned  as  the  cause  of 
fractures  in  this  region.  Agnew^  says:  ''A  colored  man  was  brought  into 
the  Pennsylvania  Hospital  with  a  fracture  of  the  tibia  and  fibula,  four  inches 
above  the  ankle,  which  was  caused  by  the  violent  muscular  effort  made  to 
recover  his  equilibrium  after  slipping  upon  an  orange-peel.  He  was  thirty 
years  of  age,  of  an  excellent  constitution,  and  without  any  evidence  whatever 
of  pre-existing  bone-disease.    He  had  never  before  had  a  fracture."  Gross 

>  Gurlt,  in  his  statistics,  gives  fractures  of  the  malleoH  separately;  they  numbered  32,  and 
thus  would  be  11  per  cent,  of  his  283  fractures  of  the  leg.  Middeldorpf  gives  2,  which  would 
be  about  3.5  per  cent,  of  his  59  cases  of  fracture  of  the  leg. 

2  See  p.  21.  3  Am.  Med.  Times,  Jan.  5.  1861. 

4  Op.  cit.,  vol.  i.  p.  981. 


FRACTURES  OF  THE  BONES  OF  THE  LEG. 


239 


mentions  that  "  an  instance  of  fracture  of  both  bones  of  tlie  leg  by.  muscular 
action,  in  a  man  forty-two  years  old,  has  been  recorded  by  Ilevlliard  d'Arcy." 
Hamilton  says  "Eight  times  I  have  found  the  bones  broken  by  muscuhir 
action  alone." 

It  does  not  often  happen  that  both  bones  are  fractured  at  the  same  level ; 
very  generally  the  fibula  yields  at  a  higher  point  than  the  tibia.  Sometimes 
the  fractures  are  very  far  apart,  so  as  really  to  constitute  separate  lesions,  as 
in  two  specimens  mentioned  by  Stoker.^  Here  the  tibia  was  broken  low 
down,  and  the  tibula  high  up,  the  obliquity  of  the  two  fractures  being  in  con- 
verse directions.  These  cases,  rare  as  they  are,  are  not  without  analogues  in 
the  forearm.  _  Occasionally  the  leg  is  broken  in  more  than  one  place,  when 
the  violence  is  very  great,  as  in  some  machinery  accidents.  Bransby  Cooper^ 
saw  a  case  in  which  both  bones  of  the  left  leg  were  fractured  in  three  distinct 
l)laces  ;  the  patient,  a  niaii  aged  forty-eight,  had  had  his  leg  crushed  over  the 
side  of  a  boat  by  the  falling  of  a  heavy  weight ;  amputation  was  proposed, 
but  he  declined  to  submit  to  it,  and  although  for  a  time  his  symptoms  were 
very  threatening,  he  ultimately  did  well,  his  convalescence  being  considered 
established  by  the  eleventh  week.  In  a  specimen  without  history,  in  the 
Museum  of  the  Pennsylvania  IIospital,3  "  the  shaft  of  the  tibia  presents  three 
nearly  equidistant,  slightly  oblique  fractures,  and  several  small  frao;ments 
have  been  broken  off  from  the  bone.  There  are  also  three  equidistant  frac- 
tures of  the  shaft  of  the  fibula,  the  upper  two  of  which  are  oblique,  the  other 
tnins verse."  A  similar  specimen  is  in  the  Pathological  Cabinet  of  the  Xew^ 
York  Hospital."  The  fibula  is  "  broken  near  its  upper  end,  while  the  tibia 
has  been  traversed  by  several  very  oblique  fractures  at  and  below  its  middle, 
separating  the  shaft  into  four  fragments,  all  of  which  are  firmly  united  bv 
bone  deposited  between  the  opposed  surfaces  and  in  the  cavities  left  by  pro- 
jecting angles." 

Fractures  of  both  bones  of  the  leg  at  their  upper  part  are  always  due  to 
great  direct  violence,  such  as  the  passage  of  a  wheel,  the  caving  in  of  eartn, 
entanglement  in  heavy  machinery,  etc.  These  fractures  may  or  may  not  in- 
volve the  knee-joint,  a^nd  tlieir  exact  mechanism  is  often  difficult  to  determine. 

When  the  knee-joint  is  involved,  it  sometimes  seems  probable  that  the  tibia 
first  gave  way  across  its  long  axis,  and  then  that  the  lower  or  shaft  portion  was 
forced  mto  the  upper,  bursting  it  into  tw^o  or  more  fragments.  The  line  of 
separation  is  seldom  exactly  transverse,  but  it  is  not  often  very  oblique. 
Occasionally  the  fibula  escapes ;  but  this  is  a  matter  of  small  moment,  not 
affecting  the  gravity  of  the  injury,  or  influencino;  the  symptoms. 

^  In  the  i^ithological  Cabinet  of  the  Xew  York  Hospital,  there  is  a  specimen* 
from  a  man,  aged  thirty-two,  who  had  a  compound  fracture  of  the  left  tibia, 
caused  by  a  blow  from  a  heavy  piece  of  iron.  "  Both  tuberosities  are  sepa- 
rated from  the  shaft  by  a  line  of  fracture  running  across  the  bone  an  inch  or 
.so  below  the  joint,  {ind  a  small  portion  of  the  internal  tuberosity  is  still  fur- 
ther separated  by  a  fracture  running  from  the  first  one  up  into  the  joint." 

\Vhen  both  bones  are  broken  in  the  upper  thirds  of  their  shafts,  the  frac- 
aires  are  as  a  rule  oblique,  and  they  are  apt  to  be  more  nearlv  on  a  level  with 
each  other  than  when  the  injury  is  lower  down.  In  the  latter  case,  as  before 
stated,  the  fibula  is  generally  broken  higher  up  than  the  tibia. 

^  By  far  the  largest  number  of  cases,  however,  afiect  the  bones  of  the  le^ 
either  at  or  below  the  middle.  I  have  said  that  the  line  of  breakao-e  is 
most  generally  oblique ;  yet  it  is  not  always  so,  and  one  or  two  specimens  of 

»  British  Med.  Journal,  Dec  24,  1881.  2  Hospital  Reports,  vol.  i.  1836. 

3  Catalogue,  p.  42  ;  No.  1174.  4  Catalogue,  p.  122  f  No.  243.  . 

*  Catalogue,  p.  116 ;  No.  226.  o    >  ^  , 


240 


INJURIES  OF  BONES. 


almost  exactly  transverse  fracture  in  this  region  have  come  under  my  obser- 
vation. Tillaux  says  that  one  reason  why  the  tibia  is  apt  to  break  below  the 
middle,  is  that  it  has  there  its  least  diameter  ;  another,  that  it  there  assumes  a 
cylindrical  instead  of  a  triangular  form  ;  and  he  mentions  a  third,  "  a  pecu- 
liar arrangement  of  the  bony  tissue,  pointed  out  by  MM.  Fayel  and  Duret ; 
the  cancellous  structure  of  the  tibia  is,  according  to  these  authors,  disposed 
in  two  independent  systems  of  vertical  columns ;  the  one  occupies  the  upper 
two-thirds,  and  the  other  the  lower  third,  so  that  the  minimum  of  resistance 
corresponds  to  the  junction  of  the  two  systems." 

In  the  middle,  or  indeed  anywhere  in  the  extent  of  the  actual  shaft  of  the 
bone,  if  force  is  applied  to  the  tibia  sufficient  to  break  it,  and  especially  if  it 
be  indirect,  the  fibula  can  scarcely  escape :  the  exceptions  being  perhaps  slight 
torsion,  and  such  force  as  the  kick  of  a  horse,  or  any  pressure  brought  sud- 
denly to  bear  upon  the  tibia,  for  an  instant  only  ;  in  such  cases  the  elasticity 
of  the  fibula  may  allow  it  to  yield,  and  to  spring  back  into  shape.  Some- 
times, indeed,  the  slenderness  of  the  fibula  may  exempt  it  from  direct  force 
which  breaks  the  tibia.  If  the  leg  is  strongly  bent  between  the  knee  and 
the  foot,  both  bones  may  give  way  at  once,  or  the  tibia  may  be  first  broken, 
and  the  fibula  may  yield  secondarily  from  the  stress  put  upon  it  when  it  is 
no  longer  supported  by  the  larger  bone. 

Holmes^  figures  a  specimen  in  the  Museum  of  St.  George's  Hospital,  show- 
ing "  the  lower  epiphyses  of  the  femur  and  tibia,  and  both  epiphyses  of  the 
fibula,  separated  in  the  same  injury  ;  the  shaft  of  the  tibia  is  also  fractured.'' 
He  quotes  also  Prof.  R.  W.  Smith's  account  of  a  case  of  separation  of  the 
lower  epiphysis  of  the  tibia,  observed  in  a  boy,  aged  sixteen,  who  recovered. 

The  symptoms  of  this  injury  are  often  very  distinct.  As  a  general  rule, 
there  is  immediate  loss  of  power,  and  the  patient  falls  ;  but  to  this  there  have 
been  noted  numerous  exceptions.  Ormerod^  mentions  the  case  of  a  man  aged 
thirty-two,  admitted  into  St.  Bartholomew's  Hospital  in  1843,  who  had  sus- 
tained, by  the  kick  of  a  horse,  a  transverse  fracture  of  the  right  tibia  a  little 
below  the  middle,  with  fracture  of  the  fibula  in  its  lower  third.  He  had 
walked  to  the  hospital,  consuming  about  four  hours  in,  so  doing,  with  a 
crutch  about  the  length  of  a  walking  stick ;  his  leg  was  very  crooked  at  the 
time  of  his  admission.  Bryant  says,  "  I  have  seen  more  than  one  patient 
walk  upon  the  fractured  limb  directly  after  the  accident,  and  in  one  case  a 
man  went  up  a  whole  fiight  of  stairs  to  his  ward  with  but  a  slight  limp.  In 
another,  under  care  in  1874,  a  woman  with  a  fractured  tibia  and  fibula  went 
about  for  a  week."  A  case  is  recorded^  of  a  patient  walking  about  for  twelve 
days  after  sustaining  a  fracture  of  the  leg. 

Pain  is  very  seldom  absent,  and  may  be  very  severe ;  there  is  always  ten- 
derness over  the  seat  of  injury,  or  if  the  limb  is  grasped  above  and  below, 
and  stress  put  upon  the  fractured  portion. 

The  deformity  is  sometimes  very  slight,  but  may  be  extremely  marked ; 
its  character  depends  chiefly  upon  the  fracturing  force.  When  this  has  been 
great,  the  limb  may  be  wrenched  entirely  out  of  shape,  bent,  twisted,  and 
perhaps  shortened.  But,  as  will  be  further  detailed  hereafter,  in  some  very 
grave  fractures  there  may  be  scarcely  any  change  of  form. 

Preternatural  mobility  is  another  symptom  which  varies  greatly  in  degree 
in  diff'erent  cases.  Sometimes  the  lower  part  of  the  limb  dangles  in  the 
loosest  way,  but  sometimes  the  fragments  are  held  together  by  interdigita- 
tions,  so  that  there  is  very  little  movement  between  them. 

1  Surgical  Treatment  of  Children's  Diseases,  1st  ed.  p.  259. 

2  Clinical  Collections  and  Cases  in  Surgwry,  p.  50.    London,  1846. 

3  Am.  Journal  of  the  Med.  Sciences,  Oct.  1845,  from  Recueil  de  Mem.  de  M6d.,  de  Chir.,  et  de 
Phar.  Militaires. 


FRACTURES  OF  THE  BONES  OF  THE  LEG. 


241 


Crepitus  is  rarely  wanting,  and  is  in  general  developed  by  the  slightest 
handling  of  the  injured  limb. 

Swelling  occurs'very  rapidly,  and  may  mask  the  other  symptoms  in  a  great 
deo-ree.  Ecchymosis  also  attends  almost  every  case,  by  reason  of  the  tearing 
of  die  periosteum  ;  it  often  takes  place  only  gradually,  and  increases  for  some 
days.  T  have  repeatedly  seen  the  discoloration  of  the  skin  outlast  the  period 
of  consolidation  of  the  bone.  Along  with  the  eccliymosis  there  is  very  apt 
to  be  a  formation  of  huWee  or  blebs,  containing  a  more  or  less  bloody  scrum ; 
but  these,  if  carefully  let  alone,  will  dry  away  without  trouble.  They  are 
apt  to  be  a  source  of  great  alarm  to  the  patient  and  his  friends,  and  to  inex- 
perienced pnictitioners. 

Gross^  says  that  a  symptom  which  is  seldom  absent  is  "  a  spasmodic  twitch- 
ino;  of  the  lini]),  coming  on  soon  after  the  accident,  and  frequently  lasting  for 
several  days,  or  even" weeks,  much  to  the  annoyance  and  distress  of  the 
patient."  I  have  never  had  my  attention  called  to  this  phenomenon  unless 
other  symptoms  of  disorder  of  the  nervous  system  were  also  manifested. 

The  covrse  of  these  fractures  is  subject  to  like  variations.  In  some  cases, 
after  the  first  dressing,  there  is  no  pain,  union  takes  place  promptly,  and  the 
l)atient  s  only  inconvenience  is  in  the  contiiiemeiit  necessarily  imposed  upon 
him.  Sometimes,  however,  very  grave  symptoms  manifest  themselves.  Mr. 
Green^  reports  a  case  of  simple  fracture  of  the  leg  followed  by  gangrene,  for 
which  amputation  was  performed,  with  a  fatal  result ;  the  autopsy  showed 
no  wound  of  the  vessels,  which  may,  however,  have  been  pressed  upon  by 
one  of  the  fragments.  The  patient  w^as  a  man  aged  forty-seven.  Another 
case  is  rei)orted  by  Trask.^  Dupuj'tren'*  records  six  cases  in  which  arteries 
were  wounded  by  the  fragments,  the  anterior  tibial,  the  posterior  tibial,  and 
the  peroneal  being  known  to  have  thus  suffered.  Three  times  amputation 
w^as  called  for,  and  twice  ligation  of  the  femoral.  Leigh^  records  the  case 
of  a  man,  aged  forty-eight,  who  fell  from  a  height,  and  fractured  both  bones 
just  l)el()W  the  knee.  On  the  twentieth  day  he  was  thought  to  have  an  abscess, 
whirh  was  punctured,  but  only  blood  escaped  ;  two  days  afterward  the  Avound 
was  oi)ened,and  the  anterior  tibial  artery  was  found  torn  across.  The  vessel 
was  tied,  but  death  occurred  in  a  few  hours.  Borcheim^  has  published  an 
account  of  a  case  of  fracture  of  both  bones,  in  which  an  aneurism  of  the 
l)osterior  tibial  artery  was  formed,  and  the  femoral  was  tied  at  the  apex  of 
Scarpa's  ti'iangle  ;  union  was  not  interfered  with.  Edwards^  has  reported  to 
the  Pathoiogical  Society  of  London,  the  case  of  a  woman,  aged  sixty-three, 
who  was  run  over,  sustaining  a  fracture  of  the  right  tibia  at  the  junction  of 
the  middle  and  lower  third.  On  the  third,  day  some  bullae  appeared  on  the 
foot ;  on  the  fifth  day  the  foot  was  cold ;  amputation  was  performed,  but 
death  ensued.  "  The  anterior  tibial  vessels  had  been  occluded  by  being 
nipped  between  the  fragments ;  and  a  large  blood-clot  w^as  found  in  the 
pressing  on  the  posterior  tibial  vessels."  Stimson®  says  that  I\'epveu  in  a 
recent  pa})er,®  cites  more  than  fifty  cases  of  fracture  involving  injury  to 
various  vessels  in  the  leg.  Occasionally  the  nerves  are  likewise  injured. 
Callender^'*  records  four  cases  of  this  kind,  in  which  bull?e,  causalgia,  glazed 
skin,  and  the  other  phenomena  recognized  as  due  to  nerve-lesions,  were 
present. 

>  Op.  cit.,  vol.  i.  p.  991.  «  St.  Thomas's  Hospital  Reports,  vol.  i.  1836. 

*  Am.  Journal  of  tlip  Med.  Sciences,  Oct.  1850. 

*  Lesions  of  the  Vascular  System,  ete.  ;  Syd.  Society's  Translation. 

*  St.  George's  Hospital  Reports,  vol.  iii.  1868. 

«  Medical  Record,  Dec.  30,  1882.  7  Med.  Times  and  Gazette,  May  26,  1883. 

*  Treatise  on  Fractures,  p.  568.  ^  Bulletins  de  la  Soc.  de  Chirurgie,  1875. 
"  St.  Bartholomew's  Hospital  Reports,  1870. 

VOL.  IV. — 16 


242 


INJURIES  OF  BONES. 


It  must  not  be  forgotten  that  fat-embolism,  of  which  mention  was  made  at 
some  length  in  the  early  part  of  this  article,  is  especially  apt  to  ensue  upon 
fractures  of  the  leg,  in  which  the  conditions  upon  which  that  pathological 
process  depends  are  more  fully  met  than  in  fractures  of  any  other  part  of  the 
skeleton. 

A  peculiar  form  of  fracture,  affecting,  almost  if  not  quite  exclusively,  the 
lower  part  of  the  leg,  was  described  w4th  much  accuracy  by  Gosselin,^  nearly 
thirty  years  ago.  Both  bones  are  broken ;  but  it  is  the  lesion  of  the  tibia 
which  is  important.  This  bone  yields  to  a  force  of  which  torsion  is  a  princi- 
pal element,  according  to  some  observers  the  only  one  ;  but  I  think  that  there 
is  ground  for  believing  that  there  is  first  a  flexion  or  cross-breaking  strain. 
However  this  may  be,  the  tibia  sustains,  first,  a  V-shaped  fracture,  the  apex 
of  the  V  presenting  downward,  and  in  some,  if  not  in  all  the  cases,  on  the 
antero-internal  face  of  the  bone,  instead  of  along  its  crest.  From  this  apex, 
or  from  a  part  of  the  V  ("^ose  to  it,  there  runs  downward  a  fissure,  always  in 
a  spiral  direction,  to  cross  the  ankle-joint,  from  behind  forward,  and  then  to 
run  upward  and  join  the  main  fracture  at  some  other  point.  I  think  that 
the  mode  of  production  of  this  fissure  will  at  once  suggest  itself  in  the 
lateral  pressure  of  the  apex  of  the  V  against  the  sides  of  the  corresponding 
part  of  the  lower  fragment.  This  is  the  explanation  admitted  by  Tillaux,^ 
who  has  given  a  very  clear  and  practical  discussion  of  the  whole  subject. 
These  fractures  have  been  designated  as  V-shaped,  wedge-shaped,  spiroid,  or 
helicoid;  but  none  of  these  terms  adequately  describe  them.  The  V-shaped 
portion  is  of  importance  only  as,  under  torsion,  causing  the  fissure ;  it  does 
not  act  as  a  wedge ;  "  spiroid"  is  at  best  a  mongrel  word,  and  neither  it  nor 
"helicoid"  is  suggestive  of  the  very  long  and  really  but  slightly  curved  line 
in  which  the  bone  splits.  Tillaux  thinks  the  phrase  "  oblique  fracture  of  the 
leg"  a  good  one,  with  the  addition,  if  another  epithet  be  required,  of  the  word 

helicoid."  I  venture  to  suggest  that  "  Y -fractures  of  the  tibia"  w^ould  con- 
vey the  idea  of  the  essential  features  of  the  lesion. 

Hulke^  says  that  the  fracture  of  the  fibula,  in  these  cases,  always  has  more 
or  less  of  the  V-shape  ;  and  that  this  bone  sometimes  gives  way  at  more  than 
one  point.    Tillaux  gives  an  instance  in  which  it  remained  intact. 

There  are  obvious  reasons  why  fractures  of  the  kind  just  described  should 
be  attended  w^ith  danger  of  serious  consequences.  Besides  the  involvement 
of  the  ankle-joint,  the  damage  done  to  the  bone  itself  is  extensive,  and  the 
medulla  can  scarcely  escape  bruising,  hemorrhage  into  its  substance,  and  in- 
terference with  its  nutrition.  Hence,  arthritis,  osteo-myelitis,  pyaemia,  or 
septicsemia,  ma}^  ensue,  and  cost  the  patient  his  life.  Yet  these  risks  are 
often  successfully  met,  as  in  cases  recorded  by  Gosselin.  Two  specimens  are 
known  to  me,  one  in  the  Miitter  Museum  and  the  other  in  the  Wistar  and 
Horner  Museum  at  the  University  of  Pennsylvania,  in  which  union  has  taken 
place  in  a  very  perfect  manner,  the  line  of  the  fractures,  however,  being  clearly 
traceable.'^ 

Fractures  of  the  leg  at  its  lower  part  have  been  sometimes  said  to  be 
analogous  to  those  at  or  just  above  the  wrist ;  but  it  seems  to  me  that  this 
idea  is  apt  to  lead  to  error.  Supra-malleolar  fractures  are  in  some  small  de- 
gree similar  to  those  of  both  bones  of  the  forearm  close  to  the  wrist ;  but 
even  here  the  resemblance  is  but  slight  and  superficial. 

1  Grazette  des  Hopitaux,  1855  ;  Mem.  de  la  Societe  de  Chirurgie,  tome  v.  1855  ;  and  Bulletin 
de  la  Societe  de  Chirurgie,  tomes  vi.  et  ix.    See  also  Clinical  Lectures  on  Surgery,  translated 
by  Stimson,  pp.  90  et  seq. 
*2  Op  cit.,  p.  1149.  3  Holmes's  System  of  Surgery,  vol.  i.  p.  1043. 

■*  For  tiirtlier  in  formation  in  regard  to  these  fractures,  the  i-eader  is  referred  to  the  articles  and 
Works  bctoro  <iiioted  ;  also  to  an  interesting  pai)er  on  the  subject,  by  Dr.  K.  M.  Hodges,  in  the 
Boston  Med.  and  Surg.  Journal,  Jan.  11,  1877. 


FRACTURES  OF  THE  BONES  OF  THE  LEG. 


243 


The  ankle-joint  is  a  hinge,  with  no  other  motion  except  a  very  slight  pos- 
sible rotation  of  the  foot'in  extreme  extension.  The  astragalus  is  keyed 
or  mortised  between  the  malleoli,  and  if  the  foot  is  fixed,  the  leverage  which 
may  be  exerted  from  above  through  the  leg  is  very  powerful.  According  to 
circumstances  not  easy  to  define,  tlie  stress  may  be  brought  to  bear  either 
upon  both  bones  just  above  the  ankle,  or  upon  the  inner  malleolus  and  the 
lower  i>art  of  the  fibula.  The  outer  malleolus  sometimes  sufi:ers,  as  will  be 
sliown  in  speaking  of  fractures  of  the  fibula  alone. 

Supra-malleolar  fractures  may  be  due  to  direct  violence,  or  to  a  wrenching 
by  outward  or  inward  movement  of  the  knee  when  the  foot  is  fixed,  or,  as  I 
believe,  in  some  cases  to  extreme  extension  or  flexion  of  the  ankle,  the  foot 
beini;'  fixed.  I  have  several  times  seen,  in  persons  who  had  fallen  from 
heii^hts,  alii2;hting  on  the  feet,  fractures  which  seemed  to  be  explicable  in  the 
latter  way  alone. 

Fracture  of  the  inner  malleolus,  with  fracture  of  the  fibula  at  some  point 
generally  about  three  inches  above  the  ankle,  is  commonly  known  as  Pott's 
fracture,  having  been  first  described  w^ith  accuracy  by  the  distinguished  sur- 
geon of  that  name.  It  had  previously  been  regarded  either  as  a  sprain  or 
as  a  (lislocjition. 

Although,  as  I  shall  presently  further  show,  this  lesion  varies  greatly  in 
difierent  cases,  there  are  certain  features  which  always  belong  to  it  and  dis- 
tinctly characterize  it.  There  are  two  ways  in  which  it  may  be  produced. 
When  the  foot  is  strongl}^  everted,  so  that  the  sole  looks  outward,  the  internal 
lateral  ligament  is  put  upon  the  stretch,  and  a  cross-breaking  strain  is  brought 
to  bear  upon  the  inner  malleolus,  which  gives  way.  As  soon  as  this  happens, 
the  astragalus  and  calcaneum  are  forced  up  against  the  end  of  the  fibula, 
which  bends  and  breaks,  generally  at  a  point  some  three  inches  above.  On 
the  other  hand,  if  the  foot  is  strongly  inverted,  so  that  the  sole  looks  inward, 
the  inner  malleolus  may  be,  as  it  were,  pushed  ofii",  while  the  outer  malleolus  is 
drawn  inward,  and  the  fibula  gives  way  to  stress  tending  to  bend  it  outward. 

In  either  case,  the  force  is  brought  to  bear  across  the  columns  of  the  can- 
cellous tissue  of  the  inner  malleolus,  while  the  point  at  which  the  fibula 
generally  gives  way  is  where  it  is  slenderest  and  least  able  to  resist. 

By  way  of  illustrating  the  difierences  presented  by  the  lesions  in  these 
cases,  I  may  simply  quote  the  descriptions  of  three  specimens  in  the  Patho- 
logical Cabinet  of  the  Xew  York  IIos[)ital.^  In  one,  taken  from  a  man  aged 
thirty,  injured  l)y  the  caving  in  of  a  bank  of  earth,  the  fibula  is  seen  to  be 
fractured  ti-ansversely  two  inches  above  the  joint;  the  internal  malleolus  is 
torn  ofi",  and  the  posterior  margin  of  the  articular  surface  of  the  tibia  is 
broken  into  three  pieces." 

In  another,  "  the  internal  malleolus  is  bi-oken  off",  and  the  fibula  is  fractured 
obliquely  one  inch  above  its  lower  end."    jS'o  history  of  the  case  is  given. 

In  the  third,  taken  from  a  man  aged  fifty-three,  who  made  a  mis-step  and 
iell  upon  the  pavement,  "  there  was  a  fracture  of  the  fibula,  commencing  at 
the  level  of  the  ankle-joint,  and  running  so  obliquely  upward  and  backw^ard 
as  to  leave  a  fragment  nearly  three  inches  long  connected  with  the  astragalus. 
The  internal  malleolus  was  torn  oft',  and  the  whole  of  the  posterior  third  of 
the  articulating  surface  of  the  tibia  was  comminuted  and  broken  off"  by  a 
fracture  running  upward  and  backward  from  within  the  joint,  thus  leaving 
several  large  fragments  still  attached  to  the  astragalus  below." 

Occasionally  the  portion  detached  from  the  tibia  is  very  small,  consisting 
merely  ot  the  tip  of  the  malleolus ;  and  the  lesion  may  then  be  properly 
ranked  among  "  sprain-fractures." 

The  symptoms  of  the  fractures  now  described  are  placed  together  here  by 


1  Catalogue,  p.  119 ;  Nos.  233,  234,  and  235. 


244 


INJURIES  OF  BONES. 


Deformity  in  "Pott's  fracture.' 


way  of  contrast.    Those  of  the  "  V-sliaped  fracture"  are :  projection,  but  not 

generally  very  marked,  of  the  up- 
^ig-  844.  per  fragment ;  pain,  utter  loss  of 

power,  swelling,  ecchymosis ;  mo- 
bility and  crepitus  only  at  the  seat  of 
the  oblique  fracture,  the  bone  as  a 
rule  not  being  noticeably  separated 
at  the  fissures.  General  tenderness 
alway  s  exists  along  the  whole  course 
of  the  fracture.  Effusion  occurs 
rapidly  into  the  ankle-joint. 

In  "  Pott's  fracture"  there  is  gen- 
erally very  marked  deformity,  the 
ankle  being  bent  as  in  the  cut 
(Fig.  844),  and  very  movable  until 
effusion  has  taken  place  in  the  joint, 
Ecchymosis  occurs  gradually. 

Fractures  of  the  lower  portion  of 
the  leg,  involving  both  bones,  usu- 
ally unite  well,  although  some  cases 
of  non-union  in  this  region  are  upon 
record,  and  sometimes  consolidation 
takes  place  but  slowly.  In  cases  of  Pott's  fracture,  unless  the  deformity  is 
effectively  remedied  by  treatment,  the  ankle  remains  permanently  distorted, 
in  a  position  similar  to  that  of  talipes  valgus,  and  for  a  long  time  there  is 
serious  difficulty  in  walking.  Sometimes,  however,  even  when  the  bones 
have  united  in  bad  position,  there  is  ultimately  a  much  better  result  than 
might  have  been  expected. 

The  treatment  of  fractures  of  the  leg  has  long  been  recognized  as  a  matter 
of  great  importance,  and  to  describe  all  the  contrivances  for  the  purpose 
which  have  been  brought  forward  would  be  a  formidable  task.  I  shall  en- 
deavor to  give  an  idea  of  the  principles  to  be  carried  out,  and  of  the  chief 
methods  proposed  for  so  doing,  dwelling  especially  upon  those  which  are  of 
most  practical  value. 

As  in  most  other  fractures,  the  main  points  are  the  correction  of  the  defor- 
mity, the  restoration  of  the  normal  shape  of  the  part,  and  the  maintenance  of 
the  limb  in  this  condition  until  the  fragments  shall  have  become  firmly  united. 

Sometimes  the  reduction  is  accomplished  with  ease,  but  sometimes  it  pre- 
sents great  difiiculties.  When  the  fragments  are  very  loose,  the  distal  por- 
tion of  tbe  limb  dangling  and  very  movable,  the  replacement  is,  as  a  rule, 
easier  than  when,  though  the  displacement  is  less  marked,  the  two  portions 
of  the  tibia  are  interlocked.  Very  oblique  fractures  are  sometimes  attended 
with  great  overlapping,  but  this  may  be  rectified  without  much  trouble ;  its 
recurrence,  however,  can  scarcely  be  obviated,  except  by  well-adapted  means, 
carefully  applied. 

Angular  deformity  is  in  general  overcome  by  gentle  manipulation,  and 
ought  not  to  be  permanent  under  proper  treatment.  The  rotation  of  the 
lower  portion  of  the  leg  outward  or  inward  must  be  carefully  corrected,  and 
in  so  doing  the  surgeon  should  make  sure  that  both  bones  are  placed  in  pro- 
per line ;  otherwise  the  tibia  may  be  straight,  but  the  fibula  bent  so  as  perhaps 
to  give  the  patient  a  limp  in  his  gait. 

It  will  readily  be  seen  that  the  reduction  should  be  effected  at  the  earliest 
possible  moment,  for  two  reasons:  in  the  first  place,  because  the  swelling 
which  soon  ensues  increases  the  difficulty  of  the  procedure,  and  prevents  the 
sui^geon  from  j.udging  how  far  he  has  succeeded  in  accomplishing  his  object; 
and  secondly,  because  the  resistance  of  the  muscles  is  greater  the  longer  the 


FRACTURES  OF  THE  BONES  OF  THE  LEG. 


246 


frai>;inent8  have  remained  in  their  false  position.  Muscular  action  is  not  the 
sole  cause,  often  not  even  the  chief  cause  of  the  deformity,  which  is  in  gen- 
eral due  to  the  fracturing  force,  or  to  the  weight  of  the  parts;  but  it  very 
commonly  is  an  obstacle  to  its  correction.  Hence  this  process  is  facilitated 
by  relaxing  the  muscles,  whi(;h  is  done  by  flexing  the  knee,  and  slightly 
extending  the  foot.  Fractures  which  cannot  be  reduced  at  all  with  the  knee 
straight  will  often  yield  promptly  as  soon  as  it  is  bent. 

The  test  of  th*e  limb  being  in  jiroper  line  is  that  the  inner  edge  of  the 
patella,  the  inner  side  of  the  ankle,  and  the  inner  side  of  the  great  toe,  are  in 
the  same  vertical  plane.  And  the  fingers  passed  along  the  tibia  should  detect 
no  angular  irregularity  in  its  surface. 

I  have  said  that  the  main  difliculties  in  reduction  are  due  to  interlocking 
of  the  fragments  of  the  tibia,  and  to  muscular  contraction.  Sometimes  the 
condition  of  things  is  more  complicated,  and  may  be  very  obscure : — 

A  woman,  aged  fifty,  was  brought  into  St.  Joseph's  Hospital,  Philadelphia,  having 
been  run  over  by  a  wagon  which  had  produce<l  a  severe  compound  fracture  at  the  upper 
part  of  the  right  leg  ;  reduction  was  impossible,  although  the  most  apparent  obstacle  was 
removed  by  cutting  off  the  end  of  the  upper  tibial  fragment,  which  protruded  through  the 
skin.  Eiglit  days  afterward,  amputation  being  performed  through  the  knee-joint,  it 
was  found  tliat  the  upper  end  of  the  lower  fragment  of  the  fibula  was  wedged  in  between 
the  upper  fragments  of  both  bones,  and  that  this  had  constituted  the  difficulty  in  replace- 
ment. 

The  reduction  being  effected,  some  surgeons  are  willing  to  trust  for  its 
maintenance  to  the  pressure  of  a  pillow,  lapped  around  the  limb  and  tied  fibout 
with  tapes  or  strips  of  bandage.  Although  this  plan  has  been  sanctioned 
by  some  high  authorities,^  I  have  never  myself  seen  a  case  in  which  I  should 
liave  felt  justified  in  using  it,  except  as  a  temporary  resource. 

Plaster  bandages,  the  Bavarian  splint,  and  other  forms  of  solidifying  dress- 
ing, have  found  many  advocates  within  the  last  forty  years,  since  the  revival 
of" this  method  by  Larrey  and  Seutin.  One  objection  holds  against  every 
form  of  it  as  a  primary  dressing  for  fractures  of  the  leg,  namely,  that  it  pre- 
vents the  constant  inspection  of  the  limb  which  can  alone  assure  the  surgeon 
that  it  is  prope/dy  kept  in  shape.  Skilfully  applied,  and  carefully  watched, 
I  do  not  believe  that  the  immovable  apparatus  is  likely  to  do  any  harm  by 
constricting  the  Umb,  although  under  other  circumstances  serious  trouble  has 
arisen  in  this  way.  At  a  later  stage  of  the  case,  when  the  union  between  the 
fragments  has  become  somewhat  firm,  a  plaster  or  silicated  bandage,  or  the 
Bavarian  splint,  may  be  employed  to  great  advantage,  enabling  the  patient  to 
jsit  up,  and  to  move  about  on  crutches. 

The    fracture-box"  is  an  appliance  which  has  long  been  used  in  the  Penn- 
sylvania Hospital,  and  which  has  some  great  merits.    It  consists  of  a  board, 
having  two  sides  attached  by  hinges,  and  a  foot-piece. 
(Fig.  845.)  The  sides  being  let  down,  a  pillow  is  laid  Fig-  845. 

in  the  box ;  the  leg  is  carefully  adjusted  in  the  pil- 
low, and  the  foot  secured  by  a  stri[)  of  wide  bandage 
passed  under  the  heel,  its  ends  being  then  crossed 
over  the  instep  and  put  through  two  slits  in  the  foot- 
piece,  to  be  tied  at  its  outer  side.    Xow  the  sides  of  ^covimG^ 

the  box  are  brought  up,  pressing  the  pillow  against     Fracture-box  ^yith  movable  sidei 

the  leg  so  as  to  give  it  uniform  and  complete  support. 

Of  course,  the  size  of  the  box  must  be  adapted  to  that  of  the  limb.  If  the 
fragments  tend  to  form  an  angle  forward,  the  heel  can  be  raised;  if  backward, 
it  can  be  lowered. 

•  Skey,  Lancet,  Jan.  9,  1864:  Wicks,  British  Med.  Journal,  Nov.  25,  1882;  Duke,  ibid.,  Dec. 
16,  1882.    Sand-bags  are  generally  added  in  order  to  promote  the  steadiness  of  the  limb. 


246 


INJURIES  OF  BONES. 


In  England,  the  splint  known  as  Mclntyre's  or  Liston's  has  been  very 
largely  used,  generally  with  a  Stromeyer  screw^  for  the  purpose  of  changing 
|;he  angle  of  the  knee  when  desired  ;  and  the  ordinary  double  inclined  plane 
has  also  been  employed,  not  only  by  British  surgeons,  but  on  the  continent 
of  Europe  and  in  this  country.  I  think,  however,  that  although  there  can 
be  no  question  of  the  fact  that  good  results  have  been  obtained  by  such 
means,  the  want  of  more  effective  lateral  pressure  than  is  likely  to  be  made 
by  a  mere  bandage,  and  the  uncertainty  of  posterior  support  through  the 
muscles  of  the  calf,  make  these  forms  of  apparatus  less  available  for  general 
use  than  might  be  supposed  from  the  reputation  accorded  them. 

Lateral  support,  indeed,  seems  to  me  to  be  of  prime  importance  in  the 
treatment  of  the  injuries  in  question ;  and  my  own  practice  is  to  employ  it 
sedulously  in  every  case-  For  this  purpose  I  prefer  moulded  splints  of 
binder's  board,  gutta-percha,  or  sole-leather,  accurately  adapted  to  the  limb, 
properly  lined  or  padded,  and  secured  by  careful  bandaging,  so  as  to  control 
the  leg  and  foot  as  perfectly  as  possible.  Pressure  upon  the  bony  points,  the 
head  of  the  fibula,  the  malleoli,  and  the  tarsal  bones  in  very  thin  persons,  must 
be  guarded  against  by  cutting  out  holes  in  the  splints,  and  all  the  edges  must 
be  nicely  bevelled.  The  side-splints  should  extend  up  along  the  sicle  of  the 
foot,  so  as  to  keep  it  steady  and  in  line ;  but  they  should  not  reach  so  high 
as  to  interfere  with  the  free  flexion  of  the  knee. 

Patients  with  fractures  of  the  leg  are  rendered  far  more  comfortable  by 
having  the  injured  limb  suspended,  so  that  it  can  move  freely  without  dis- 
turbing the  fragments.    By  this 
Fig-  846.  arrangement  they  are  enabled  to 

sit  up,  and  even  to  be  out  of  bed, 
with  perfect  safety.  When  the 
fracture-box  is  used,  it  may  be  hung 
in  a  frame  (Fig.  846)  by  means  of 
cords  attached  to  the  ends  of  the 
arms;  the  frame  should  be  made  of 
iron  bars  stiff  enough  to  sustain  the 
weight  without  bending.  When 
the  lateral  splints  are  employed,  I 
Frame  for  suspending  fracture-box.  prefer  suspeusiou  by  means  of  a 


Fig.  847. 


Wire  frame  for  suspending  leff. 


FRACTURES  OF  THE  BONES  OF  THE  LEG. 


247 


wire  frame  like  Smith's  splint,  using  only  the  portion  corresponding  to  the 
foot  and  leo-.  (Fig.  847.)  Iii  this  frame  the  leg  may  be  cradled  by  double  strips 
of  bandagettied  or  pinned.  (Fig.  848.;  To  attach  the  suspension  apparatus,  1 
use  a  support  consisting  of  a  wooden  upright  about  six  feet  high,  having  at  its 
top  an  arm  at  right  angles,  into  the 
under  surface  of  which  is  screwed  a 
pulley ;  its  lower  end  is  set  in  a 
tripod,  one  long  foot  extending  out 
parallel  with  the  upper  arm,  and 
the  other  two  at  right  angles  to  it. 
The  long  foot  goes  under  the  bed. 
A  cord  run  through  the  ptdley, 
with  a  tent-block,  serves  to  attach 
the  cords  connected  w^ith  the  sus- 
pension-frame. From  this  descrip- 
tion   I  think  the  working  of  the  Mode  of  supporting  leg  with  strips  of  bandap:e. 

whole  apparatus  may  be  readily  i    •  i    i    i    i  • 

understood.  By  having  the  gallow^s-frame  unconnected  with  the  bed,  it  may 
be  moved  to  another  part  of  the  room,  and  the  patient  may  be  dressed  and 
sit  up,  with  his  leg  securely  swung.  ^  . 

I  may  here  mention  that  I  have  sometimes  had  occasion  to  move  patients 
with  fractures  of  the  leg,  and  have  found  that  they  can  bear  the  motion  of  a 
carriao-e  or  railroad  train  with  perfect  ease,  by  having  the  injured  limb,  pro- 
perly splinted,  laid  on  strips  of  rubber  bandage  nailed  across  a  wooden  frame 
supported  on  sides  like  those  of  a  box.^  ^       ^  ^ 

Other  devices  for  suspension  have  been  employed.  Salter  s  swing  is  well 
known  in  England.  The  late  Dr.  Ilodgen^  published  a  description  of  a  swing- 
ino-  fracture  box,  which  was  only  open  to  the  objection  that,  in  order  to  let 
down  the  sides,  the  whole  box  had  to  be  lowered  and  placed  upon  the  bed. 
Dr.  ^Tathan  R.  Smith's  apparatus  for  fracture  of  the  leg,  consisting  of  a  thigh 
piece,  with  a  frame  for  the  leg,  and  a  foot-piece,  is  well  known,  and  had  a 
somewhat  extensive  popularity  at  one  time.  I  do  not  think  that  it  is  largely 
used  at  present— perhaps,  because  it  has  been  superseded  by  simpler  and 
apparently  more  secure  contrivances.  ,  ^'^ 

By  some  of  the  older  surgeons  it  was  advised  that  the  limb  should  be  laid 
on  its  outer  side,  secured  by  slips  of  Avood  bandaged  so  as  to  steady  the 
bones,  and  with  the  muscles  relaxed  by  bending  the  knee.  Such  a  position 
would  no  doubt  be  comfortable,  but  it  may  be  doubted  whether  the  proper 
coaptation  of  the  fragments  would  be  effectively  maintained.  ^  Yet  it  is 
spoken  of  with  approval  by  Hulke,^  as  adapted  to  some  cases  in  which  there 
is  a  tendency  to  displacement  of  the  fragments  when  the  leg  is  straightened." 
I  cannot  but  think  that  suspension  of  the  leg  would  answer  the  same  pur- 
pose, with  less  risk  of  displacement. 

Cases  sometimes  present  themselves  in  which  extension  and  counter-exten- 
sion are  required  to  counteract  the  tendency  to  shortening.  Swinburne,''  in- 
deed, advocates  the  treatment  of  all  fractures  of  the  leg  by  this  means  alone, 
without  splints  or  other  means  of  lateral  support ;  but  I  do  not  think  that  he 
has  had  manv  converts  to  this  peculiar,  and  in  my  opinion  dangerous,  doctrine. 
Reference  has  been  already  made  to  the  fact  that  Sands,  St.  John,  and  some 

1  An  arrangement  of  this  kind  is  figured  by  Benjamin  Bell  (System  of  Surgery,  Edinburgh, 
1788  Plate  fxxiii  ¥i<^.  3),  but  with  straps  and  buckles,  and  without  any  elastic  support;  it 
is  described  as  an  appai-atus  for  compound  fractures,  to  admit  of  the  dressing  of  a  wound  with- 
out disturbing  the  limb. 

2  St.  Louis  Med.  and  Surg.  Journal,  March  10,  18/1.  ^  ^  or: 
'  Holmes's  System  of  Surgery,  3d  ed.,  vol.  i.  p.  1046.  Op.  cit.,  p.  25. 


248 


INJURIES  OF  BONES. 


Fig.  849. 


Others,  have  thought  that  a  sufficient  degree  of  extension  was  effected,  even  in 
fractures  of  the  thigh,  bj  tirm  lateral  support  and  compression;  this  they 
would  obtain  by  bandaging,  with  or  without  plaster  of  Paris,  the  limb  beino- 
placed  m  such  a  posture  as  to  relax  the  muscles.  The  experience  of  most  sur- 
geons, however,  would  lead  them  to  seek  more  direct  methods,  in  cases  where 
shortening  was  seriously  threatened ;  and  a  variety  of  appliances  have  been 
proposed  and  employed  for  the  prevention  of  this^vil,  chiefly  modifications 
of  those  already  described  in  connection  w^ith  the  treatment  of  fractures  of  the 
thigh. 

The  method  which  I  myself  employ  consists  in  the  use  of  adhesive  plaster, 
with  the  side-splints  already  spoken  o£ 

Extension  may  be  made  by  means  of  the  side-splints,  as  follows :  Four 
strips  of  adhesive  plaster  are  cut  lengthwise  of  the  piece,  and  of  lencrth  and 
breadth  corresponding  to  the  size  of  the  limb— for  an  adult,  about  eighteen 
inches  long  by  two  inches  wide.  Each  of  them  is  then  split  up  from  one  end 
lor  about  half  its  length ;  the  end  which  remains  whole  is  next  folded  on  itself, 

the  adhesive  surfaces  in  contact,  and  a 
small  slip  of  wood  is  placed  in  the  loop 
so  made.  A  slit  is  iioav  cut  close  to  the 
bit  of  wood,  through  which  a  loop  of 
bandage  may  be  passed.  The  split  ends 
being  applied  so  as  to  embrace  the  ankle 
below^  and  the  upper  part  of  the  leg 
above,  the  strips  are  brought  round  the 
ends  of  the  splints,  and  the  correspond- 
ing pairs  tied  together  on  the  outside  of 
the  latter.  Ext'ension  is  made  by  the 
two  low^er  strips  against  counter-exten- 
sion by  the.  two  upper,  the  force  being  in- 
creased or  lessened  by  drawing  the  strips 
of  bandage  more  or  less  tightly. 

This  plan  I  have  employed  especially 
.  ■         in  cases  of  fracture  near  the  ankle-joint, 

i)ut  I  think  that  it  will  be  found  efl:ectual  whenever  the  bones  are  broken,  at 
whatever  point,  so  obliquely  as  to  threaten  overlapping  and  consequent  short- 
ening of  the  limb.  It  may  be  better  understood  by  a  reference  to  the  cuts, 
Fio:s.  849,  850. 


Side-splint  for  making  extension  in  fractures  of  the 
leg. 


Fig.  850. 


Extension-splint  adjusted. 

^  A  marked  projection  forward  of  the  upper  fragment  of  the  tibia  is  some- 
times obscM^ved,  in  (;ases  especially  where  the  fracture  of  this  bone  is  very 
oblique.  P>y  elevating  the  heel,  this  prominence  is,  i^enerally,  almost  if  not 
altog(^ther  made  to  disappear;  or  perhaps  it  would  be  more  correct  to  say 
that  the  lower  fragment  is  thus  caused  to  follow  the  upper,  so  that  they  are 


FRACTURES  OF  THE  BONES  OF  THE  LEG. 


249 


restored  to  their  normal  relation.  Care  must  be  taken  not  to  overdo  this,  so 
as  to  produce  an  angle  salient  backward,  which  would  give  rise  to  most 
troublesome  lameness.  Ormerod'  records  two  cases  in  which  this  anterior 
displacement  was  not  manifested  for  some  time  after  the  receipt  of  the  injury ; 
under  such  circumstances  it  would  seem  attributable  to  defective  treatment. 

Section  of  the  tendo  Achillis,  according  to  Malgaigne,  was  first  proposed 
and  employed  as  a  remedy  for  this  condition  by  Laugier.  It  would  seem  to 
have  found  more  favor  in  England^  than  elsewhere ;  a  case  has  very  recently 
been  reported  by  Bryant,^  in  which  the  operation  was  attended  with  success. 

Malgaigne  proposed,  for  the  correction  of  this  deformity,  the  use  of  a  steel 
point  on  a  screw  stem,  passed  through  the  centre  of  a  bow  of  metal,  which 
could  be  fastened  to  the  back  splint  by  means  of  a  strap  and  buckle  ;  the  bow 
being  placed  over  the  limb  a  little  above  the  seat  of  fracture,  tbe  point  was 
carried  down  through  the  skin,  and  screwed  in  so  as  to  produce  the  requisite 
amount  of  pressure.  An  equally  efficient  and  safer  plan  would  be  to  sub- 
stitute for  tlie  point  a  little  plate  carrying  a  pad.  By  slightly  shifting  the 
point  of  pressure  from  time  to  time,  all  risk  of  its  injuring  the  skin  could  be 
readily  avoided.  I  am  not  aware  that  Malgaigne's  contrivance  has  ever  been 
used,  except  in  the  very  few  instances  mentioned  in  his  work ;  and,  indeed, 
nature  does  so  much,  in  the  way  of  rounding  olf  projecting  points  of  bone, 
that  it  would  seem  to  me  needless  to  interfere,  unless  the  deformity  were 
more  marked  than  in  any  case  that  has  ever  come  under  my  notice. 

A  curious  consequence  of  fracture  of  the  leg  has  been  recorded  by  Terrier;* 
two  months  after  the  injury,  a  small  cyst-like  tumor  show^ed  itself  on  the 
inner  surface  of  the  limb  near  the  fracture,  and  proved  to  contain  free  oil, 
effused  from  the  broken  bone;  it  was  evacuated,  and  finally  disappeaued. 

Pseudarthrosis  is  not  uncommon  after  fracture  of  l:)oth  bones  of  the  leg. 
In  Agnew's  tables,^  out  of  685  cases,  100,  or  nearly  15  per  cent.,  were  in  this 
region.  In  thirty -one  of  these  the  exact  seat  of  fracture  is  not  given  :  in  one 
it  is  said  to  have  been  at  the  junction  of  the  upper  and  middle  thirds;  in 
twenty-four  at  the  middle;  in  six  in  the  middle  third;  in  nine  at  the  junc- 
tion of  the  middle  and  lower  thirds;  and  in  twenty -nine  in  the  lower  third. 
Hence  it  would  appear  that  non-union  is  met  with,  in  both  bones,  very  nearly 
as  often  in  the  low^er  third  of  th,e  leg  as  in  the  middle  third ;  but  the  fact 
that  in  so  large  a  proportion  out  of  the  whole  number  the  exact  seat  of  the 
lesion  is  not  stated,  prevents  the  drawing  of  absolutely  positive  inferences 
upon  this  point. 

The  treatment  of  this  condition  has  been  sufficiently  discussed  in  a  pre- 
vious part  of  this  article. 

Union  with  deformity  has  been  observed  in  a  large  number  of  cases  of 
fracture  of  both  bones  of  the  leg,  and  is  often  productive  of  such  total  dis- 
ability as  to  demand  surgical  interference.  In  not  a  few  of  these  cases  it  has 
happened  that  the  callus  has  yielded  after  the  patients  luive  be2:un  to  walk, 
and  in  almost  all  there  has  been  a  progressive  increase  of  the  bending  of  the 
limb.  When  the  shafts  of  the  bones  are  concerned,  the  angle  is  almost 
always  salient  anteriorly;  I  know  of  only  a  few  exceptions  to^^this  rule,  in 
which  the  bones  projected  backward.  Toward  the  lower  part  of  the  leg,  the 
deformity  is,  for  the  most  part,  like  that  of  talipes  valgus,  the  upper  tibial 

*  Op.  cit.,  p.  54. 

*  See  Med.-Chir.  Transactions,  vol.  xxxiii-  1849,  and  Guy's  Hospital  Reports,  1855. 
3  Lancet,  June  2,  1883. 

*  London  Med.  Record,  Oct.  15,  1878,  from  Revue  Mensuelle  de  Medecine  et  de  Cliirurgie,  No. 
7,  1878. 

*  Op.  cit.,  vol.  i.  pp.  752  et  seq. 


250 


INJURIES  OF  BONES. 


fragment  projecting  inward,  and  the  outer  side  of  the  foot  being  drawn  up. 
In  some  recorded  cases  there  has  been  atrophy  of  the  bones  also. 

The  procedures  resorted  to  for  the  relief  of  this  condition  have  been  of 
various  degrees  of  severity.  JN'orris^  quotes  Dupuytren^  as  authority  for  the 
use  of  combined  pressure  and  extension,  and  cites  a  case  thus  treated  with 
success  by  M.  Desgranges,  four  months  after  the  receipt  of  the  injury. 

Forcible  refracture  has  been  found  effectual.  Malgaigne  cites  cases  from 
Bosch  and  Oesterlen,  and  one  has  been  reported  by  Mussey.^  In  1851,  I 
witnessed  the  performance  of  an  operation  of  this  kind,  by  Dr.  W.  E.  Horner, 
on  a  leg  broken  twelve  weeks  previously ;  the  result  was  perfectly  successful. 

Brainard^  made  refracture  easier  by  first  drilling  the  bones  at  the  abnormal 
angle ;  ten  days  afterward  the  callus  yielded  readily,  and  a  good  result  was 
obtained.  Hunt^  resorted  to  similar  means,  and  with  ultimate  success, 
although  the  patient's  life  was  for  a  time  in  great  danger. 

Section  of  the  callus  was  first  performed,  according  to  Malgaigne,  by  Oes- 
terlen in  1815;  afterwards  by  Dunn,^  Portal,^  Key, «  Barton,^  Miitter,^^and 
Josse."  ^^orris  mentions  that  he  knew  of  similar  operations  by  Warren,  of 
Boston,  and  Stevens,  of  ^ew  York,  and  cites  one  by  Rynd,  of  Dublin.  I 
myself  witnessed  one  such  operation  by  the  late  Prof.  Joseph  Pancoast,  and 
believe  that  he  had  others,  never  published. 

The  modern  method  of  subcutaneous  osteotomy,  which  seems  admirably 
adapted  to  the  treatment  of  deformed  union  in  some  situations,  cannot  be  so 
readily  employed  in  cases  afiecting  the  leg,  for  obvious  reasons,  unless  the 
chisel  is  substituted  for  the  saw.  Dr.  Fenger,  of  Chicago,  has  published^^ 
accounts  of  three  cases  in  which  he  obtained  success  in  this  way.  Another 
w^as  reported, ^3  and  the  patient,  a  man  fifty-eight  years  old,  shown  to  the 
Leeds  and  West  Riding  Medico-Chirurgical  Society,  bv  Mr.  Jessop,  of  Leeds ; 
the  case  was  one  of  Pott's  fracture,  which  had  firmly  united  in  such  a  posi- 
tion as  to  render  the  limb  useless.  A  section  was  made  through  the  fibula, 
2 J  inches  above  the  ankle,  and  another  thi^ough  the  base  of  the  inner  mal- 
leolus ;  and  union  was  obtained  so  that  the  limb  became  straight  and  useful. 

Compound  fractures  of  the  leg  are  always  serious  injuries,  and  are  of  very 
common  occurrence  in  hospital  practice.  The  damage  to  the  soft  parts  may 
be  due  to  the  fracturing  force,  as  in  railway  accidents  ;  or  it  may  be  produced 
by  eftbrts  to  walk  on  the  part  of  the  patient,  by  Vv^hich  the  broken  ends  are 
thrust  through  the  skin.  Occasionally,  the  displacement  being  irreducible, 
the  skin  gives  way  over  the  projecting  fragments,  and  a  fracture  at  first  sim- 
ple becomes  compound  subsequently.  Sometimes  the  fracture  of  one  of  the 
bones  only  is  compound,  that  of  the  other  being  simple. 

Often  in  these  cases  the  question  of  amputation  presents  itself,  and  must  be 
settled  upon  principles  elsewhere  laid  down.  If  the  attempt  to  save  the  limb 
be  decided  upon,  I  think  it  right  to  cleanse  the  parts  thoroughly  with  carbo- 
lized  water ;  reduction  should  then  be  accomplished,  the  wound  closed,  but 
with  suitable  provision  for  drainage,^^  and  dressings  applied.    I  prefer  hot 

'  Contributions  to  Practical  Surgery,  p.  113. 

2  Injuries  and  Diseases  of  Bones,  Syd.  Soc.'s  translation,  pp.  63,  66,  and  68. 

3  Am.  Journal  of  the  Med.  Sciences,  April,  1851.  *  Chicago  Med.  Journal,  Jan.  1859. 

5  Philadelphia  Med.  Times,  Oct.  26,  1872,  and  Surgery  in  the  Pennsylvania  Hospital,  p.  151. 
s  Med.-Chir.  Transactions,  vol.  xii.  p.  181. 

1  Am.  Journal  of  the  Med.  Sciences,  Oct.  1841,  from  an  Italian  Journal. 

s  riuy's  Hospital  Reports,  1839.  9  Med.  Examiner,  Jan.  8,  1842. 

'0  Am.  Journal  of  the  Med.  Sciences,  April,  1842.       "  Quoted  by  Malgaigne. 

12  Medical  News,  April  15  and  22,  1882.  '3  British  Med.  Journal,  April  14,  1883. 

'1  See  an  excellent  article  by  Markoe,  on  Through-drainage  in  Compound  Fractures  of  the 
Leg,  in  the  Am.  Journal  of  the  Med.  Sciences,  April,  1880  ;  and  a  paper  by  Dr.  E.  Mason,  with 
its  discussion  by  the  New  York  Surgical  Society,  in  the  Medical  News,  Jan.  7  and  Jan.  14,  1882. 


FRACTURES  OF  THE  BONES  OF  THE  LEG. 


251 


water,  hot  laudanum,  or  laudanum  and  lead-water.  The  fracture-box  answers 
admirably  in  these  cases,  but  my  own  practice  is  always  to  suspend  it,  not 
only  because  the  patient  is  thus  rendered  more  comfortable,  but  because  the 
fragments  are  thus  less  likely  to  become  displaced. 

At  a  later  stage,  when,  as  very  generally  hap})ens,  suppuration  ensues,  and 
especially  if  the  discharge  be  profuse,  the  bran-dressing  devised  by  the  late 
Dr.  J.  R.  Barton  is  of  great  value.  It  is  applied  by  means  of  a  fracture-box, 
in  which  is  placed  a  lining  of  muslin  on  which  the  bran  is  heaped,  making  a 
bed  for  the  limb,  which  is  then  covered  over  with  more  bran,  and  the  sides 
of  the  box  brought  up.  It  is  not  always  necessary  to  secure  the  foot  to  the 
foot-piece,  but  if  is  better  to  do  so  if  suspension  is  to  be  used.  At  this  stage 
patients  are  apt  to  have  become  accustomed  to  conlinement,  and  to  have 
learned  to  lie  perfectly  still. 

Bracketed  splints  of  various  forms,  intended  to  control  the  limb  while 
leaving  the  wound  exposed  for  the  purpose  of  changing  the  dressings,  have 
been  devised.  Their  value  depends  entirely  upon  the  accuracy  of  their 
adaptation  to  the  size  and  shape  of  the  limb  in  each  case ;  and  it  seems  to 
me  safer  for  most  practitioners  to  rely  upon  simpler  means. 

As  soon  as  the  wound  has  healed,  or  the  fragments  have  been  so  covered 
up  by  granulations  as  to  be  no  longer  exposed  to  the  atmosphere,  the  lesion 
assumes  the  character  of  a  simple  fracture,  and  nmch  of  the  danger  is  set 
aside.  In  the  former  case,  the  side  splints,  moulded  to  the  limb,  or  the  im- 
movable apparatus,  may  be  resorted  to ;  but  care  should  always  be  taken  lest 
by  undue  or  misplaced  pressure  the  soft  parts  should  be  irritated,  and  fresh 
mischief  ensue. 

Various  circumstances  may  arise  in  the  course  of  cases  of  this  kind  re- 
quiring special  interference.  Extreme  swelling  and  tension  of  the  soft  parts 
sometimes  come  on  within  a  few  hours  of  the  injury,  and  may  be  greatly 
relieved  by  free  incisions.  Hemorrhage  may  occur  to  an  extent  that  demands 
the  use  of  prompt  and  thorough  means  for  its  control.  At  a  later  period, 
there  may  be  burrowing  of  pus"  along  the  limb ;  and  counter-openings,  drain- 
age, and  properly  applied  pressure  may  be  needed. 

Fractures  of  the  tibia  alone  are,  according  to  some  observers,  much  less 
frequent  than  those  of  the  fibula  alone  ;  but  the  statements  of  others  are  de- 
cidedly at  variance  with  this,  as  may  be  seen  by  a  glance  at  the  table  quoted 
from  Gurlt  on  a  preceding  page.  The  widest  difference  exists  between  the 
figures  given  by  Malgaigne,  29  of  the  tibia  to  108  of  the  fibula,  and  those  of 
Blasius,"30  of  the  tibia  to  15  of  the  fibula. 

When  the  tibia  is  broken  of  itself,  it  is  generally  by  direct  violence,  but 
sometimes  by  indirect.  One  instance  has  been  recorded  by  Caspary,^  in 
wdiich  it  was  thought  that  the  bone  had  yielded  to  muscular  contraction,  in 
a  strong  healthy  man  of  twenty-six;  but  as  he  had  had  a  venereal  sore  six 
years  previously,  and  had  complained  of  rheumatic  pains  for  some  time  before 
the  occurrence  of  the  accident,  it  seems  probable  that  the  texture  of  the  bone 
may  have  undergone  pathological  change. 

The  fracture  may  be  but  slightly  oblique ;  it  is  seldom  as  markedly  so  as 
when  both  bones  give  way.  "l  have  met  with  three  recorded  instances  of 
incomplete  fracture  of  the  tibia.  One,  quoted  by  Malgaigne  from  0am- 
paignac,  was  that  of  a  girl,  twelve  years  old,  run  over  by  a  cabriolet ;  at  her 
death  the  lesion  just  stated,  with  a  curvature  of  the  fibula,  was  ascertained 
by  dissection.    Gray^  reported  to  the  Boston  Society  for  Medical  Improve- 


»  Berl.  klin.  Wochenschrift,  28  Jan.  1867. 

2  Am.  Journal  of  the  Med.  Sciences,  Oct.  1853. 


252 


INJURIES  OF  BONES. 


ment  the  case  of  a  boy  of  six,  who  "  was  standing  on  an  iron  rail  fence, 
and  in  trying  to  jump  down  was  caught  by  the  heel  and  left  hanging  in  that 
position  ;"  the  subsequent  deformity,  without  crepitus,  and  the  straightening 
of  the  limb  by  means  of  splints,  seemed  to  warrant  the  diagnosis  given, 
which,  however,  could  not  be  absolutely  verified,  as  the  patient  recovered.' 
The  third  case  was  observed  by  Menzel,i  of  Trieste,  in  a  man  aged  forty-eight', 
who  was  run  over.  There  was  some  elastic  mobility  of  the  bone  ;  the  patient 
died  of  pyaemia,  and  "  the  left  tibia  was  found  partially  fractured  between 
the^  inferior  and  middle  thirds  ;  about  seven-eighths  of  its  substance  was 
divided  transversely ;  the  remainder  presented  not  even  a  trace  of  fissure." 

Sometimes,  although  the  main  line  of  fracture  is  nearly  transverse,  there 
are  subordinate  breakages,  making  a  commiimtion  of  the  bone.  James^  ha." 
recorded  a  case  of  longitudinal  and  transverse  fracture  of  the  tibia,  witlf 
extensive  extravasation  of  blood  into  the  tissues  of  the  leg. 

Epiphj^seal  disjunctions  have  been  observed  in  the  tibia:  Madame  Lacha- 
pelle's  case,  in  which  the  lower  epiphysis  of  the  femur  and  the  upper  of  the 
tibia  were  detached  in  the  delivery  of  a  child,  has  been  already  mentioned, 
as  has  one  of  separation  of  the  lower  epiphysis  of  the  tibia,  quoted  by  Holmes 
from  E.  W.  Smith.  Stimson^  has  reported  to  the  ^ew  York  Surgical  Society 
the  case  of  a  child,  aged  eighteen  months,  run  over  by  a  horse-c^r,  in  whom 
the  upper  epiphysis  of  the  tibia  was  cleanly  separated  ;  the  upper  end  of  the 
shaft  was  denuded  of  periosteum,  which  was  adherent  to  the  epiphyseal 
fragment.  A  specimen  of  separation  of  the  upper  epiphysis  of  the  tibia,  from 
a  crush  of  the  leg  which  required  amputation,  is  figured  by  Ashhurst.^  The 
original  is  in  the  Museum  of  the  Episcopal  Hospital.  Another  case,  in  a 
boy  of  seventeen,  has  been  placed  on  record  by  Quain  f  the  lower  epiphysis 
was  detached,  the  boy  falling  with  his  foot  doubled  under  him.  Martin^ 
reports  a  case  of  compound  separation  of  the  lower  epiphysis  of  the  tibia, 
which  may  be  mentioned  here,  although  the  fibula  was  also  fractured  about 
four  inches  above.  The  patient,  a  German  boy,  eleven  years  old,  fell  from 
about  half  the  height  of  a  telegraph  pole.  "  The  distal  end  of  the  shaft  of 
the  tibia  had  been  separated  from  the  epiphysis,  and  was  protruding  through 
the  integuments.  It  had  been  thrust  into  the  hard  frozen  earth,  friction 
with  which  had  stripped  the  periosteal  covering  of  the  bone  from  its  entire 
external  surface  for  the  space  of  at  least  one  and  three-quarter  inches.  The 
peculiar  stellate  radiations  of  the  extremity  of  the  shaft  where  it  joins  the 
epiphysis  were  found  to  be  perfect,  when  the  dirt  which  had  been  packed 
into  them  had  been  removed."    The  boy  recovered  perfectly  in  two  months. 

Eeference  has  already  been  made,  in  the  early  part  of  this  article,^  to 
sprain  fractures."  Besides  the  instances  there  mentioned,  a  very  instructive 
account  is  quoted  by  Hulke^  from  Dr.  Hutton,  with  a  representation  of  the 
specimen,  of  detachment  of  the  spine  and  central  portion  of  the  head  of  the 
tibia,  with  part  of  its  left  articular  surface,  the  fragment  remaining  adherent 
to  the  anterior  crucial  ligament.    The  injury  was  sustained  in  wrestling. 

The  symptoms  of  fracture  of  the  tibia  are  not  always  very  marked.  Although 
the  uninjured  fibula  is  not  strong  enough  to  sustain  the  weight  of  the  body, 
it  is  sufficiently  so  to  prevent  any  great  separation  between  the  fragments  of 

>  London  Med.  Record,  May  27,  1874  ;  from  Gazz.  Med.  Ital.  Lomb.,  28  Marzo. 

2  Australian  Med.  Journal,  1882  ;  quoted  in  Index  Medicus  for  May.  1883. 

3  Med.  Record,  July  15,  1882. 

4  Principles  and  Practice  of  Surgery,  3d  ed.  page  269,  Figs.  132,  133.  Philadelphia,  1882. 
6  British  Med.  .Journal,  Aug.  31,  18()7  ;  Holmes's  System  of  Surgery,  3d  ed.,  vol  i.  p.  1039. 

6  Boston  Med.  and  Surg.  Journal,  Sept.  27,  1877.  7  See  page  19. 

s  Holmes's  System  of  Surgery,  3d  ed.,  vol.  i.  p.  1039  ;  the  original  account  is  in  the" Dublin 
Hospital  Gazette  for  1846. 


FRACTURES  OF  THE  BONES  OF  THE  LEG. 


253 


the  tibia,  and  the  deformity  is  hence  limited.  Some  projection  of  the  edge 
of  one  or  the  other  fragment,  generally  the  upper,  can  be  felt  on  passing  the 
fingers  along  the  bone,  and  this  is  apt  to  be  more  marked,  the  nearer  the 
fracture  is  to  either  end  of  the  bone.  Haj's,  however,  has  reported^  a  case 
of  fracture  of  the  internal  malleolus,  clearly  defined,  without  any  displace- 
ment. The  pain  is  for  the  most  part  severe  enough  to  forbid  attempts  at 
standing  or  walking.  Crepitus  may  be  felt,  and  decidedly,  although  the 
fragments  may  be  but  slightly  movable  upon  one  another.  Swelling  and 
eccliymosis  are  apt  to  ensue,  just  as  in  fractures  of  both  bones;  and  even 
although  the  fibula  is  not  broken,  it  may  be  bruised,  so  that  this  symptom 
will  present  itself  on  the  outer  side  of  the  leg  as  well  as  in  the  neighborhood 
of  the  more  serious  injury. 

The  diagnosis  may  be  made  out  clearly  enough  as  regards  the  fracture  ot 
the  tibia,  but  it  is  by  no  means  always  easy  to  determirie  whether  or  not  the 
fibula  has  also  given  way.  On  this  point  it  will  be  better  for  the  surgeon  to 
restrain  his  curiosity ;  if  mobility  be  not  at  once  detected,  it  sbould  not  be 
vigorously  or  persistently  sought  for.  In  any  case  of  doubt,  the  prudent 
course  is  to  assume  the  probability  of  fracture. 

When  the  tibia  alone  is  broken,  the  tixatmeM  is  essentially  the  same  as  that 
of  fracture  of  both  bones,  and  need  not  be  again  detailed.  N^on-union  is  very 
rare  in  these  cases,  by  reason  of  the  support,  slight  as  it  would  seem  to  be, 
afi:brded  by  the  unbroken  fibula ;  yet  Schiiller  has  reported^  an  instance  in 
which  this  condition  was  due  to  the  interposition  of  the  tibialis  anticus  ten- 
don between  the  fragments ;  the  patient,  a  healthy  German  woman,  aged 
forty,  had  been  run  over  by  a  wagon  ;  subperiosteal  resection  Avas  performed, 
and  afterward  the  periosteum  was  suiured,  with  the  result  of  obtaining  com- 
plete bony  union,  with  very  little  shortening,  in  four  months.  Sometimes 
consolidation  takes  place  very  rapidly.  Schweich^  relates  the  case  of  a  peasant, 
aged  forty,  whose  tibia  was  fractured  transversely  at  about  its  middle,  pro- 
ducing obvious  displacement.  A  starched  bandage  was  applied,  and  the  re- 
porter ceased  his  attendance  on  the  sixth  day.  The  patient  walked  in  his 
room  on  the  t^velfth  day,  and  returned  to  his  work  on  the  fourteenth.  On  the 
twenty-fifth  he  called  on  his  surgeon,  and  exhibited  a  well-formed  callus. 

Fracture  of  the  fibula  alone  may  be  produced  by  direct  violence,  at  any 
point ;  when  due  to  indirect  force,  it  is  generally  seated  within  two  or  three 
inches  of  the  external  malleolus.  In  the  former  class  of  cases  the  mechanism 
is  sufiaciently  obvious ;  in  the  latter  it  admits  of  some  question,  Avhich  is, 
however,  not  of  serious  importance.  It  may  simply  be  said  here,  that  it  is 
probable  that  sometimes,  as  when  the  foot  is  brought  very  forcibly  into 
abduction,  so  that  the  sole  is  turned  outward,  the  tarsal  bones  are  pushed 
against  the  malleolus  so  as  to  bend  the  fibula  toward  the  tibia,  and  cause  it 
to  break  at  its  w^eakest  point.  On  the  other  hand,  wdien  the  foot  is  violently 
adducted,  so  as  to  turn  the  sole  inward,  the  stress  upon  the  external  lateral 
ligament  may  be  such  as  to  bow  the  fibula  outward,  and  oause  it  to  yield  in 
the  opposite  direction,  but  at  the  same  point — possibly  a  little  lower  down. 
Wagstafte^  has  reported  two  cases  in  which,  by  a  twisting  movement,  the 
lower  end  of  the  fibula  was  split  longitudinally,  and  a  fragment  detached 
which  became  rotated  and  wedged  against  the  tibia  so  firmly  that  its  re})lace- 
ment  was  found  impossible.    In  one,  recovery  took  place,  though  Avalking 

^  Am.  Journal  of  tlie  Med.  Sciences,  Aug.  1837. 

2  Quoted  in  the  London  Med.  Record,  Dec.  15,  1878,  from  the  Gaz.  Hebdomadaire,  12  Juillet. 
'  Am.  Journal  of  the  Med.  Sciences,  Oct.  1848  ;  from  Caspar's  Wochenschrift. 
*  St.  Thomas's  Hospital  Reports,  vol.  vi. 


254 


INJURIES  OF  BONES. 


was  difficult ;  in  the  other,  the  patient  dying  in  thirteen  hours,  the  con- 
dition was  verified  by  dissection. 

When  the  fibula  gives  way  by  extreme  abduction,  there  may  be  either  a 
rupture  of  the  internal  lateral  ligament,  or  a  tearing  off  of  the  tip  of  the  inner 
malleolus — sometimes  of  a  larger  portion.  When  the  opposite  condition 
obtains,  the  malleolus  may  be  broken  ofl'  by  the  forcible  impact  of  the  tarsal 
bones  against  it.  But  these  cases  have  already  been  discussed  under  the  head 
of  Pott's  fracture.^ 

The  symptoms  of  fracture  of  the  fibu«la  are  occasionally  obscure.  Some- 
times the  patient  can  walk,  but  there  is  always  some  pain,  by  reason  of  the 
fragments  irritating  the  muscles,  or  by  the  slight  strain  brought  to  bear  upon 
the  broken  part  in  the  balancing  motion  of  which  walking  so  largely  consists. 
Pain  on  pressure  is  alwa^^s  present,  and  swelling  and  ecchymosis  are  very  apt 
to-occur.  Crepitus  is  generally  very  slight,  on  account  of  the  small  size  of 
the  bone,  and  there  may  be  no  perceptible  deformity. 

Keen^  has  pointed  out,  as  a  symptom  of  fracture  in  the  lower  third  of  this 
bone,  a  widening  of  the  ankle,  allowing  of  motion  to  a  more  than  normal 
degree  of  the  astragalus  between  the  malleoli.  This  can  be  developed  by 
grasping  the  leg  above  the  ankle,  at  about  the  supposed  seat  of  fracture,  and 
then  with  the  other  hand  taking  hold  of  the  astragalus  itself.  Malgaigne^ 
speaks  of  the  widening  of  the  inter-malleolar  space,  but  only  very  casually. 
Fractures  of  the  fibula  are  sometimes  attended  with  other  serious  symptoms, 
especially  when  the  upper  portion  of  the  bone  is  involved.  Duplay^  has 
reported  two  such  cases,  in  woi'kmen  caught  in  machinery  bands  and  thrown 
against  a  wall.  Among  many  other  lesions,  "  there  was  found  above  the 
ordinary  position  of  the  head  of  the  fibula  a  bony  prominence,  immovable, 
continuous  with  the  tendon  of  the  biceps.  Below  there  was  a  manifest  de- 
pression A  few  days  later,  a  paralysis  of  the  extensors  of  the  foot 

and  of  the  peronei  muscles  was  noted,  due  doubtless  to  lesion  of  the  external 

popliteal  nerve  In  one  case  the  diagnosis  was  verified  post  mortem; 

the  other  man  left  the  hospital  after  several  months,  the  paralysis  remaining, 
as  it  still  does."  M.  Perrin  mentioned  a  similar  case  in  a  rider  whose  horse 
fell  with  him,  and  caught  his  right  leg  beneath  him  for  a  moment.  There 
was  arrachement "  of  the  head  of  the  fibula,  and  very  considerable  diastasis 
of  the  knee-joint,  with  some  etFusion.  Complete  aneesthesia  and  paralysis  of 
the  anterior  and  outer  part  of  the  leg  ensued.  The  ultimate  result  is  not 
stated.  Callender*  mentions  two  cases  of  compound  fracture  of  the  head  of 
the  fibula,  in  both  of  which  amputation  became  necessary  on  account  of  the 
injury  inflicted  on  the  peroneal  nerve.  BarwelP  has  recorded  an  instance  in 
which  fracture  of  the  fibula  was  followed  by  the  development  of  malignant 
disease.  In  the  majority  of  cases,  however,  fractures  of  this  bone  unite 
favorably,  and  the  functions  of  the  limb  are  early  and  completely  restored. 

As  to  the  treatment  of  fractures  of  the  fibula,  it  may  often  be  almost  iden- 
tical with  that  of  other  fractures  of  the  bones  of  the  leg.  When  there  is  no 
marked  displacement,  the  limb  may  be  simply  kept  at  rest  in  a  fracture-box, 
or  done  up  with  side  splints,  or  with  the  Bavarian  splint.  If  there  is  a 
strong  tendency  to  either  eversion  or  inversion  of  the  foot,  it  may  be  cor- 
rected by  placing  a  single  long  splint  on  the  side  toward  which  the  foot  is 

1  A  very  elaborate  memoir  on  fractures  of  the  fibula  was  published  by  Maisonneuve  in  the 
Archives  G(inerales  de  Medecine,  for  1840,  and  was  republished  in  his  Clinique  Chirurgicale,  tome 
i.  Paris,  18G3.    The  reader  may  consult  it  with  advantage, 

2  Pliiladelphia  Med.  Times,  Aug.  15,  1872.  »  Traite  des  Fractures,  etc.,  tome  i.  p.  813. 

4  Gaz.  Med.  de  Paris,  17  Avril,  1880. 

5  St.  Bartholomew's  Hospital  Reports,  1870.        ^  British  Med.  Journal,  Feb.  11,  1882. 


FRACTUKES  OF  THE  BONES  OF  THE  FOOT. 


255 


twisted,  with  a  well-adjusted  pad  or  long  wedge-shaped  compress  to  push  the 
toot  outward  or  inward  as  the  case  may  be. 

Fractures  of  the  Bones  of  the  Foot. 

Fractures  of  the  tarsal  bones  are  not  of  very  common  occurrence.  Those 
of  the  astragalus  and  calcaneum  are  the  only  ones  which  need  be  considered 
separately,  although  the  other  bones  may  be  crushed,  as  in  cases  of  railroad 
accident,  or  of  other  very  great  violence  applied  to  the  ankle — the  fall  of  a 
heavy  stone  upon  it,  for  instance.  Such  fractures  are  very  apt  to  be  compound, 
or  to  be  attended  with  so  much  damage  to  the  soft  parts  that  amputation  is 
inevitable. 

Fractures  of  the  astragalus  are  very  possibly  more  frequent  than  has  been 
suspected,  since  they  may  easily  escape  recognition,  and  be  regarded  simply 
as  severe  sprains.  Lonsdale^  mentions  a  case  in  which  the  patient  jumped 
from  a  height,  alighting  on  his  feet ;  there  was  no  deformity,  and  the  ankle 
was  supposed  to  be  badly  sprained.  Intlanm:iation  of  the  joint  ensued,  and 
the  man  died  on  the  twelfth  day,  when,  on  dissection,  the  astragalus  was 
found  to  be  split  in  two  or  three  directions.  Here  it  seems  to  me  that  the 
violence  was  direct,  although  exerted  through  the  medium  of  the  os  calcis. 
In  a  case  recorded  by  Croly,^  the  fracture  was  due  to  the  patient  catching  his 
foot  in  the  stirrup  as  he  fell  from  a  horse ;  and  here  the  force  was  jDrobably 
indirect.  Sheppard^  observed,  in  the  dissecting-room,  four  specimens  of  frac- 
ture affecting  the  outer  projecting  edge  of  the  groove  for  the  tendon  of  the 
Hexor  longus  pollicis ;  in  three  the  detached  piece  was  connected  by  fibrous 
tissue  with  the  rest  of  the  bone,  and  in  one  osseous  union  had  taken  place. 
These  specimens  were  without  history  ;  it  would  seem  proper  to  place  them 
in  the  category  of  "  sprain-fractures."  i^eilP  has  recorded  an  instance  in 
which  the  posterior  extremity  of  the  bone  was  broken  off,  and  remained  un- 
united. 

Displacement  of  the  broken  portion  sometimes  takes  place.  Bryant  says, 
"  I  have  recently  removed  from  the  inner  aspect  of  the  ankle  of  a  man  the 
upper  half  of  the  astragalus,  that  had  been  fractured  six  months  previously, 
and  displaced  so  as  to  present  its  upper  articular  facet  inward."  This  case 
had  been  previously  supposed  by  the  surgeon  in  attendance  to  be  a  fracture 
of  the  tibia  and  fibula.  Vollmar^  reports  an  instance  of  fracture  of  the  head 
(>f  the  astragalus,  in  a  stout  countryman  who  fell  from  a  height  of  eight  or 
nine  feet,  and  presented  a  bony  prominence  in  the  arch  of  the  left  foot.  In 
front  of  the  articulating  extremity  of  the  tibia  and  fibula  there  lay,  under 
the  raised  integuments,  a  bony  swelling,  separated  by  a  deep  depression  from 
-the  outer  malleolus."  'No  hollow  could  be  detected.  Eeplacement  was  effected 
by  extension,  and  in  four  weeks  the  patient  was  able  to  walk  about. 

MacCormac^  has  reported  a  fracture  of  the  neck  of  the  bone,  the  posterior 
portion  only  being  dislocated,  so  that  the  trochlear  surface  ^vas  directed  in- 
ward and  slightly  backward ;  the  inner  malleolus  was  als*o  detached.  He 
refers  to  a  similar  case  seen  by  LeGros  Clark.  Other  cases  of  fracture  with 
dislocation  have  been  recorded  by  I^'orris''  and  John  Ashhurst,  Jr.^  Goyder^ 

'  Op.  cit.,  p.  531.  2  British  Med.  Journal,  March  18,  1882. 

3  Medical  News,  Aug.  5,  1882  ;  from  Lancet,  July  1. 

*  Am.  Journal  of  the  Med.  Sciences,  Julj,  1849. 

6  Med.  Times  and  Grazette,  Jan.  27,  1855  ;  from  Zeitschrift  fiir  Chirurgie  und  Greburtsk.,  1854. 

5  Trans,  of  Path.  Society  of  London,  voL  xxvi.  1875, 

'  Am.  Journal  of  the  Med.  Sciences,  August,  1837. 

8  Ibid.,  April,  1862.  9  Med.  Times  and  Gazette,  Oct.  15,  1882. 


256 


INJURIES  OF  BONES. 


has  reported  a  case  of  compouod  comminuted  fracture  of  the  astragalus,  the 
malleoli  being  unbroken  ;  recovery  took  place  with  a  movable  joint.  In 
a  case  seen  by  Bryant,^  a  compound,  complicated  fracture  of  the  head  of  the 
bone  was  produced  by  a  fell  from  a  height  of  some  ten  or  twelve  feet,  the 
patient  alighting  on  his  feet.  The  head  of  the  bone  was  removed,  and  the 
body  of  it  restored  to  its  normal  position.  Recovery  ensued  "  with  some  use 
of  the  limb." 

The  sym.jptoms  of  fracture  of  the  astragalus  are  only  obscure  when  there  has 
been  great  violence,  and  swelling  occurs  rapidly.  If  there  is  luxation  of 
either  portion,  the  deformity  will  call  attention  to  it,  when  crepitus  will 
probably  be  readily  detected.  When  the  bone  retains  its  place,  there  will 
be  tenderness  on  pressure  across  it,  and  crepitus  may  be  perceptible.  Walk- 
ing, or  standing  on  the  injured  foot,  will  be  impossible.  Swelling  and  ecchy- 
mosis  will  almost  certainly  come  on  ;  but  a  patient  in  my  wards  at  the 
Episcopal  Hospital,  in  1882,  presented  neither  of  these  symptoms,  although 
the  line  of  fracture  could  easily  be  felt,  and  crepitus  was  distinct. 

The  treatment  in  uncomplicated  cases  consists  simply  in  keeping  the  foot 
at  rest  and  preventing  or  allaying  inflammation.  When  there  is  luxation,  it 
may  be  a  question  whether  the  fragment  should  be  removed  or  left  to  itself, 
if  reduction  is  found  to  be  impossible.  In  i^'orris's  case  one  fragment  was 
excised,  and  the  other  was  allowed  to  remain ;  it  became  carious  and  loose, 
and  was  removed,  but  the  adjoining  bones  also  became  carious,  and  at  length 
amputation  of  the  leg  was  performed,  with  a  fatal  result.  In  deciding 
the  question  of  operation,  the  patient's  age,  habits,  and  constitution  must  be 
taken  into  account,  the  prospects  of  a  young  and  sound  person,  who  has 
never  been  debilitated  by  excesses  or  hardships,  being  much  better  than  those 
of  an  old,  or  dissipated,  or  broken-down  subject. 

When  the  fracture  is  merely  compound,  the  surgeon  should  be  guided  by 
general  principles. 

So  great  a  probability  of  permanent  stiffening  of  the  ankle  exists  in  all 
these  cases,  that  a  very  guarded  prognosis  should  be  given. 

Fracture  op  the  os  calcis  was  formerly  supposed  to  be  always  the  result 
of  muscular  action  ;  but  it  is  now  known  to  have  occurred  in  a  number  of 
instances  by  crushing.  I  believe  that  the  two  causes  are  apt  to  be  combined,  the 
tension  of  the  muscles  of  the  calf  acting  strongly  upon  the  posterior  portion  of 
the  bone,  and  exerting  a  leverage  which  must  aid  in  overcoming  the  resistance 
of  its  tissue  to  force  applied  from  without.  On  examination  of  a  vertical,  antero- 
posterior section  of  a  well-developed  calcaneum,  it  will  be  seen  that  the 
arrangement  of  the  cancellous  structure  is  principally  in  radiating  lines  from 
the  upper  articular  surfaces ;  and  that  although  this  is  admirably  adapted  to 
meet  the  stress  ordinarily  sustained,  it  makes  the  bone,  crushing  being  once 
begun,  very  liable  to  be  rent  apart. 

The  accident  which  has  most  frequently  given  rise  to  this  injury  is  a  fall 
from  a  height,  the  patient  alighting  on  the  heel.  Lawrence^  saw  a  case  in 
which  the  patient  had  jumped'from  a  stage-coach,  and  fractured  the  posterior 
part  of  the  bone ;  the  fragment  was  drawn  upward  by  the  muscles  of  the 
calf,  but,  upon  pulling  it  into  place,  crepitus  could  be  readily  elicited.  The 
case  did  well,  although  the  patient  halted  somewhat  in  walking. 

CostancG^  met  with  a  case  in  which  a  woman,  aged  fifty,  had  her  heel 
crushed  under  an  overturned  coach,  and  the  fractured  portion  of  the  calca- 


!  Lancet,  June  2,  1883.  2  Lancet,  May  29,  1830. 

*  Am.  Journal  of  the  Med.  Sciences,  Nov.  1829  ;  from  Midland  Med.  and  Surg.  Reporter,  May, 
1829. 


FRACTURES  OF  THE  BONES  OF  THE  FOOT. 


257 


neura  was  drawn  up  "  as  high  as  five  inches."  It  could  not  be  replaced,  and 
the  patient,  after  extensive  inflammation  and  sloughing  of  the  soft  pa4'ts, 
recovered  with  the  fragment  firmly  adherent  in  its  false  position,  and  its 
place  filled  by  soft  "  cellular  substance." 

South^  says  that  in  the  Museum  of  St.  Bartholomew's  Hospital  there  is  a 
specimen  of  horizontal  fracture  of  the  tuberosity  of  the  calcaneum,  ^'extending 
to  its  hinder  upper  joint-surface,  where  it  is  continued  upwards  at  nearly  a 
right  angle  ;  the  fractured  piece  does  not  appear  to  have  been  actually  pulled 
out  of  place."    He  knew  nothing  of  its  history. 

He  relates  a  fatal  case  of  compound  fracture  of  this  bone,  under  his  own 
care,  and  quotes  another  seen  by  Lisfranc,  in  which  union  was  first  fibrous, 
and  afterwards  bony.^ 

Sometimes  both  calcanea  are  simultaneously  broken.  Of  this  Malgaigne 
says  that  he  himself  saw  an  instance,  and  that  one  was  reported  by  Voille- 
mier.^  Fifield^  records  the  case  of  a  robust  German,  who  fell  about  eighteen 
feet,  alighting  on  his  heels  ;  in  the  right  foot  a  compound  comminuted  fracture 
of  the  inner  side  of  the  calcaneum  was  at  once  detected,  but  in  the  left  there 
was  simply  great  swelling.  About  a  month  afterward,  the  swelling  having 
subsided,  a  plaster  bandage  was  applied,  and  in  less  than  an  hour  the  patient 
died  from  pulmonary  embolism.  The  left  os  calcis  was  then  found  to  be 
completely  smashed. 

Fractures  of  the  os  calcis  by  muscular  action  have  been  reported  by  Coote,* 
in  a  woman  aged  fifty-five,  and  by  Anningson,^  in  a  woman  aged  forty-two. 
Stimson^  presented  to  the  ^ew  York  Surgical  Society  a  specimen  supposed 
to  be  of  this  character.  The  accident  had  occurred  eight  years  previously,  and 
the  history  of  it  was  somewhat  obscure.  It  appeared  that  the  patient,  a  man 
then  aged  forty-five,  had  been  knocked  down  by  a  passing  wagon.  "  The 
fragment  was  the  portion  to  which  the  tendo  Achillis  was  attached,  at  least 
partially.  It  was  more  than  an  inch  in  length,  and  about  three-fourths  of 
an  inch  in  breadth.  On  its  outer  side  the  periosteum  was  complete ;  on  the 
inner  side  there  was  a  growth  of  bone  which  presented  the  appearance  of 
having  been  the  result  of  reparative  process.  The  fragment  had  united  with 
the  bone  at  its  upper  border,  but  was  about  half  an  inch  anterior  to  its  origi- 
nal position." 

It  seems  to  me  that  in  some  of  these  instances  (the  last  mentioned,  for  ex- 
ample), the  lesion  might  be  properly  ranked  among  "sprain-fractures." 

Although  it  might  seem  very  natural  to  expect  that  both  the  astragalus 
and  the  calcaneum  would  often  suffer  together,  such  is  very  rarely  th.e  case. 
I  have,  however,  seen  two  specimens  of  this  kind,  one  derived  from  a  case  of 
railroad  injury,  and  the  other  said  to  have  been  caused  by  a  fall  on  the  heel. 
Of  course  in  the  crushes  due  to  falls  from  great  heights,  to  the  passage  of 
wheels,  to  entanglement  in  machinery,  or  to  the  fall  of  a  heavy  body  upon 
the  part,  there  can  be  no  limit  set  to  the  damage  likely  to  be  done.  In  the 
Museum  of  the  Pennsylvania  HospitaP  there  is  a  specimen  in  which  "  the 
inner  malleolus  is  broken  off',  and  there  is  a  transverse  but  fissured  fracture 
of  the  fibula  two  inches  above  the  malleolus.  A  small  piece  has  been  broken 
oft'  from  the  postero-inferior  part  of  the  astragalus,  and  an  irregular  trans- 

1  Translation  of  Chelius's  Surgery,  vol.  1.  p.  640. 

*  See  Archives  Grenerales  de  Medecine,  Janvier,  1828. 

*  Malgaigne  gives  no  reference  for  this  case,  and  I  have  not  been  able  to  find  it. 

4  Medical  News,  Feb.  3,  1883.  5  Lancet,  April  28,  1866. 

6  British  Med.  Journal,  .Tan.  26,  1878.  I  find  also  in  the  Index  Medicus  for  July,  3  883,  the 
following  reference  :  Saussol,  Un  cas  de  fracture  du  calcaneum  par  arrachement ;  Graz,  Hebd.  des 
Sciences  Med.  de  Montpellier-. 

7  Annals  of  Anatomy  and  Surgery,  July,  1883  ;  also  Medical  News,  Feb.  3,  1883. 

8  Catalogue,  p.  45  ;  No.  1189. 

VOL.  IV. — 17 


258 


INJURIES  OF  BONES. 


verse  fracture  of  the  os  calcis  has  occurred  half  an  inch  below  its  articulation 
with  the  astragalus."  The  patient  had  fallen  from  a  second-story  window ; 
he  refused  amputation,  and  died  of  pyaemia,  after  erysipelas,  sloughing, 
abscess,  and  secondary  hemorrhage,  for  which  the  anterior  tibial  artery  was 
tied.. 

Fracture  of  the  lesser  process,  or  sustentaculum  tali,  has  been  studied  and 
described  by  Abel.^  It  is  said  to  be  due  to  falls  on  the  sole  of  the  foot, 
or  to  forced  inversion  of  the  foot,  so  that  the  sole  looks  inward.  The  me- 
chanism of  such  an  injury  is  obvious. 

The  symptoms  of  fracture  of  the  os  calcis,  as  may  appear  from  what  has 
already  been  said,  are  not  always  such  as  to  lead  to  its  easy  recognition.  Of 
course  there  is  pain,  inability  to  bear  weight  on  the  heel,  and  tenderness  on 
pressure,  while  sometimes  the  posterior  fragment  is  drawn  upward  by  the 
muscles  of  the  calf  acting  through  the  tendo  Achillis.  But  Malgaigne  says 
that  he  mistook  the  lesion,  in  the  first  case  seen  by  him,  for  fracture  of  the 
fibula,  and  that  the  same  error  was  fallen  into  by  Voillemier  as  well  as  by 
Bonnet ;  and  it  is  very  possible  that  surgeons  of  less  experience  have  been 
deceived  in  like  manner. 

Abel  says  that  when  the  sustentaculum  tali  is  detached,  any  attempt  to 
stand  or  walk  everts  the  foot,  giving  the  ankle  the  valgus  position ;  crepitus 
and  abnormal  mobility^  although  present,  may  be  masked  by  the  sw^elling ; 
but  the  astragalus  and  tibia  are  displaced  somewhat  backward,  lessening  the 
distance  between  the  posterior  border  of  the  inner  malleolus  and  the  tendo 
Achillis. 

The  course  of  these  cases  can  hardly  be  definitely  laid  down.  Consolida- 
tion would  appear  to  take  place  only  very  slowly,  and  it  is  apt  to  be  a  long 
time  before  the  foot  becomes  useful  again.  I  think  that  sometimes,  in  the 
cases  of  caries  or  necrosis  of  the  os  calcis,  which  are  met  with  in  children, 
there  may  have  been  in  reality  an  unrecognized  fracture,  the  nutrition  of  the 
bone  being  irretrievably  damaged.    The  prognosis  must  always  be  doubtful. 

As  to  the  treatment^  it  must  consist  in  obviating  displacement  as  far  as  pos-. 
sible,  by  keeping  the  foot  in  a  proper  position,  attention  being  at  first  paid, 
of  course,  to  keeping  down  inflammatory  action.  The  best  dressing  for  these 
cases  is  a  splint  along  the  front  of  the  leg,  extending  as  far  as  the  roots  of  the 
toes,  and  having  an  obtuse  angle  corresponding  to  the  instep  ;  it  may  be  kept 
in  place  by  an  ordinary  roller,  and  afterward  by  a  plaster  or  silicate  bandage. 
The  old  plan  of  putting  a  slipper  on  the  foot,  and  attaching  it  by  a  band  to  a 
fillet  around  the  lower  part  of  the  thigh,  is  open  to  the  grave  objection  that 
the  pressure  of  the  heel  of  the  slipper  would  itself  tend  to  push  the  posterior 
fragment  out  of  place. 

Fractures  of  the  other  tarsal  bones  can  hardly  occur  except  from  crush- 
ing force,  and  present  no  features  which  need  be  dwelt  upon.  I  have  never 
seen  such  a  case,  except  when  the  w^hole  ankle  was  smashed,  and  when  ampu- 
tation was  the  only  resource. 

Fractures  of  the  metatarsal  bones  result  only  from  crushing,  as  by  heavy 
weights  falling  upon  the  foot,  and  are  nearly  always  compound.  If  amputa- 
tion is  not  demanded,  the  only  course  open  to  the  surgeon  is  to  allay  inflam- 
mation, and  to  keep  the  foot  at  rest  until  union  shall  have  occurred.  Any 
displacement  of  the  fragments  must  be  remedied  as  far  as  possible  by  careful 
manipulation;  the  result  is  apt  to  be  favorable.  Malgaigne  says  :  "I  recently 
had  to  treat  a  carter,  who  was  thrown  down  under  his  vehicle,  and  had  the 

1  British  Med.  Journal,  Nov.  9,  1878  ;  from  Arch,  fiir  klin.  Chirurgie. 


CONTUSIONS  OF  BONES. 


259 


three  middle  metatarsal  bones  broken  by  the  wheel  passing  over  them.  The 
anterior  fragments  were  very  greatly  depressed;  there  was  a  lacerated  wound 
on  the  back  of  the  foot,  and  the  inflammation  was  most  intense.  It  was 
therefore  impossible  to  remedy  the  displacement,  and,  indeed,  the  saving  of 
the  foot  could  hardly  be  hoped  for.  The  patient  recovered,  and  could  plant 
his  foot  very  firmly  on  the  ground,  but  the  great  projection  of  the  upper 
fragments  at  the  back  of  the  foot  obliged  him  to  wear  a  peculiarly-shaped 
shoe."  Hammond^  reports  a  case  of  compound  comminuted  fracture  of  the 
right  ankle  as  well  as  of  the  first  and  second  metatarsal  bones  of  the  left  foot, 
iif  which  the  patient  made  a  good  recovery  without  amputation.  Boyd, 
however,  has  recorded^  the  case  of  a  woman,  aged  fifty-nine,  with  fracture  of 
the  four  outer  metatarsal  bones,  followed  by  thrombosis  of  the  femoral  artery, 
pulmonary  embolism,  and  death.  Such  cases  are  not  very  uncommon  among 
the  broken-down  subjects  of  hospital  treatment. 

Fractures  of  the  phalanges  of  the  toes  are  very  rare,  except  from  great 
direct  violence.  Yet  I  have  several  times  seen  them  produced  by  accidents 
to  persons  bathing  at  the  seashore,  without  serious  injury  to  the  soft  parts, 
the  pain,  crepitation,  and  abnormal  mobility  placing  the  character  of  the 
lesion  beyond  doubt.  In  these  cases  the  treatment  is  the  same  as  for  like 
injuries  to  the  phalanges  of  the  fingers,  although  the  small  size  of  the  parts 
renders  the  aplication^of  splints  at  the  same  time  more  difiicult  and  less  need- 
ful. A  little  bit  of  pasteboard  may  be  laid  along  the  back  of  the  toe,  and 
bound  on  with  a  strip  of  adhesive  plaster.  I  have  never  seen  permanent 
lameness  follow  a  hurt  of  this  kind. 

Compound  fractures  of  the  toes,  as  a  rule,  require  amputation ;  but  there  is 
room  for  the  exercise  of  judgment  in  deciding  this  question,  as  nature  will 
sometimes  do  more  in  the  way  of  repair  than  might  at  first  be  thought  likely 
or  even  possible.  The  risk  of  tetanus  from  such  injuries  ought  never  to  be 
wholly  overlooked. 

Other  Injuries  of  Bones. 

Besides  fractures,  the  bones  are  liable  to  other  forms  of  injury  concerning 
which  the  surgeon  should  not  be  ignorant. 

Contusions  of  bones  are  not  very  uncommon ;  and  although  the  soft  parts 
are  also  bruised,  and  the  soreness  in  them  masks  that  of  the  bone,  yet  there 
is  often  perceptible  for  a  long  time  a  deep-seated  tenderness  which  ^ives  ev  1 
dence  that  the  bone  has  suftered.  Such  injuries  generally  aftect  the  super- 
ficial bones,  and  especially  the  tibia,  which  is  very  apt  to  be  hurt  in  the  rough 
sports  of  boyhood.  As  a  rule  nature  repairs  the  damage  inflicted  in  this  way; 
but  occasionally  the  results  are  more  serious,  and  inflammation  may  ensue ; 
the  periosteum  may  swell,  and  necrosis  of  the  underlying  bony  substance,  or 
perhaps  osteitis,  may  follow.  In  rare  instances,  and  probably  only  where 
there  is  a  constitutional  vice,  the  nutrition  of  the  entire  bone  becomes  in- 
volved, and  its  inflammation  or  its  death  may  take  place.  Or,  if  the  dis- 
order be  more  localized,  an  abscess  may  form  in  the  cancellous  substance,  and 
give  rise  to  very  troublesome  symptoms. 

The  treatment  of  contusions  of  bone  consists  in  the  enforcement  of  rest, 
and  the  use  of  hot-water  dressings,  and  perhaps  leeches ;  but  it  is  seldom  that 

1  Trans,  of  the  New  Hampshire  Medical  Society,  1882,  p.  105. 

2  Trans,  of  the  Pathological  Society  of  London,  vol.  xxxiii.  1882. 


260 


INJURIES  OF  BONES. 


the  surgeon  is  called  upon  in  such  cases  until  the  more  serious  secondary 
symptoms  have  declared  themselves,  the  mode  of  managing  which  will  be 
elsewhere  detailed 


Incised  wounds  of  bone  sometimes  occur.  They  are  most  frequent  as  the 
result  of  accidents  m  saw-mills,  hut  are  occasionally  met  with  in  carpenters 
or  wood-cutters.  I  once  saw  an  old  man  who  had  fallen  with  his  knee  on  the 
upturned  edge  of  a  scythe,  which  had  cut  clean  through  the  patella,  and  laid 
the  joint  open  entirely  across.  Gross^  mentions  the  case  of  a  man,  aged  thirty- 
nine,  who  had  had  his  olecranon  severed  by  a  cut  with  a  butcher-knife;  the 
joint  was  of  course  laid  open,  and  there  was  free  bleeding.  Union  took  place 
with  anchylosis.  In  1876, 1  had  in  my  ward  in  the  Episcopal  Hospital,  a  man 
aged  twenty-five,  who  had  had  a  very  similar  injury  inflicted  ui:)on  him  with 
a  "drawing-knife;"  the  closure  of  the  wound  was  impossible,  and  I  excised 
the  entire  joint,  with  a  fairly  good  result,  although  the  motion  of  the  parts 
was  very  limited. 

Of  course  injuries  of  this  kind  must  always  be  compound,  and  their  gravity 
will  vary  according  to  the  seat  and  extent  of  the  damage  inflicted  on  the 
bone,  as  well  as  the  degree  to  which  the  soft  parts  are  involved.  If  a  limb 
be  cat  entirely  through,  the  question  will  necessarily  arise  whether  union  can 
take  place  or  not.  Some  marvellous  stories  are  told  of  cases  in  which  severed 
fingers  have  been  readjusted,  and  with  perfect  success  ;2  but  my  own  experi- 
ments in  this  way  have  uniformly  failed. 

^  The  treapnejit  must  be  adapted  to  the  circumstances  of  each  case.  Some- 
times it  will  consist  simply  in  arresting  hemorrhage,  closing  the  wound,  and 
putting  the  parts  at  entire  rest  by  means  of  splints  and  bandages ;  just  as  in 
compound  fractures.  Sometimes  amputation  will  be  clearly  indicated  ;  and 
sometimes,  as  in  my  case  above  mentioned,  excision  may  be  the  proper  course. 

Punctured  wounds  of  bone  have  been  met  with,  especially  in  Indian  war- 
fare. These  have  already  been  considered  at  sufficient  length  in  the  article 
on  Bayonet  and  Arrow  Wounds.^ 

I  once  myself,  in  making  an  autopsy,  sustained  a  punctured  w^ound  of  the 
second  phalanx  of  the  middle  finger ;  the  point  of  a  scalpel  penetrated  the 
bone,_  and  it  was  seven  months  before  the  w^ound  healed,  the  bone  itself 
remaining  s woollen  and  tender. 

^  Gunshot  wounds  of  bone  have  already  been  fully  discussed  m  the  article  on 
injuries  of  that  class.'' 

1  Op  cit.,  vol.  i.  p.  831.  . 

2  For  one  of  the  most  extraordinary,  in  which  the  forearm  is  said  to  have  been  cut  through  ali 
but  a  strip  of  skin,  and  to  have  healed  again  perfectly,  see  the  quotation  of  General  Hunter's 
case.  (Med.  and  Surgical  History  of  the  War  of  the  Rebellion.  Part  Second,  Surgical  Vol.  v. 
918,  note.)  °  ' 

3  See  VoL  II.  pp.  105  et  seg.  <  See  Vol.  II.  pp.  125,  147  et  seq. 


INJURIES  OF  THE  BACK, 


INCLUDING  THOSE  OF  THE  SPINAL  COLUMN,  SPINAL  MEMBRANES, 

AND  SPINAL  CORD. 

BY 

JOHN  A.  LIDELL,  A.M.,  M.D., 

liATE  SURGEON  TO  BELLEVUE  HOSPITAL,  NEW  YORK  ;    ALSO   LATE  SURGEON  U.  S.  VOLUNTEERS  IN  CHARGE 
OF  STANTON  U.  S.  ARMY  GENERAL  HOSPITAL  ;  INSPECTOR  OF  THE  MEDICAL  AND  HOSPITAL 
DEPARTMENT  OF  THE  ARMY  OF  THE  POTOMAC,  ETC. 


The  region  whose  injuries  are  to  be  considered  in  this  article,  embraces 
the  posterior  part  of  the  neck,  chest,  abdomen,  and  pelvis,  or,  in  other  words, 
the  posterior  part  of  the  whole  trunk  excepting  the  head.  The  organs  con- 
tained in  this  region  are,  (1)  the  spinal  cord,  with  the  spinal  meninges  and 
the  roots  of  the  spinal  nerves ;  (2)  the  vertebral  column,  from  atlas  to  tip  of 
coccyx  inclusive ;  and  (3)  the  muscles  both  great  and  small  which  are 
attached  to  the  vertebrae,  together  with  the  integuments  that  cover  them. 

The  welfare  of  these  organs  is  a  subject  of  extremely  great  importance, 
inasmuch  as  their  integrity,  considering  them  as  a  unit,  is  essential  to  the 
very  existence  of  man  as  an  animal.  I  cannot  emphasize  this  point  in  any 
better  way  than  by  calling  attention  to  the  fact  that  the'  vertebral  column  is 
the  first  portion  of  the  skeleton  to  appear  in  man,  and  the  centre  around 
which  all  other  parts  of  the  skeleton  are  produced ;  that  the  spinal  cord 
is  the  first  formed  portion  of  the  nervous  system,  and  the  centre  to  which  all 
other  parts  of  the  nervous  system  are  appended;  and  that  the  chorda  dorsalis 
of  the  embryo  "  forms  the  basis  around  which  the  vertebral  column  is  deve- 
loped." At  first,  the  vertebral  column  is  a  simple  cartilaginous  tube  which 
surrounds  and  protects  the  primitive  trace  of  the  nervous  system  in  the  em- 
bryo;  but,  as  it  advances  in  growth  and  organization,  it  becomes  divided 
into  33  distinct  pieces  constituting  the  vertebrje ;  of  which  24  are  called  true 
and  9  false.  At  a  still  later  period,  the  false  vertebrpe  coalesce,  the  upper  5  of 
them  to  form  the  sacrum,  and  the  lower  4  to  constitute  the  coccyx,  the  process 
of  coalescence  being  completed  at  maturity  or  the  termination  of  growth. 
The  true  vertebrae,  however,  do  not  coalesce  ;  but,  placed  one  above  the  other, 
they  constitute  a  flexible  tubular  column,  composed  of  ring-shaped  bones 
alternating  with  lenticular  disks  of  firm  yet  elastic  intervertebral  substance, 
and  bound  together  by  broad,  thin  planes  or  bands  of  ligamentous  tissue, 
many  of  which  are  also  elastic.  The  vertebral  tube  is  lined  by  the  spinal 
dura  mater,  or  theca  vertebralis,  which  is  continuous  with  the  cerebral  dura 
mater  ahove  it,  and  contains  much  cerebro-spinal  fluid  in  which  the  spinal 
cord,  attended  by  large  plexuses  of  veins,  hangs  suspended  from  the  base  of 
the  brain  by  its  attachments  to  the  pons  Varolii,  as  it  were,  in  a  well.  The 
cerebro-spinal  or  sub-arachnoidean  fluid  also  keeps  up  a  constant  and  gentle 

( 261 ) 


262 


INJURIES  OF  THE  BACK. 


Fig.  851. 


pressure  upon  the  entire  surface  of  the  spinal  cord  as  well  as  upon  that  of 
the  hrain,  and  jdelds  with  the  greatest  facility  to  the  various  movements  of 
the  spinal  cord  and  spinal  column,  giving  at  the  same  time  to  the  delicate 
structures  of  the  cord  and  hrain  the  advantages  of  the  mechanical  principles 
so  usefully  applied  by  Dr.  Arnott  in  the  hydrostatic  bed.  Thus  we  find  that 
the  spinal  cord  is  protected  iu  a  truly  wonderful  manner  from  the  ill  eftects 
of  blows,  and  shocks,  and  pressure,  by  an  elastic,  fluid  medium  which  every- 
where surrounds  and  gentlj^  compresses  it. 

The  traumatic  lesions  of  the  back  naturally  arrange  themselves  in  three 
groups,  as  follows  : — 

I.  Injuries  of  the  integuments  and  muscles,  or  soft  parts  generally. 
II.  Injuries  of  the  vertebral  column. 

III.  Injuries  of  the  spinal  membranes,  spinal  cord,  and  spinal  nerves. 

For  the  purposes  of  study  and  description,  this  classification  of  the  trau- 
matic lesions  to  which  the  dorsum  of  the  trunk  is  exposed  presents  some 

advantages  which  are  quite  obvious, 
and,  therefore,  I  shall  follow  it  as  far 
as  may  be  found  se r viceable.  It  sh ould 
be  borne  in  mind,  liowever,  that  the 
examples  which  claim  the  surgeon's 
attention  in  practice  usually  illustrate 
at  least  two  of  these  forms  of  injury; 
and  that,  not  unfrequently,  all  three 
are  simultaneously  exhibited  in  the 
same  patient.  The  symptoms  and 
treatment  of  these  lesions  must  there- 
fore be  described  from  general  or  com- 
mon, as  well  as  from  specific  points  of 
view. 

From  most  writers  on  surgery,  inju- 
ries of  the  back  have  not  received 
that  degree  of  attention  which  their 
importance  j  ustly  demands.  This  neg- 
glect  may  have  arisen  on  the  one  hand 
from  undervaluing  the  functions  of  the 
spinal  cord  itself,  and  holding  it  to  be 
merely  an  appendage  of  the  brain,  or^ 
on  the  other  hand,  from  considering  the 
injuries  which  involve  the  vertebral 
column  and  spinal  cord,  in  general,  to 
be  hopeless  lesions  for  which  the  sur- 
geon's art  can  do  no  good.  ^N^everthe- 
less,  I  am  fully  persuaded  that  a  con- 
siderable share  of  even  the  least  pro- 
mising cases  are  susceptible  of  per- 
manent relief  by  judicious  treatment 
from  the  surgeon ;  and  I  am  supported 
in  this  view  by  the  extremely  large 
proportion  of  recoveries  which  has  resulted  from  the  attempts  to  reduce 
dislocations^  and  fractures  of  the  vertebrae  that  have  been  recorded.  For 
instance,  thirty-four  cases  are  mentioned  in  Dr.  Ashhurst's  tables,^  in  which 
reduction  was  attempted  by  various  appropriate  procedures,  and  recovery 


Posterior  view  of  the  vertebral  column,  ribs,  etc.,  the 
integuments  and  muscles  having  been  laid  open  and 
deflected  from  them.  (Sibson's  Medical  Anatomy,  PI. 
XII.) 


Injuries  of  the  Spine,  pp.  71-121.  Philadelphia,  1867. 


INCISED  AND  PUNCTURED  FLESH-WOUNDS  OF  TlfE  BACK. 


263 


ensued  in  all  but  four.  In  many,  the  successful  issue  of  the  efforts  at  reduc- 
tion was  indicated  by  an  audible  sound  or  a  snap."  In  several  the  paralysis 
was  instantly  relieved. 


I.  INJURIES  OF  THE  SOFT  PARTS. 


Incised  and  Punctured  Flesh-wounds  of  the  Back. 

Wounds  are  inflicted  with  cutting  and  puncturing  instruments  in  the  back 
part  of  the  neck,  chest,  abdomen,  and  pelvis,  by  accidents,  by  criminal  de- 
sign, and  in  war,  with  so  much  frequency  as  to  require  at  least  some  mention 
of  them  in  this  place.  For  instance,  "  punctured  and  incised  flesh-wounds 
of  the  back  were  exemplified  by  fifty-six  instances  [thiring  our  late  civil  war]^ 
of  which  twenty-one  were  cases  of  bayonet-stabs,  thirteen  of  sabre-cuts,  and 
twenty-two  of  punctures  and  incisions  by  sundry  weapons.  None  of  these 
cases  are  recorded  as  terminating  fatally,  though  in  six  the  result  has  not 
been  ascertained ;  forty-five  were  sent  to  duty,  and  five  were  discharged. 
Several  of  these  cases  were  examples  of  severe  though  not  dangerous  sword- 
wounds."^  Of  the  thirteen  examples  of  sabre-cuts,  twelve  were  received  in 
action.  The  bayonet-stabs,  however,  appear  to  have  been  inflicted  almost 
entirely  by  sentries,  or  by  provost-guards,  or  in  brawls,  or  through  accidents. 
But  one  example  is  specified  as  a  wound  received  in  action,  and  this  wound 
may  not  have  been  inflicted  by  the  enemy.  Sabre- wounds  of  the  back  are 
seldom  mentioned  in  the  literature  of  surgery.  No  instance  is  related  by 
either  Gathrie  or  Hennen.  Bilguer,  however,  gives  an  instance  that  occurred 
in  the  Seven  Years  War  (1756-63) :  A  cavalry  soldier,  J.  R.,  while  retreating 
and  leaning  over  his  horse's  neck,  received  two  cuts  in  the  lumbar  region.^ 
He  appears" to  have  recovered.  But  Morgagni  records  an  autopsy  in  a  case 
of  sabre-thrust  in  the  back.^ 

Incised  wounds  which  sever  to  a  considerable  extent  the  fasciculi  of  the 
trapezius,  latissimus  dorsi,  or  rhomboid  muscles,  are  apt  to  gape  widely  open. 
In  treating  such  wounds,  it  is  necessary,  after  stanching  the  bleeding  and 
removino;  the  coagula  and  all  other  foreign  bodies,  to  introduce  at  the  outset 
sutures  of  carbolized  silk,  which  are  antiseptic,  or  of  silver  or  iron  wire, 
which  are  also  antiseptic  ijer  se,  in  sufficient  number  and  at  sufiiciently  short 
intervals,  and  at  a  sufficient  depth,  to  bring  the  divideil  parts  into  complete 
apposition,  where  they  should  be  allowed  to  remain  until  the  union  is  com- 
plete. Under  this  plan  of  treatment,  with  quietude,  the  results  of  flesh- 
wounds  of  the  back  (incised)  are  almost  always  very  favorable.  But  if  no 
sutures  be  introduced,  and  the  gaping  wound  be  allowed  to  fill  up  and 
heal  by  granulation,  some  considerable  time  may  be  required  before  recovery 
takes  place. 

Incised  or  Punctured  Flesh-wounds  of  the  Back  of  the  Neck. — If  these 
penetrate  deeply,  they  may  open  the  vertebral  or  the  occipital  artery,  and 
thus  cause  a  hemorrhage  which,  if  not  restrained,  Avill  speedily  prove  fatal, 
on  the  one  hand  ;  or,  unless  promptly  treated  in  a  radical  manner,  will  give 
rise  to  a  traumatic  aneurism  of  an  almost  equally  fatal  character,  on  the 

>  Med.  and  Surg.  History  of  the  War  of  the  Rebellion,  Second  Surgical  Vol.  p.  429. 
2  Chirurg.  Wahrnehmungen,  S.  493.    Berlin,  1763. 
»  De  Sed.  et  Causis  Morb.,  Ep.  liii.  p.  270.  1765. 


264 


INJURIES  OF  THE  BACK. 


other.  Hennen,  indeed,  remarks  that  "  simple  incised  wounds  on  the  back 
of  the  /leck,  although  sometimes  penetrating  to  a  great  depth,  and  even  un- 
covering the  vertebral  arteries,  are  not  beyond  the  reach  of  simple  bandage, 
and  retention  by  adhesive  strips  and  sutures ;  feebleness  of  the  extremities, 
particularly  the  lower,  is  a  more  frequent  source  of  complaint,  in  these  cases, 
than  hemorrhage."^  ^Nevertheless,  there  are  many  cases  on  record  in  which 
stabs  in  the  nape  of  the  neck  opened  one  of  the  vertebral  arteries,  and  thus 
gave  rise  to  most  disastrous  consequences.  Dr.  Kocher,  of  Berne,  relates  an 
excellent  example  of  this  sort,  in  Langenbeck's  Archives  f  and  he  remarks 
that  it  is  the  twenty-first  recorded  case  of  traumatic  aneurism  of  the  verte- 
bral artery.  In  twelve  of  these  twenty-one  cases,  the  wounds  were  stabs. 
In  ten  cases  the  result  was  fatal  before  any  pulsating  swelling  appeared. 
In  eleven  cases  where  life  was  prolonged  until  there  was  pulsating  swell- 
ing, but  two  recoveries  occurred.^  Thus  it  appears  that  flesh-wounds  in 
the  nape  of  the  neck  which  involve  either  of  the  vertebral  arteries  are  ex- 
ceedingly dangerous  to  life,  that  the  ratio  of  mortality  for  this  lesion  has, 
hitherto,  exceeded  90  per  cent.,  inasmuch  as  nineteen  out  of  twenty-one 
recorded  cases  have  proved  fatal,  and  that  the  surgical  treatment  of  this 
form  of  injury  is  a  subject  of  very  great  importance  to  practitioners  as  well 
as  to  patients.  It  may  be  useful  to  state  in  this  connection  the  chief  causes 
of  this  striking  want  of  success.  In  eleven  cases,  the  carotid  artery  was 
tied,  through  error  in  diagnosis,  and  this  operation  probably  rendered  the 
evil  greater,  by  increasing  the  blood-pressure  in  the  wounded  vertebral 
artery ;  indeed,  in  two  of  the  cases  thus  operated  on,  the  patient  died  of 
violent  hemorrhage  from  the  seat  of  injury ;  and  in  three  other  cases  belonging 
to  the  same  category,  death  occurred  from  bursting  of  the  aneurism.  In  five 
instances,  the  ligation  of  the  carotid  was  followed"  by  paralysis  that  proved 
fatal.  Liicke,  in  a  case  where  the  aneurismal  swelling  increased  rapidly  after 
ligating  the  carotid,  injected  into  the  sac  chloride  of  iron,  and  also  applied 
plugs  saturated  with  the  perchloride ;  the  patient,  however,  died  with  symp- 
toms of  paralysis.  Maisonneuve,  in  a  case  of  gunshot  wound,  tied  both  the 
vertebral  and  the  inferior  thyroid  arteries,  and  extracted  the  missile.  The  bleed- 
ing was  arrested,  but  death  ensued  from  the  infiltration  of  pus  into  the  spinal 
canal,  and  consequent  inflammation.  One  patient  died  of  septicemia  follow- 
ing suppuration  of  the  connective  tissue  of  the  neck.  In  several  cases  there 
was  hemorrhage  that  resulted  in  death.*  But,  as  stated  above,  an  error  in 
diagnosis,  a  mistaking  of  the  wounded  artery  for  a  branch  of  the  carotid 
with  consequent  ligation  of  that  vessel,  was  by  far  the  most  frequent  cause  of 
failure  in  treating  these  cases  ;  and,  inasmuch  as  such  errors  in  diagnosis  are 
avoidable  when  the  likelihood  of  their  occurrence  is  borne  in  mind  by  sur- 
geons, there  is  good  reason  to  hope  that  much  better  results  will  hereafter 
be  achieved  in  treating  flesh-wounds  in  the  nape  of  the  neck  which  involve 
either  of  the  vertebral  arteries. 
^  But  flesh-wounds  of  the  posterior  cervical  region  may  lay  open  other  arte- 
ries of  importance  as  well  as  the  vertebral,  for  instance,  the  jwofunda  cervicis, 
a  branch  of  the  subclavian,  the  arieria  princeps  cervicis,  a  branch  of  the  occi- 
pital which  inosculates  freely  with  the  profunda  cervicis,  and  even  the  occi- 
pital artery  itself  In  Dr.  Kocher's  case  it  was,  at  first,  uncertain  whether 
the  \'ertebral  or  the  deep  cervical  was  injured ;  but  the  occurrence  of  hemor- 
rhage on  removing  the  dressing,  and  the  result  obtained  by  introducing  a 
finger  into  the  wound  as  far  as  the  transverse  processes  of  the  vertebrae, 

*  Principles  of  Military  Surgery,  p.  285,  Am.  ed. 
«  Archiv  fiir  klin.  Chirurg.,  Bd.  xiii.  S.  867. 

*  New  Sydenham  Soc.  Bien.  Retrospect,  1871-72,  pp.  202,  203.  *  Ibid.,  p.  204. 


INCISED  AND  PUNCTURED  FLESH-WOUNDS  OF  THE  BACK. 


265 


whereby  the  blood  was  perceived  to  issue  from  a  point  between  two  trans- 
verse processes,  apparently  the  fifth  and  sixth,  soon  made  the  diagnosis  clear. 
In  Mobus's  case,  which  is  mentioned  by  Dr.  Kocher  as  the  only  instance  of 
traumatic  aneurism  of  the  vertebral  artery,  besides  his  own,  which  eventuated 
in  recovery,  there  was  a  pulsating  tumor  below  the  occipital  bone  on  the  right 
side.  It  might  have  arisen  from  a  wound  of  the  occipital  just  as  well  as  from 
a  wound  of  the  vertebral  artery ;  but  the  pulsation  was  not  arrested  by  com- 
pressing the  occipital  artery,  and  the  tumefaction  was  not  lessened  by  com- 
pressing the  carotid,  wherefore  the  vertebral  was  inferred  to  be  the  seat  of 
the  lesion.* 

Flesh-wounds  in  the  posterior  cervical  region  that  also  lay  open  one  of  the 
occipital  arteries,  have  proved  almost  as  deadly  as  similar  wounds  that  lay 
open  the  vertebral  arteries,  mentioned  above.  The  princii)al  reason  for  these 
untoward  results  has  been  that  surgeons,  owing  to  difficulties  real  or  fancied 
that  they  have  met  with  in  trying  to  tie  the  wounded  occipital  artery  in  the 
wound  itself,  have  resorted  to  untrustworthy  expedients,  instead  of  persevering 
as  they  should  have  done  until  success  had  crowned  their  etibrts  to  ligature 
the  bleeding  vessel  on  each  side  of  the  aperture  in  its  walls.  From  the  em- 
ployment of  temporizing  measures,  it  has  resulted  that  the  hemorrhage, 
although  restrained  for  a  brief  period,  has  burst  forth  afresh  from  day  to 
day  or  from  time  to  time,  until,  finally,  the  patient  has  perished  miserably 
from  ansemic  exhaustion,  or,  in  other  words,  has  slowly  bled  to  death,  and 
that,  too,  beneath  the  surgeon's  very  eyes.  The  following  example  well 
illustrates  this  subject. 

A  young  man,  aged  22,^  received  in  an  affray  a  stab-wound  in  the  neck,  two  inches  in 
length  by  one  inch  in  depth,  behind  the  left  ear,  and  about  two  inches  distant  from  the 
auditory  meatus.  Half  an  hour  afterward  the  medical  man  found  him  pale  and  faint 
from  loss  of  blood.  The  hemorrhage  still  continued  in  feeble  jets  ;  but  pressure  ap- 
plied at  the  bottom  of  the  wound  with  a  finger  readily  suppressed  it.  On  failing  to 
grasp  the  wounded  artery  with  forceps,  it  was  resolved  to  treat  the  hemorrhage  by  com- 
pression. Thereupon  the  wound  itself  was  stuffed  with  lint,  and  the  lips  thereof  Avere 
drawn  together  over  it,  and  secured  in  apposition  with  interrupted  sutures.  This  pro- 
ceeding controlled  the  hemorrhage  for  five  days,  when  slight  bleeding  recurred.  On 
the  sixth  day  there  was  more  hemorrhage.  On  removing  the  dressing  the  bleeding 
was  very  profuse,  and  could  not  be  entirely  suppressed  by  pressure  with  a  finger  in  the 
(\^ound.  The  left  common  carotid  artery  was  then  tied,  and  the  bleeding  ceased. 
Three  days  afterward,  however,  a  slight  hemorrhage  appeared  in  the  original  wound, 
and  in  twelve  days  more  hemorrhage  again  occurred  from  the  same  wound^  on  opening 
which,  the  blood  was  found  to  issue  from  the  occipital  artery,  at  a  point  behind  the 
mastoid  process.  Manual  compression  was  now  resorted  to,  but  two  days  subsequently 
the  patient  died,  having  survived  the  wound  twenty-three  days,  and  the  deligation  of 
the  common  carotid  artery  seventeen  days.  An  autopsy,  made  ten  hours  after  death, 
showed  that  the  knife  had  penetrated  between  the  mastoid  process  of  the  left  temporal 
bone  and  the  transverse  process  of  the  atlas,  and  had  opened  the  occipital  artery  in  the 
occipital  groove.  The  occlusion  of  the  carotid  was  perfect.  The  brain  was  not  diseased. 
Death  appears  to  have  resulted  from  anaemic  convulsions  and  anaemic  exhaustion,  that 
were  caused  by  the  regurgitant  hemorrhages  from  the  wounded  artery. 

Deligation  of  i;he  common  carotid  in  this  case  failed  to  control  the  hemor- 
rhage, because  it  did  not  control  the  circulation  of  blood  in  the  wounded  part 
of  the  occipital  artery ;  and  it  did  not  control  the  circulation  because  of  the 
great  freedom  with  which  the  terminal  branches  of  the  two  occipital  arteries 
inosculate  with  each  other  across  the  median  line,  and  with  branches  of  the 
temporal  and  posterior  auricular  arteries  in  the  scalp,  and  likewise  by  meana 


1  Ibid-,  p.  204. 


2  American  Medical  Times,  May  18,  1861,  p.  320. 


266 


INJURIES  OF  THE  BACK. 


of  the  arteria  priiiceps  cervicis  with  the  profunda  cervicis  in  the  deep  part  of 
the  neck.  In  consequence  of  the  great  freedom  of  this  arterial  intercom- 
munication, the  closure  of  the  common  carotid  was  not  attended  with  such  a 
stoppage  of  the  blood-flow  in  the  wounded  part  of  the  occipital  artery  as  is 
requisite  for  the  formation  of  blood-clots  which  can  permanently^  close  the 
aperture  in  the  arterial  tunics,  and  thus  effectually  restrain  the  hemorrhage. 
Wherefore  it  happened,  that,  as  soon  as  the  blood-pressure  rose  again  after 
the  operation  of  tying  the  common  carotid  was  performed,  the  occluding  clots 
were  driven  out  of  the  aperture  in  the  arterial  tunics,  and  the  bleeding  started 
afresh  from  the  distal  as  well  as  from  the  proximal  portion  of  the  w^ounded 
artery.  Thus  it  is  shown  that  the  only  procedure  which  might  have  saved 
this  patient  would  have  consisted  in  tying  the  injured  artery  in  the  wound 
itself  with  two  ligatures,  one  of  them  being  applied  on  each  side  of  the  aper- 
ture in  its  walls,  so  as  to  prevent  the  regurgitant  as  well  as  the  direct  hemor- 
rhage ;  and  had  this  operation  been  promptly  performed  by  the  physician 
who  first  saw  the  patient,  there  is  good  reason  to  believe  that  he  would  have 
promptly  recovered. 

In  treating  flesh-wounds  of  the  posterior  cervical  region  which  open  any 
iDloodvessel  of  importance,  the  first  and  the  most  important  indication  consists 
in  suppressing  the  hemorrhage,  without  delay,  by  applying  two  ligatures  to 
the  injured  vessel  in  the  wound  itself,  placing  one  of  them  on  each  side  of  the 
bleeding  aperture  in  its  walls.  To  fulfil  this  indication  it  will  be  necessary 
to  bring  the  bleeding  orifice  or  ends  of  the  vessel  distinctly  into  view  ;  and, 
to  this  end,  whenever  the  wound  is  not  large  enough  to  allow  the  bleeding 
point  or  points  to  be  seen  and  secured  with  ligatures,  the  surgeon,  having 
first  introduced  a  finger  of  his  left  hand  into  the  w^ound,  and  placed  the  tip 
of  it  on  the  spot  whence  the  blood  issues  from  the  vessel,  feo  as  to  control 
the  hemorrhage  for  the  time  being,  should  enlarge  the  wound  with  a  bistoury, 
held  in  his  right  hand,  until  the  source  of  bleeding  is  fairly  brought  into 
view,  bearing  in  mind,  of  course,  the  anatomical  structure  of  the  parts  in- 
volved, and  carefully  avoiding  all  nerves  and  other  organs  of  importance. 
Then  he  must  ligature  the  distal  as  well  as  the  proximal  end  of  the  wounded 
artery,  in  order  to  repress  the  regurgitant  as  well  as  the  direct  hemorrhage ; 
and,  in  cases  where  the  artery  is  not  already  completely  divided,  it  is  well  to 
finish  the  operation  by' completing  the  division  of  the  arterial  tube  with  a 
bistoury,  applied  midway  betw^een  the  two  ligatures,  so  that  the  ends  of  the 
vessel  may  be  allow^ed  to  retract  and  contract.  However  great  the  obstacles 
in  such  cases  may  be,  the  surgeon  must  persevere  until  he  has  overcome  them, 
and  has  suppressed  the  hemorrhage  in  this  radical  manner;  otherwise  he  will 
pretty  certainly  be  annoyed  and  mortified  by  seeing  his  patient  slowly  bleed 
to  death,  in  spite  of  all  that  he  has  done,  as  happened  in  the  case  just  related. 

The  application  of  a  distal  as  well  as  a  proximal  ligature  to  the  vertebral 
artery,  when  wounded,  is  quite  as  necessary  as  it  is  in  the  case  of  the  occipital, 
or  the  profunda  cervicis ;  for  the  two  vertebrals  unite  together  to  form  the 
basilar  artery,  and,  therefore,  the  blood  is  capable  of  regurgitating  in  either  of 
them  with  great  force.  But  a  large  part  of  the  course  of  each  vertebral  artery 
is  occupied  by  its  passage  through  the  foramina  in  the  transverse  processes  of 
the  upper  six  cervical  vertebrae,  together  with  the  spaces  intervening  between 
the  transverse  processes  of  these  six  cervical  vertebrge.  E'ow,  the  vertebral 
artery  is  not  unfrequently  wounded  in  this  part  of  its  course,  and  here, 
because  of  its  anatomical  relations,  ligatures  cannot  be  applied.  What,  then, 
is  to  be  done  in  such  cases  in  order  to  stanch  the  hemorrhage  ?  Happily  this 
problem  has  been  solved  by  Dr.  Kocher,  w^ho  has  presented  us  with  a  success- 
ful example,  already  several  times  referred  to  above.  His  plan  of  treatment 
I  shall  now  proceed  to  describe : — 


INCISED  AND  PUNCTURED  FLESH-WOUNDS  OF  THE  BACK. 


267 


The  patient  was  a  man,  aged  48.  He  had  a  stab-wound  in  the  nape  of  liis  neck,  the 
hemorrhage  from  whicli  had  been  restrained  to  a  considerable  extent  by  plugs  soaked  in 
styptic  solutions,  etc.  On  removing  the  dressings,  there  was  seen  at  the  level  of  the 
fifth  and  sixth  cervical  vertebra?,  about  an  inch  to  the  left  of  the  spine,  a  roundisii 
wound  about  two-thirds  of  an  inch  in  diameter.  On  removing  tiie  coagulum  which  lay 
in  the  wound,  some  dark  blood  escaped;  and,  on  withdrawing  the  finger  used  for 
exploration,  a  rather  violent  hemorrhage  of  bright  red  blood  followed.  The  wound 
was  then  laid  open  to  the  extent  of  about  three  inches,  and  a  large  quantity  of  coagu- 
lum was  removed  by  the  finger.  Thus  a  cavity  was  found,  having  the  size  of  a  small 
apple,  and  at  the  bottom  the  posterior  surfaces  of  the  left  articulating  processes  were 
felt,  and,  more  distinctly,  the  transverse  processes  of  the  vertebrae.  A  transverse 
incision  was  now  made,  an  inch  and  a  half  in  the  anterior,  and  half  an  inch  in  the 
posterior  direction  ;  and  the  blood  was  then  seen  to  issue  from  a  point  between  the 
transverse  processes  of  two  vertebriis,  apparently  tiie  fifth  and  fcixth  cervical.  The 
blood  escaped  from  the  distal  as  well  as  from  the  proximal  portion  of  the  artery  ;  and 
the  hemorrhage  was  arrested  by  pressing  against  the  transverse  processes,  either  from 
above  or  from,  below.  No  ligatures  could  be  applied  to  the  wounded  artery.  A  plug 
of  charpie  of  the  size  of  a  pea,  soaked  in  a  solution  of  the  perchloride  of  iron,  was 
therefore  introduced  between  the  transverse  processes,  and  left  there.  It  stopped 
the  bleeding.  The  external  wound  was  closed  with  sutures,  and  dressed  antiseptically. 
The  head  was  kept  fixed  by  a  stiff  collar.  On  the  fourth  day  after  the  operation,  the 
plug  in  the  deep  part  of  the  wound  was  removed,  partly  by  means  of  a  stream  of  water, 
partly  by  forceps ;  no  bleeding  followed.  The  patient  was  discharged  cured,  a  little 
more  than  five  weeks  after  the  operation.^ 

Ill  similar  cases,  the  wounded  vertebral  artery  might  be  successfully  plug- 
ged by  pressing  into  its  lumen  one  or  more  cones,  made  out  of  fresh  animal 
tendons  (readily  procurable  at  almost  any  butcher's  stall),  having  the  diameter 
of  a  pea,  and  having  been  smeared  over  with  a  strong  solution  of  ferric  per- 
chloride, instead  of  a  wad  of  charpie.  The  animal-tissue  plugs  could  be 
allowed  to  remain  in  situ,  where  ultimately  they  would  undergo  absorption 
and  be  replaced  by  new  connective  tissue.  Both  ends  of  the  wounded  verte- 
bral artery  must,  in  general,  be  plugged. 

When  the  muscular  and  connective  tissues  of  the  neck  are  extensively  infil- 
trated with  blood,  as  soon  as  the  wounded  artery  has  been  securely  ligatured 
or  pluo'o-ed,  and  the  coagula  have  been  removed,  the  wound  itself  should  be 
thoroif^hly  cleansed  with  a  two-per-cent.  solution  of  carbolic  acid.  Exter- 
nally, the  wound  having  been  closed  by  interrupted  sutures  should  be  dressed 
antiseptically,  and  should  have  left  in'^it  an  adequate  drainage  tube,  reaching 
to  the  bottom.  Thus,  septicaemia,  which  is  very  apt  to  appear  and  prove  fatal 
in  such  cases,  may  be  avoided. 

Hennen  calls  attention  to  the  fact  that  in  wounds  of  the  back,  "  sinuses  are 
also  very  apt  to  form  along  the  spine,  and  they  often j^rove  very  troublesome; 
I  would  never  trust  [he  justly  observes]  to  pressure  In  t"hese  cases,  but  would 
make  a  free  though  cautious  incision.  These  incisions  are  sometimes  ren- 
dered very  necessary  by  the  lodgment  of  balls,  pieces  of  cloth,  etc."^ 

These  sinuses  and  abscesses  along  the  spine  and  in  the  muscles  of  the  back 
having  been  freely  opened,  their  contents  discharged,  and  all  foreign  bodies 
removed,  they  should  be  thoroughly  washed  out  by  injecting  a  two-per-cent. 
solution  of  carbolic  acid,  and  should  be  treated  by  securing  complete  drainage 
with  velvet-eyed  tubes  of  rubber,  deeply  inserted,  as  well  as  by  applying 
antiseptic  dressings  externally. 

To  sum  up  the  treatment  of  flesh-wounds  which  also  lay  open  important 
arteries  in  the  posterior  cervical  region : — 

«  New  Sydenham  Soc.  Bien.  Retrospect,  1871-2,  pp.  202,  203. 
2  Op.  cit.,  p.  350. 


268 


INJURIES  OF  THE  BACK. 


(1)  The  diagnosis  as  to  what  vessel  is  injured  must  be  made  by  exploring; 
the  wound  Itself  with  a  finger,  ascertaining  by  the  tactile  sense  the  point 
whence  the  blood  issues,  and  determining  by  the  same  means  its  anatomical 
relations. 

(2)  The  bleeding  vessel  must  be  brought  into  view  by  enlarging  the  wound 
without  delay ;  and  it  must  then  be  tied  at  the  place  of  injury  with  two 
ligatures,  one  of  them  being  applied  on  each  side  of  the  aperture  in  its  walls 
or  to  each  end  of  the  artery  if  it  be  severed.  The  artery  should  be  divided 
midway  between  the  two  ligatures,  for  the  purpose  of  allowing  its  ends  to 
retract  and  contract,  in  all  cases  where  it  has  not  been  severed  by  the  orie-inal 
wound.  ^  ^ 


•  (3)  When  one  of  the  vertebral  arteries  is  wounded  in  that  part  of  ita 
course  which  lies  in  the  canal  formed  by  the  foramina  in  the  transverse  pro- 
cesses of  the  SIX  upper  cervical  vertebrae,  the  hemorrhage  must  be  restrained 
by  plugging  the  injured  artery  in  the  manner  described  above,  because  in  this 
situation  ligatures  cannot  be  applied. 

(.4)  These  wounds  should  be  thoroughly  cleansed  with  antiseptic  lotions. 
Iheir  hps  should  then  be  drawn  together,  and  held  in  apposition,  by  means 
ot  interrupted  sutures.  Should  the  occurrence  of  deep-seated  suppuration 
be  probable,  adequate  drainage  tubes  should  be  inserted.  Antiseptic  dress- 
ings should  be  employed  externally. 

(5)  Inasmuch  as  there  is  great  flexibility  in  the  neck,  fixing  the  head  by 
means  of  a  stiff  collar,  so  as  to  secure  quietude  in  the  cervical  muscles  will 
considerably  expedite  the  recovery,  and  diminish  the  liability  to  secondary 
hemorrhage;  and  it  should  therefore  always  be  employed  in  these  cases. 

^  I  have  considered  the  flesh-wounds  in  the  posterior  cervical  region  which 
mvolve^  also  the  vertebral,  the  occipital,  the  deep  cervical,  or  other  arteries 
at  considerable  length,  because  of  the  enormously  high  rate  of  mortality 
which  has  attended  the  reported  examples  of  these  lesions,  amounting  to 
tully  90  per  cent.;  and  I  believe  that  the  principles  of  treatment  enunciated 
above,  when  generally  applied  in  practice,  will  greatly  lessen  this  awful  ratio, 
and  correspondingly  increase  the  chances  of  recovery  from  these  exceedingly 
troublesome  forms  of  inj  liry. 

Incised  or  Punctured  Flesh-wounds  of  the  Back,  received  between  the 
Shoulder-blades.— These  wounds  not  unfrequently  penetrate  the  thoracic 
cavity.  The  following  example,  taken  from  my  note-book,  affords  a  good 
illustration  of  this  point : — 

A  government  teamster,  middle-aged  and  robust,  was  stabbed  in  the  back,  at  Wash- 
ington, August  15,  1861,  in  a  brawl.  He  received  a  cut  about  three  inches  in  length, 
extending  up  and  down,  between  the  base  of  the  left  scapula  and  the  spinous  processes 
of  the  dorsal  vertebrae,  but  rather  nearer  to  the  scapula  than  to  the  spinous  processes. 
The  muscles  were  divided  down  to  the  ribs,  and  the  left  pleural  cavity  was  freely 
opened,  so  that  air  in  large  quantity  was  drawn  into  and  expelled  from  that  cavity  by 
each  respiratory  movement.  He  was  at  once  taken  to  the  E  Street  Infirmary.  When 
admitted,  he  was  much  prostrated  from  shock,  and  had  considerable  dyspnoea.  As 
soon  as  the  bleeding  was  completely  stopped,  which  required  a  little  time,  the  lips  of 
the  wound  were  brought  into  apposition  and  retained  by  three  points  of  interrupted 
suture,  and  by  strips  of  adhesive  plaster. 

August  20 — Most  of  the  wound  has  united  by  the  "  first  intention,"  and  he  has  con- 
valesced thus  far  without  even  one  unfavorable  symptom.  There  has  been  no  pain  in 
the  side  nor  any  other  sign  of  pleurisy.  Subsequently  he  did  well  in  every  respect, 
and  soon  left  the  hospital  entirely  cured. 


INCISED  AND  PUNCTURED  FLESH-WOUNDS  OF  THE  BACK. 


269 


It  was  observed  in  this  case  that  the  wound  gaped  considerably ;  and, 
therefore,  each  of  the  three  points  of  interrupted  suture  was  passed  through 
the  rhomboid  muscle,  as  well  as  through  the  exterior  plane  of  muscles  and 
the  skin.  Thus  the  edges  of  the  wound  were  securely  held  in  close  appo- 
sition, and  a  speedy  recovery  was  obtained. 

Incised  wounds  of  the  back  not  unfrequently  perforate  the  theca  verte- 
bralis,  and  lay  open  the  spinal  canal.  The  occurrence  of  this  lesion  is  attended 
with  the  escape  of  cerebro-spinal  fluid ;  and,  in  cases  where  the  spinal  cord 
and  spinal  nerves  had  not  been  injured,  the  escape  of  this  fluid  through  the 
wound  would  alone  indicate  the  nature  of  the  lesion. 

Professor  Agnew  has  pointed  out  "  the  exposed  condition  of  the  contents 
of  the  spinal  canal' in  the  posterior  region  of  the  neck,"  and  states  that  "  it  is 
due  to  the  horizontal  direction  of  the  spinous  processes,  by  which  vulnerable 
spaces  are  left  between."  Professor  Agnew  also  says :  "  The  popular  notion 
that  posterior  cervical  wounds  are  followed  by  sexual  impotence  must  be 
founded  on  cases  of  injury  to  the  cord  or  its  membranes.  ^  The  testimony  of 
Leo-ouest,  who  had  abundant  opportunities  for  observation  on  this  point 
during  the  conflicts  of  the  French  with  the  Turks,  gives  no  countenance  to 
this  opinion."^ 

But  incised  wounds  in  the  posterior  region  of  the  chest  also  not  unfre- 
quently penetrate  the  spinal  canal,  and  cause  paraplegia  by  injuring  the  spinal 
cord,  notwithstanding   that  the  spinous 

processes  of  the  dorsal  vertebrae  do  not  ex-  Fig.  852. 

tend  in  a  horizontal  direction.  The  follow- 
ing example  occurred  during  the  late  civil 
war : — 

Private  George  S.,  Co.  B,  loth  New  York 
Engineers,  was  admitted  to  Armory  Square  Hos- 
pital, Washington,  April  22,  1863,  having  been 
stabbed  with  a  knife  in  the  back  at  Falmouth, 
Va.,  on  the  20th,  that  is,  two  days  before.  He 
was  completely  paraplegic  ;  the  urine  had  to  be 
drawn  off  by  a  catheter ;  and  nothing  but  cro- 

ton  oil,  in  three  drop  doses,  succeeded  in  moving  ..u^ 

1  /•     '    J     •    •  4.        A    Z        The  fourth,  fifth,  and  a  part  of  the  Sixth  dorsal 

his  bowels,  three  days  after  admission  ;  two  days  ^^^^^^^^^  ^^^^  ^^^^  ^^^.^.^  ^ 
after  that,  involuntary  defecation  and  micturition    ^^^^^  ^^-^^^        broken  off  after  traversing 

set  in.     Sphacelus  of  all  the  projecting  points  on     the  spinal  canal  and  spinal  cord.    (Spec.  1160, 

the  lower  part  of  his  body  soon  followed,  and    a.  m.  m.) 
proceeded  rapidly  until  it  nearly  exposed  the 

spines  of  the  sacrum.  On  May  10,  chills  came  on,  and  recurred  daily.  Death  ensued 
on  May  26,  from  exhaustion.  The  autopsy  showed  that  the  knife  had  penetrated  the 
fifth  dorsal  vertebra.  The  fourth,  fifth,  and  a  part  of  tlie  sixth  dorsal  vertebrae  were 
removed  and  sawn  through  longitudinally  to  exhibit  the  knife-blade,  which  appears  to 
have  been  broken  off,  and  to  have  remained  fixed  in  the  body  of  the  fifth  dorsal  verte- 
bra ever  since  the  injury  was  inflicted.  The  specimen  is  preserved  in  the  Army  Medi- 
cal Museum  ;  and  it  is  represented  by  the  accompanying  wood-cut.  (Fig.  852.)^ 

Another  instance  of  incised  wound  of  the  back,  involving  the  vertebral 
column,  was  likewise  recorded  during  the  late  civil  war: — 

Private  Wm.  D.  Cook,  company  D,  6th  Tennessee  Cavalry,  aged  25,  was  admitted  to 
Overton  Hospital,  Memphis,  Tenn.,  November  25,  1864,  with  an  incised  wound  of  the 
spine  inflicted  on  the  10th,  that  is,  fifteen  days  before,  with  a  knife.  Simple  dressings 
were  applied.    The  patient  was  returned  to  duty  on  December  15.' 

1  Principles  and  Practice  of  Surgery,  vol.  i.  p.  321. 

•  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Volume,  p.  425. 
»  Ibid.,  p.  45. 


270 


INJURIES  OF  THE  BACK. 


In  this  case  it  does  not  appear  that  the  spinal  cord  or  spinal  nerves  sus- 
tained any  injury.  No  other  examples  belonging  to  this  category  were  re- 
ported during  the  late  civil  war. 

Dr.  Meryon^  presents  a  very  instructive  case  of  incised  wound  in  the  back, 
penetrating  the  vertebral  column  and  injuring  the  spinal  cord,  in  which  com- 
plete recovery  took  place. 

A  boy,  aged  15,  received  a  wound  from  a  cutting  instrument  in  the  back,  which 
penetrated  between  the  tenth  and  eleventh  dorsal  vertebra,  and,  probably  divided  the 
right  half  of  the  spinal  marrow.  There  was  complete  paralysis  ol'  motion,  and  incom- 
plete loss  of  sensibility  in  the  right  thigh  and  leg.  The  patient  made  a  good  recovery, 
and  at  the  end  of  two  months  was  able  to  walk  four  or  five  miles.  •  A  prominent  symp- 
tom in  this  case,  which  has  often  been  observed  in  similar  cases,  was  the  escape  of 
a  quantity  of  cerebro-spinal  fluid  from  the  wound  during  the  first  twelve  days  after  the 
injury. 

Dr.  Schwandner  reports  a  somewhat  similar  instance,  in  which  a  punctured  wound  of 
the  back  injured  the  spinal  cord  between  the  second  and  third  dorsal  vertebrae.  Paralysis 
of  the  right  foot  and  leg,  shortness  of  breathing,  together  with  involuntary  defecation 
and  micturition,  were  present.  The  foot  remained  partially  paralyzed  ;  but,  in  other 
respects,  the  recovery  was  complete.^ 

Under  the  head  of  punctured  wounds  of  the  back,  the  followina"  examples 
are  also  embraced  : —  ^ 

Hennen  reports  that,  "in  a  sergeant  of  the  Enniskillen  Dragoons,  wounded 
at  Waterloo,  a  piece  of  the  shaft  of  a  Polish  lance  stuck  fast  between  the 
spinous  processes  of  the  last  two  dorsal  vertebrge,  completely  paralyzing  him 
until  it  was  removed. 

In  arrow-wounds  of  the  back  the  missile  sometimes  penetrates  the  verte- 
bral column,  as  happened  in  a  case  the  specimen  from  which  is  represented 
by  the  accompanying  wood-cut  (Fig.  853).   This  speci- 
Fig.  853.  nien  was  obtained  from  the  body  of  a  white  man 

killed  by  Indians  (by  an  arrow-wound  of  the  heart, 
etc.)  in  1869,  at  an  outpost  near  Fort  Concho,  Texas, 
and  was  sent  to  the  Army  Medical  Museum.  It  con- 
sists of  the  fourth  and  fifth,  together  with  portions  of 
the  third  and  sixth,  dorsal  vertebrse.  An  arrow-head 
is  shown  impacted  in  the  right  transverse  process  of 
the  fourth  dorsal  vertebra  and  posterior  extremity  of 
the  rib.  The  spinal  canal  was  not  opened  by  the 
missile.'*  "The  force  with  which  arrows  are  pro- 
jected by  the  Indians  is  so  great  that  it  has  been  esti- 

Showing  an  arrow-head,  im- 

mated  that  the  initial  velocity  of  the  missile  nearly 
pacted  in  the  right  transverse    equals  that  of  a  musket  ball.    At  a  short  distance  an 


process  of  the  fourth  dorsal  ver-  ^^.^^^  ^- 1|  perforate  the  krgcr  boucs  without  commi- 
M.  M.)  °    nuting  them,  or  causing  a  slight  fissure  onty."^ 


tebra.— (Spec.  5673,  Sect. 


One  example  of  an  incised  flesh-wound  of  the  sacral  region  has  come  under 
my  own  observation.  The  patient  was  a  lad,  aged  about  18,  who  was  cut 
by  the  lower  angle  of  an  axe  that  accidentally  fell  from  his  right  shoulder, 
upon  which  he  was  carrying  it  as  he  walked,  and  struck  again&l^  the  sacrum, 
a  little  to  the  right  of  the  median  line.    The  wound  was  "about  two  and  a 

J  Researches  on  the  Various  Forms  of  Paralysis,  p.  69.  London,  1864.  Quoted  from  L'Union 
Medicale,  18f)0,  p.  552. 

•  2  New  Sydenham  Soc.  Year-Book,  1859,  p.  429.  3  Qp_  ^^^^  p_  359^ 

^  Circular  No.  3,  S.  Gr.  0.,  August  17,  1871,  p.  153.  «  Ibid.  p.  160. 


CONTUSIONS  AND  CONTUSED  WOUNDS  OF  THE  BACK. 


271 


half  inches  in  length,  extending  somewhat  obliquely  from  above  downward, 
and  penetrated  to  the  bone,  which  was  also  slightly  cut  by  the  edge  of  the 
axe.  There  was  considerable  hemorrhage,  but  no  ligatures  were  required. 
The  bleeding  having  been  stanched,  and  the  coagulum  entirely  removed,  the 
edges  of  the  wound  were  brought  into  apposition,  and  fixed  without  difficulty 
by  strips  of  adhesive  plaster.  The  wound  united  throughout  by  the  first 
intention,  but  the  patient  complained  for  a  long  time  of  having  pain  and 
soreness  in  the  sacrum  beneath  the  cicatrix.  These  symptoms,  however, 
ultimately  disappeared  without  the  occurrence  of  suppuration  or  the  dis- 
charge of  any  pieces  of  bone. 


Contusions  and  Contused  Wounds  of  the  Back. 

The  skin  on  the  dorsal  region  of  the  human  subject  is  so  thick  and  strong 
that  it  w^ill  stand  a  great  deal  of  hard  usage  without  breaking.  There  is, 
however,  a  considerable  liability  to  the  occurrence  of  contusions  and  con- 
tused wounds  in  the  posterior  cervical,  dorsal,  lumbar,  and  sacral  regions, 
from  railway  accidents,  from  falls,  from  blows  with  blunt  instruments,  and 
from  the  impact  of  falling  bodies  or  of  the  missiles  of  war.  The  following 
examples  are  in  point : — 

Contusion  of  the  Sacral  Region  from  a  Railway  Accident, — Private  John  Hol- 
den,  Co.  C,  29th  Infantry,  aged  23  ;  was  injured  at  Keswick,  Va.,  September  28, 
1868.  He  was  admitted  to  the  post  hospital  at  Camp  Schofield,  Lynchburg,  on  the 
next  day,  and  stated  that,  while  riding  on  the  top  of  a  box  car,  and  seeing  the  next 
car  in  front  rolling  over  an  embankment,  he  jumped  off,  but,  being  unable  to  escape, 
was  struck  on  the  back  by  the  car  as  it  rolled  over.  He  complained  of  intense  pain 
over  the  sacrum,  extending  between  the  anterior  superior  spinous  process  and  the  right 
tuber  ischii.  The  parts  over  the  sacrum  were  exceedingly  tender  under  pressure,  the 
slightest  motion  or  touch  causing  him  to  scream  with  pain.  No  crepitus  could  be 
elicited.  He  could  flex  the  leg  on  the  thigh  without  pain,  but  was  unable  to  flex  the 
thigh  on  the  pelvis.  The  injured  part  was  much  ecchymosed  ;  and  he  had  a  dull,  mov- 
ing, continuous  pain,  extending  across  the  whole  front  of  the  pelvis.  Anodynes,  with 
a  nourishing  diet,  were  administered.  The  patient  made  a  good  recovery,  and  was 
returned  to  duty  on  November  26.^ 

Contusions  of  the  Dorso-Lumhar  Region  from  Blows  with  the  Butt-end  of  a 

Musket  Private  Thomas  Carroll,  Battery  L,  1st  Artillery,  aged  23,  presented  himself 

at  surgeon's  call  October  5,  1867,  at  Fort  Porter,  N.  Y.,  stating  that,  some  time  during 
the  previous  night,  he  had  been  struck  in  the  back  with  the  butt-end  of  a  musket  in  the 
hands  of  a  sentinel.  The  blow  liad  knocked  him  down,  whereupon  he  had  been  struck 
twice  in  the  splenic  region  with  the  same  weapon.  On  examination,  a  slight  wound,  such 
as  might  have  been  made  by  the  percussion  hammer  of  a  musket,  was  found  about  an 
inch  and  a  half  to  the  left  of  the  articulation  of  the  twelfth  rib  with  the  twelfth  dorsal 
vertebra.  About  two  inches  lower,  at  the  same  distance  from  the  second  lumbar  verte- 
bra, another  wound  of  the  same  character  was  found.  The  man  was  treated  in  the  post 
hospital  at  Fort  Porter,  until  Oct.  21,  when  he  was  returned  to  duty  entirely  cured.^ 

Contusion  of  the  Back  caused  by  a  Fall  August  Burtz,  artificer  of  Co.  H,  2d 

Infantry,  aged  38,  was  admitted  to  the  hospital  at  Taylor  Barracks,  Ky.,  November 
7,  1868,  having  fallen  from  a  ladder  to  the  floor,  a  distance  of  fourteen  feet.  He  com- 
plained of  pain  in  the  bowels,  and  inability  to  pass  water,  and  suffered  considerably 
from  shock.  A  stimulant  and  an  anodyne  were  administered.  On  the  8th  he  was 
improved.  On  the  10th  he  was  taken  with  intermittent  fever,  which  yielded  to  quinine 
and  iron.    He  speedily  recovered,  and  was  returned  to  duty  on  the  loth.^ 


»  Circular  No.  3,  S.  G.  0.,  August  17,  1871,  p.  106. 

a  Ibid.,  p.  106.  *  Ibid.,  p.  106. 


272 


INJURIES  OF  THE  BACK. 


These  examples  well  illustrate  the  usual  course  of  ordinary  contusions  of 
the  back,  when  they  are  treated  with  quietude,  nourishing  food,  and  ano- 
dynes, as  required.  But,  these  excellent  results  are  not  always  so  easily,  nor 
so  speedily  obtained,  by  even  the  best-devised  plans  of  treatment;  as  the  follow- 
ing case,  in  which  a  severe  bruise  of  the  sacral  region  was  followed  by  perios- 
titis and  sub-periosteal  abscess,  will  serve  to  show : — 

Private  Thomas  Morgan,  Co.  A,  42d  Infantry,  aged  34,  was  admitted  to  the  hospital 
at  Fort  Niagara,  N.'Y.,  October  2,  1867,  the  wheel  of  a  loaded  cart  having  passed 
over  his  pelvis  on  tlie  previous  day.  There  was  swelling,  together  with  extensive 
ecchymosis,  of  the  integuments  over  the  upper  part  of  the  sacrum,  and  he  complained 
much  of  pain.  He  also  was  not  able  to  walk.  A  stimulating  lotion  was  applied  to  the 
contused  part,  and  anodynes  were  administered.  A  tumor,  which  formed  in  the  injured 
part,  was  several  times  evacuated  by  incisions.  The  patient  likewise  suffered  from 
chills  and  fever.  By  November,  his  general  health  had  improved  under  expectant 
treatment ;  but  the  wound  of  operation  was  still  open.  On  December  6,  he  was  per- 
mitted to  do  light  duty.  On  the  27th  he  was  returned  to  hospital ;  the  wound  was 
swollen,  inflamed,  and  freely  discharged  dark  purulent  matter.  The  swelling  having 
subsided  by  January  13,  1868,  and  the  condition  of  the  wound  remaining  unchanged, 
an  incision  three  inches  long  was  made  down  to  the  diseased  structure,  which  was 
found  to  be  a  hard  cartilaginous  growth  containing  osseous  deposits,  between  which 
and  the  periosteum  the  purulent  matter  had  be^n  lodged,  and  had  been  escaping  there- 
from by  means  of  an  opening.  On  dissecting  out  this  morbid  growth,  and  touching 
the  walls  of  the  residual  cavity  with  nitrate  of  silver,  the  wound  was  closed  with  adhe- 
sive strips,  and  a  compress  was  applied.  But  little  suppuration  followed;  and,  on  the 
28th,  the  wound  being  nearly  healed,  the  patient  was  returned  to  duty.^ 

Not  unfrequently,  however,  the  degree  of  injury -is  much  more  considerable 
than  it  was  in  either  of  the  above-mentioned  cases,  and  the  process  of  repara- 
tion then  consumes  much  time,  on  the  one  hand,  or  a  fatal  result  ensues  from 
sloughing  of  the  injured  part,  from  long  protracted  suppuration,  or  from 
septicaemia,  on  the  other.  One  of  these  conditions  is  very  apt  to  obtain  in 
cases  where  the  injury  is  inflicted  by  the  missiles  of  war.  A  striking  example 
of  violent  contusion  of  the  soft  parts  in  the  dorso-lumbar  region  came  under 
my  observation  at  Stanton  Military  Hospital,  during  the  late  civil  war. 

The  patient,  who  was  a  soldier,  tall,  broad-shouldered,  and  very  strongly  built,  aged 
about  30,  was  injured  by  the  explosion  of  a  shell  while  lying  on  the  ground  face  down- 
wards, probably  in  line  of  battle.  He  thought  that  the  butt-end  of  a  shell  had  struck 
his  back.  On  examination,  there  was  found  centrally  situated  in  the  dorso-lumbar 
region,  a  circular  portion  of  the  skin  fully  six  inches  in  diameter,  that  was  very  much 
discolored  by  ecchymosis,  although  wholly  unbroken,  was  raised  up  considerably  above 
the  surrounding  surface,  and  exhibited  fluctuation  distinctly  when  the  fingers  were 
applied  to  it,  because  a  copious  extravasation  of  blood  into  the  subcutaneous  connec- 
tive tissue  had  taken  place.  So  there  was  in  reality  present  an  immense  haematoma, 
having  a  flattened  shape,  and  a  diameter  of  at  least  six  inches,  the  product  of  an 
exceedingly  powerful  blow  on  the  middle  of  the  back,  which  did  not  break  the  skin.  The 
treatment  consisted  of  quietude,  a  nourishing  diet,  the  administration  of  anodynes,  and 
the  application  of  camphorated  oil  to  the  injured  part.  But,  notwithstanding  the  care 
taken  to  prevent  it,  the  integuments  sloughed  off"  throughout  the  whole  of  the  circular 
space  above  mentioned,  and  the  extravasated  blood  was  completely  discharged  thereby, 
leaving,  however,  a  healthy  granulating  surface  fully  six  inches  in  diameter.  Simple 
dressings  with  unguentum  resina?  were  applied,  the  supporting  plan  of  internal  treat- 
ment was  continued,  and  the  sore  rapidly  cicatrized.  When  his  recovery  was  far 
advanced,  the  patient  was  transferred  to  a  northern  hospital,  and  thus  passed  out  of 
my  sight. 


»  Ibid.,  p.  108. 


LACERATED  FLESH-WOUNDS  OF  THE  BACK. 


273 


Concerning  the  occurrence  of  contusions  of  the  hack  in  the  Crimean  War, 
Staif-snrgeon  T.  P.  Matthews  writes :  "  Very  many  wounds  of  this  region 
were  inflicted  by  shell,  and  the  position  uniformly  adopted  as  safest  while 
awaiting  a  shell  explosion,  viz.,  lying  on  the  face,  accounts  for  this.  The 
contusions  were  often  large  and  serious,  and,  when  not  immediately  fatal, 
enormous  masses  of  tissue  often  sloughed  out,  and  the  patient  died  exhausted 
and  worn  out  by  profuse  suppuration,  or,  if  recovery  took  place,  the  wound 
healed  by  the  granulating  process.''^ 

Hennen  reports  the  following  case  of  contusion  of  the  back  from  a  spent 
cannon-ball,  which  proved  fatal : — 

A  t^allant  artillery  officer  received  a  contusion  from  a  spent  round-shot,  at  the  battle 
of  Vi'ttoria,  which  struck  him  exactly  between  the  scapulae,  barely  leaving  a  discolora- 
tion of  the  skin,  and  a  slight  stiffness  of  the  parts.  To  this  he  was  advised  to  apply 
cloths  wet  in  a  saturnine  solution,  which  he  gradually  increased  in  strength.  He 
derived,  however,  very  little  benefit  from  this  mode  of  treatment ;  the  stiffness  still 
continued,  the  discoloration  increased,  and  he  was  advised  by  some  casual  visitor  to 
apply  a  blister  to  the  part.  In  an  evil  hour  this  advice  was  acceded  to ;  and  in  a  very 
few  days  the  whole  back,  down  to  the  lumbar  region,  was  covered  with  a  dusky  erysi- 
pelatous inflammation.  Sloughing  abscesses  speedily  formed  in  the  injured  part,  which 
were  attended  with  a  horribly  offensive  discharge;  and,  in  a  few  weeks,  death  closed 
the  scene.'^ 

Hennen  also  justly  remarks  concerning  this  case :  "  To  apply  strong  satur- 
nine solutions,  or  leeches,  to  a  part  under  these  circumstances,  is  extremely 
injurious,  because  they  tend  to  depress  stiii  more  the  powers  of  life;  to  over- 
stimulate  by  blisters  is  equally  destructive  of  the  vitality  of  the  parts,  and 
more  hurtful  to  the  general  constitution."^ 

As  to  the  treatment  of  contusions  of  the  back  when  caused  by  the  explosion 
of  shells  or  the  impact  of  spent  cannon-balls,  there  are  three  points  to  be  most 
carefully  attended  to  in  managing  these  cases :  First,  the  lotions  applied  as 
discutients  should  not  be  purely  sedative,  nor  powerfully  exciting,  but  of  a 
mildly  stimulating  nature.  Secondly,  when  effusions  of  blood  (hsematomata), 
or  formations  of  purulent  matter  (abscesses),  are  clearly  diagnosed,  and  require 
removal,  they  should  be  evacuated  through  small  valvular  apertures,  and  the 
admission  of  air  should  be  avoided,  as  far  as  possible.  Thirdly,  the  dressings 
should  be  antiseptic  in  their  nature ;  for  instance,  a  two-per-cent.  solution  of 
carbolic  acid  in  water  already  containing  ten  per  cent,  of  alcohol,  or  a  four- 
per-cent.  solution  of  carbolic  acid  in  camphorated  oil,  should  constitute  an 
important  element  of  the  dressings.  Furthermore,  a  nourishing  diet  should 
generally  be  allowed  in  these  cases,  and,  not  unfrequently,  alcoholic  stimu- 
lants also. 


Lacerated  Flesh-wounds  of  the  Back. 

Hippocrates,  in  the  twenty-third  section  of  his  work  on  wounds,  treats 
briefly  of  wounds  of  the  back,  and  directs  attention  almost  exclusively  to  those 
inflicted  by  the  lash,  that  is,  to  certain  forms  of  lacerated  wound  occurring 
in  this  region.  For  the  cure  of  these  injuries  he  recommends  the  application, 
at  first,  of  cataplasms,  consisting  of  boiled  onions  or  of  squills  ;  and,  subse- 
quently, of  an  ointment  made  of  goat's  fat  or  fresh  lard,  together  with  oil, 
resin,  and  salt  of  copper — a  preparation  upon  the  whole  not  unlike  the  cera- 
tum  resinjB  of  the  modern  pharmacopoeia  (a  most  useful  dressing  for  slowly 

I  Med.  and  Surg.  History  of  the  British  Army  in  the  Crimea,  vo\.  ii-  p.  336. 
«  Op.  cit.,  ppo  92,  93.  ^  Ibid.,  p.  93. 

VOL.  IV. — 18 


'274 


INJURIES  OF  THE  BACK. 


healing  and  indolent  sores),  to  which  a  small  percentage  of  cupric  sulphate 
or  acetate  has  also  been  added. 

But  some  of  the  most  impressive  instances  of  lacerated  flesh-wounds  of  the 
back,  on  record,  have  resulted  from  explosions  of  shells.  The  next  two 
examples  are  reported  in  the  Medical  and  Surgical  History  of  the  War  of 
the  Rebellion,  and  they  will  serve  to  illustrate  this  topic  in  an  excellent 
manner : — 

A  soldier,  aged  19,  was  wounded  July  13,  1864,  in  the  entrenched  lines  before 
Petersburg,  by  a  large  shell-fragment,  which  tore  away  the  dorsal  integuments  over  a 
space  measuring  at  least  six  by  eight  inches,  and  severely  lacerated  the  subjacent  mus- 
cles, but  without  injuring  the  ribs  or  the  vertebral  column.  There  was  no  bleeding, 
and  the  shock  was  comparatively  slight.  The  lesion  is  well  shown  by  the  accompany- 
ing wood-cut  (Fig.  854).  The  patient,  after  partaking  of  restoratives,  and  having  the 
raw  surface  of  his  wound  covered  up  by  a  water  dressing,  was  taken  to  the  Depot  Field 
Hospital,  at  City  Point.  While  here,  only  such  tissues  sloughed  as  were  utterly  disor- 
ganized by  the  projectile,  and  the  large  surface  that  was  exposed  soon  granulated  kindly, 
so  that,  after  a  month,  the  patient  was  in  a  condition  to  be  transferred  northward ;  and, 
on  August  15,  he  entered  the  Whitehall  Hospital,  at  Bristol,  Pa.  The  cicatrization 
progressed  rapidly.    On  September  12,  he  was  furloughed,  and  on  October  4,  he 


Fig.  854. 


Showing  a  shell-wound  of  the  back,  6  by  8  inches  in  extent.    Kecovery  ensued. 

was  readmitted,  being  fairly  convalescent.  On  January  23,  1865,  he  was  sent  for 
modified  duty  in  the  Veteran  Reserve  Corps.  On  June  24,  he  was  mustered  out  of 
the  service.    No  application  for  a  pension  has  been  made  by  this  man  or  his  heirs.^ 

Inasmuch  as  the  men  were  often  ordered  to  lie  on  the  ground,  face  down- 
ward, while  under  artillery-fire,  huge  lacerations  of  the  back  were  not  infre- 
quently observed  by  our  military  surgeons  during  the  late  civil  war.  Com- 
monly, however,  these  wounds  rapidly  healed,  as  happened  in  the  case  just 
related.  But,  sometimes,  the  process  of  reparation  was  very  slow  after  such 
lacerations.  Other  conditions  being  equal,  flesh-wounds  in  the  flanks  and 
buttocks  were  found  to  be  more  serious  than  those  in  the  upper  dorsal  region. 
In  cases  where  large  masses  of  muscular  tissue  were  torn  away,  the  cica- 
trization was  sometimes  protracted  for  years,  as  happened  in  the  following 
instance : — 

A  soldier,  aged  20,  was  wounded  at  the  battle  of  Chancellorsville,  May  3,  1863,  by 
the  explosion  of  a  shell.    The  integuments  over  the  gluteal  and  lumbar  regions  were 

1  Medical  and  Surgical  History,  etc.,  Second  Surgical  Volume,  p.  429. 


LACERATED  FLESH-WOUNDS  OF  THE  BACK. 


275 


torn  off,  and,  on  the  right  side,  a  large  portion  of  the  gluteal  muscles  was  also  removed. 
This  huge  wound  is  well  illustrated  by  the  accompanying  wood-cut  (Fig.  855).  The 
shock  appears  to  have  been  considerable.  On  May  8,  reaction  having  taken  place, 
the  patient  was  sent  to  Armory  Square  Hospital,  at  Washington.  He  suffered  but  little 


Fig.  855. 


Fig.  856. 


Showing  an  immense  shell-wound  of  the  lumhar  and  gluteal  regions  ;  tetanus  ;  recovery. 

pain,  and  had  a  good  appetite.    He  was  ordered  the  best  of  diet,  with  porter;  lint  wet 
with  a  disinfectant  lotion  to  the  wound  ;  and  an  anodyne  internally  at  night.  The  patient 
did  well  until  the  forenoon  of  the  15th,  when  he  complained  of  inability  to  separate  his 
jaws,  and  of  stiffness  in  the  muscles  of  the  neck.    The  trismus  was  attended  next  day 
by  opisthotonos  and  other  tetanic  symptoms,  caused  perhaps  by  spinal  meningitis. 
Large  doses  of  morphia  were  administered  at  short 
intervals,  and  with  a  good  effect.    On  the  22d,  a 
large  dejection  from  the  bowels  occurred.  From 
this  date  the  patient  steadily  improved.    On  July 
10,  he  was  furloughed.    On  November  24,  he  re- 
turned to  the  hospital.  On  December  5,  an  examina- 
tion showed  that  the  wound  had  cicatrized,  except- 
ing a  patch  having  the  size  of  the  palm  of  a  iiand, 
and  that  this  portion  was  kindly  granulating.  The 
right  buttock  was  wasted  and  flattened.    His  gait 
was  feeble  and  uncertain.   His  general  health  appear- 
ed to  be  good.    On  December  15,  he  was  discharged 
from  the  service  and  pensioned.    A  drawing  in  colors 
of  the  huge  wound  in  this  case,  as  well  as  of  that  in 
the  preceding  case,  was  made  by  Hospital  Steward 
Stauch  soon  after  the  reception  of  the  injury.  Both 
drawings  are  preserved  in  the  Army  Medical  Mu- 
seum.   An  excellent  chromo-lithograpli,  made  from 
the  drawing  in  the  last  case,  is  presented  in  the  sec- 
ond volume  of  the  Surgical  History  of  the  War.  Tlie 
accompanying  wood-cut  (Fig.  855)  is  a  copy  (re- 
duced) of  the  chromo-lithograph.    On  November 
30,  1870,  tlie  pension-examiner  reported  as  fol- 
lows in  the  case  :  "  A  shell- wound  over  sacrum  of 
large  extent ;  is  not  so  well  as  formerly  ;  the  sore 
now  shows  no  disposition  to  heal,  and,  in  all  proba- 
bility, will  remain  an  open  ulcer.   His  weight  is  130 
pounds  ;  the  pulse  70  ;  the  respiration  normal ;  dis- 
ability total."    In  1871,  the  late  Dr.  Otis,  the  much-esteemed  editor  of  the  Medical  and 
Surgical  History  of  the  War,  addressed  a  note  of  inquiry  to  this  soldier,  regarding 


Showing  tne  appearance  of  the  cicatrcx 
nine  years  after  the  wound  represented  ia 
Fig.  855  was  inflicted.  In  the  centre  of  the 
cicatrix  an  indolent  ulcer  of  irregular  ?hape 
remains. 


276 


INJURIES  OF  THE  BACK. 


the  condition  of  his  wound.  His  attorney  courteously  responded  to  this  letter,  and 
transmitted  a  photograph  and  diagram  of  the  cicatrix,  which  then  bounded  a  raw  sur- 
face of  irregular  shape,  three  inches  wide  by  two  inches  in  height.  The  photograph 
is  reproduced  in  the  accompanying  wood-cut  (Fig.  856).  For  a  long  time  the  granula- 
tions on  this  raw  surface  had  been  indolent,  and  the  cicatrization  had  made  no  progress  ; 
there  were  no  sinuses  nor  fistulous  tracks  to  indicate  the  existence  of  diseased  bone,  or 
of  any  other  internal  cause  of  irritation.  The  invalid's  general  health  was  satisfactory. 
Dr.  Otis  advised  that  M.  Reverdin's  plan  of  skin-grafting,  on  which  Messrs.  Bryant 
and  Pollock  had  latterly  reported  so  favorably,  should  be  resorted  to ;  but,  at  the  time 
of  writing,  he  had  not  been  informed  whether  this  advice  had  been  followed.^ 

G.  Fischer^  cites  the  case  of  a  French  soldier,  who,  while  kneeling,  was  struck  by  a 
rolling  cannon  ball,  which  carried  away  a  portion  of  the  buttocks  having  the  size  of  a 
dinner-plate.  In  another  instance,  a  piece  as  large  as  a  man's  hand  was  torn  off.  In 
both  cases  luxuriant  granulations  arose,  and  complete  recoveries  were  expected. 

Concerning  the  treatment  of  this  class  of  injuries,  not  much  remains  to  be 
said.  The  chief  risks  pertaining  to  them  arise  from  a  liability  to  the  occur- 
rence of  tetanus,  of  spinal  meningitis,  of  septicaemia,  of  pysemia,  or  of  ex- 
haustion from  profuseness  and  protractedness  of  the  suppuration.  The 
plans  of  treatment  should,  therefore,  be  framed  with  a  view  to  avoid  the 
occurrence  of  these  complications  as  far  as  possible.  To  this  end,  the  dress- 
ings applied  to  the  wounds  should  always  be  antiseptic  in  their  nature,  a 
nourishing  diet,  with  tonics  and  stimulants,  should  generally  be  allowed,  and 
constitutional  irritation,  as  well  as  pain,  should  be  promptly  allayed  by  a 
judicious  administration  of  opium  or  morphia.  The  action  of  opiates  in 
these  cases,  to  allay  nervous  irritation,  may  sometimes  be  advantageously 
supplemented  by  exhibiting  the  bromides  or  chloral  hydrate.  The  cicatriza- 
tion of  the  wounds,  especially  when  the  sores  are  large,  and  have  become 
chronic  J  should  be  aided  by  introducing  skin-grafts,  as  recommended  for  this 
class  of' injuries  by  Dr.  Otis. 

In  civil  life,  immense  lacerated  wounds  of  the  back  are  sometimes  inflicted 
with  the  implements  of  labor,  accidentally  or  designedly.    For  example  : — 

*'  Dominick  Jeffri,  an  Italian  laborer,  was  struck  in  the  back  with  a  pickaxe  in  the 
hands  of  John  Cannon,  a  fellow  workman,  and  fatally  injured  yesterday.  The  men, 
who  were  recently  arrived  emigrants,  were  employed  in  making  an  excavation  for  gas 
pipes  on  Atlantic  Street,  Brooklyn,  when  Jeffri  stepped  backward  in  a  stooping  position 
just  as  Cannon's  pick  was  descending.  The  full  force  of  the  blow  drove  the  sharp- 
pointed,  heavy  pick  through  the  back,  near  the  spine,  for  the  depth  of  five  or  six  inches, 
causing  the  blood  to  flow  from  a  terribly  lacerated  wound.^ 

The  treatment  of  this  form  of  injury  should  be  conducted  on  the  principles 
which  have  already  been  laid  down. 


Gunshot  (small-arm)  Flesh-wounds  of  the  Back. 

In  the  Second  Surgical  Volume  of  the  Medical  and  Surgical  History  of  the 
late  Civil  War,  at  page  428,  there  is  presented  a  tabular  statement  embracing 
12,681  cases  of  gunshot  flesh-wound  of  the  back.  The  number  of  deaths 
was  exactly  800,  which  gives  a  ratio  of  mortality  of  a  trifle  over  6  per  cent. 
The  proximate  causes  of  death  are  specified  in  380  of  these  cases.  Eighty- 
three  of  them  were  complicated  by  other  wounds.    Of  the  remaining  297 

»  Ibid.,  p.  430. 

2  Deutsche  Zeitschrift  fur  Chir.,  1872,  Bd.  I.  S.  198.  (Otis.) 

3  N.  Y.  Herald,  June  8,  1882. 


GUNSHOT  FLESH-WOUNDS  OF  THE  BACK. 


277 


patients,  27  are  reported  as  having  succumbed  to  tetanus,^  33  to  secondary 
hemorrhage,  and  28  to  gangrene.  ^  The  fatal  termination  was  ascribed  to 
surgical  or  traumatic  fever  in  17  cases,  to  pyaemia  or  septiccernia  in  67  cases, 
to  pneumonia  or  hepatitis  (probably  instances  of  embolism)  in  17  cases,  to 
erysipelas  in  8  cases,  to  typhoid  fever  in  31  cases,  to  diarrhoea  and  dysentery 
in  39  cases,  and  to  peritonitis  in  7  cases.  In  one  instance  the  administration 
of  chloroform,  it  was  thought,  caused  the  fatal  result.  Two  patients  died 
from  diphtheria,  two  from  smallpox,  and  18  from  various  intercurrent  dis- 
orders due  to  ''hospitalism,''  and  not  directly  connected  with  the  traumatic 
lesions.  Dr.  Otis  makes  the  following  observations,  which  may  be  of  special 
interest  to  statisticians:  "Analysis  of  this  large  series  of  gunshot  flesh- 
wounds  indicates  that  the  mortality  of  these  non-penetrating  wounds  has 
been  over-estimated  by  some  European  writers  of  acknowledged  authority  in 
matters  pertaining  to  surgical  statistics.  Making  every  allowance  for  errors, 
and  admitting  that  the  aggregate  may  have  been  swelled  by  the  admission  to 
liospital  of  trivial  cases  of  wounds  "^of  the  integuments,  the  percentage  of 
mortality  remains  much  lower  for  this  group  of  injuries  than  has  been  here- 
tofore represented."^ 

The  foregoing  exhibit  of  the  causes  of  death  which  were  noted  in  1^,681 
cases  of  shot  flesh-wounds  of  the  back,  shows  that  these  lesions  were  but 
seldom  mortal,  unless  septicsemia,  pyaemia,  gangrene,  or  tetanus  (that  is, 
traumatic  spinal  meningitis)  supervened,  or  arterial  hemorrhages  occurred, 
which,  doubtless,  were  not  infrequently  maltreated,  and  so  proved  fatal,  as  I 
have  shown,  on  a  previous  page,  was  the  case  in  numerous  instances  of  incised 
and  punctured  wounds  of  the  posterior  cervical  region.  ^  Nevertheless,  sep- 
ticaemia, pyaemia,  gangrene,  tetanus,  and  maltreated  arterial  bleedings,  were 
encountered  with  such  frequency  in  this  class  of  injuries  as  to  make  the  em- 
ployment of  special  precautions  against  their  occurrence  a  necessary  feature  in 
every  plan  of  treatment.  The  destructive  eftects  of  "hospitalism,"  and  of 
exposure  to  infectious  disorders,  such  as  typhoid  lever,  smallpox,  and  diph- 
theria, were  likewise  observed  with  such  frequency  as  to  require  the  adoption 
of  preventive  measures. 

But  flesh-wounds  of  the  back,  inflicted  by  small-arm  missiles,  usually — 
that  is,  in  a  large  majority  of  instances — gave  no  particular  trouble,  and  soon 
terminated  in  recovery.  The  following  example  will  serve  to  illustrate  this 
point : — 

Private  John  Cosgrove,  Company  F,  Eighth  U.  S.  Infantry,  aged  23,  was  wounded 
March  17,  1869,  by  a  conoidal  ball,  which  entered  the  right  side  of  his  back  near 
the  fifth  lumbar  vertebra,  passed  forward  and  outward,  and  emerged  immediately  oyer 
the  anterior  superior  spinous  process  of  the  iUum.  He  was  admitted  to  the  post  hospital 
at  Columbia,  S.  C,  on  the  18th.  Simple  dressings  were  applied,  and  in  April  he  was 
returned  to  duty.^ 

However,  the  observations  collected  by  surgeons  in  several  different  wars 
have  shown  that  there  are  certain  forms  belonging  to  this  group  of  injuries, 
which  are  particularly  liable  to  prove  troublesome  in  respect  to^  manage- 
ment, and  to  be  followed  by  imperfect  recovery  or  physical  disability.  For 
instance,  Hennen  found  that  "  extensive  injuries,  or  the  permanent  lodgment 
of  balls,  gave  rise  to  either  death  or  incurable  paralysis."^  Stromeyer  ob- 
served that,  while  shot  flesh-wounds  of  the  back  did  not  in  general  exhibit 

'  I  have  no  doubt  that  most  of  these  27  fatal  cases  of  so-called  tetanus  were,  in  reality, 
examples  of  traumatic  spinal  meningitis,  in  which  inflammatory  irritation  of  the  motor  filaments 
produced  tetanic  spasms  in  the  corresponding  peripheral  muscles. 

2  Op.  cit.,  p.  432. 

3  Circular  No.  3,  War  Department,  S.  G.  0.,  August  17,  1871. 

4  Op.  cit.,  p.  350. 


278 


INJURIES  OF  THE  BACK. 


a  special  tendency  to  suppuration,  it  frequent]}^  occurred  in  long  transverse 
seton-wounds  of  this  region  that,  their  orifices  having  promptly  healed  and 
remained  closed,  their  tracks,  months  afterward,  filled  up  internally  with  puru- 
lent matter  so  as  to  form  fluctuating  tumors,  which  had  to  be  lanced,  inasmuch 
as  the  thick  skin  of  the  back  was  but  slowly  pierced  by  ulceration.  He  likewise 
remarked:  "Many  surgeons  err  in  trying  to  relieve  such  ailments  by  several 
small  incisions,  or  even  punctures,  parallel  to  the  spine;  these  afibrd  no  relief, 
and  it  is  absolutely  necessary,  in  such  cases,  to  make  incisions  several  inches 
in  length,  at  right  angles  to  the  spine.''^  It  should  also  be  stated,  that,  if  the 
surgeon  does  not  lay  open  the  track  of  the  ball,  in  such  cases,  dame  is^'ature 
herself  will  not  unfrequently  do  it  by  ulceration  or  sloughing.  During  the 
late  civil  war,  1  saw  several  examples  of  long,  seton-like,  transverse  flesh- 
wounds  of  the  back,  in  which  the  bridge  of  injured  muscle  and  inte2:ument 
had  been  completely  carried  away  by  ulceration  and  sloughing,  and  the 
seton-like  wound  itself  had  been  converted  into  an  immense  open  sore  whose 
long  diameter  extended  transversely,  that  is,  was  perpendicular  to  the 
vertebral  column.  The  cicatrices  resulting  from  such  wounds,  as  a  rule, 
seriously  impaired  the  functions  of  the  injured  muscles.  Again,  I  also  saw 
during  the  late  civil  war,  several  instances  of  long  seton-like  flesh-wounds  of 
the  dorsal  region,  which  extended  between  the  scapulge  in  a  longitudinal 
direction,  that  is,  were  parallel  to  the  vertebral  column.  These  wounds  had 
been  received  by  men  deployed  as  skirmishers,  while  advancing  by  crawling 
on  their  bellies  over  the  ground.  In  some  of  them,  the  missile,  having  passed 
through  the  trapezius,  tore  for  itself  a  way  across  the  fibres  of  the  rhomboid 
muscles,  dividing  them  to  great  extent  from  above  downward,  and  escaped 
from  the  integuments  over  the  latissimus  dorsi.  In  such  cases,  a  considera- 
ble degree  of  disability  always  remained,  owing  to  the  contraction  and  agglu- 
tination of  the  injured  muscles  which  ensued.  Furthermore,  Dr.  Otis 
remarks  concerning  this  group  of  injuries:  "There  were  some  curious 
instances  of  long,  circuitous,  ball-tracks ;  and,  among  the  fatal  cases  were 
noted  several  in  which  the  projectiles  had  lodged  under  the  scapula. Dur- 
ing the  late  civil  war,  I  several  times  had  occasion  to  observe  that  the  results 
were  exceedingly  unsatisfactory,  in  all  cases  of  shot  flesh-wound  of  the  back, 
where  the  missiles  lodged  beneath  the  scapula.  These  patients  often  com- 
plained of  having  great  pain  in  the  injured  region,  and  begged  to  have  the 
missiles  extracted  by  operations  to  which  they  were  always  ready  to  submit; 
the  fistulous  tracks  made  by  the  missiles  remained  open,  discharging  purulent 
matter,  while  the  injured  muscles  became  matted  together  in  consequence 
of  the  inflammation  and  suppuration,  and  the  movements  of  the  injured 
shoulder  always  remained  much  restricted.  In  one  of  these  cases,  after  the 
lapse  of  many  months,  the  missile  which  had  penetrated  above  the  superior 
angle  of  the  scapula,  and  lodged  beneath  that  bone  on  the  inner  side  of  the 
serratus  magnus  anticus,  sank  downward  by  the  force  of  gravity  until  it 
rested  on  the  costal  origin  of  the  latissimus  dorsi  from  the  last  three  ribs. 
It  was  extracted  by  making  an  incision  through  the  integuments  and  the 
latissimus  dorsi.  Thereupon,  the  patient's  sufterings,  which  had  been  very 
great,  immediately  ceased,  and  a  fistulous  channel,  which  had  remained  open 
and  discharging,  soon  became  permanently  closed ;  but  I  do  not  think  that 
the  man  ever  regained  very  good  use  of  the  injured  shoulder. 

Dr.  Beck^  remarks,  in  substance,  that  when  the  fleshy  covering  of  the 
back  is  injured,  much  depends  on  the  depth  to  which  the  laceration  of  the 
muscles  extends,  the  length  of  the  shot  channel,  the  amount  of  concussion  (as 


'  Quoted  by  Otis,  op.  cit.,  p.  429.  a  Op.  cit.,  p.  430. 

8  Chirurgie  der  Schussverletzungen,  1872,  S.  448.    (Quoted  by  Otis,  op.  cit.,  p.  430.) 


GUNSHOT  FLESH-WOUNDS  OF  THE  BACK. 


279 


from  large  shot  or  shell  fragments),  and  the  degi-ee  of  implication  of  the  ribs  or 
spine.  §hot  wounds  limited  to  the  areolar  tissue  and  muscles  mamly,  are 
of  no  special  interest,  unless  attended  by  exceedingly  large  loss  of  substance, 
or  by  a  very  long,  seton-like  ball-track.  Cases  in  which  bloodvessels  of  the 
laro-er  order,  and  the  main  branches  of  nerves,  arc  contused  or  lacerated, 
are^more  serious.  The  functions  of  the  dorsal  muscles  are,  in  some  cases, 
much  impaired  by  shot  lacerations.  :Many  invalids  of  this  class  are  unable 
to  move  freely,  and  complain  of  difficulty  in  breathing,  stooping,^  turning 
the  head,  etc. ;  complications  due,  unquestioiTably,  to  cicatrices  resulting  from 
lacerated  shot  wounds  that  have  either  been  attended  by  sloughing,  or  have 
required  incisions  to  relieve  deep  suppuration.  These  observations  of  Dr.  B. 
Beck  confirm  those  of  other  surgeons,  which  have  been  presented  above. 

Flesh  wounds  of  the  back  from  small-arm  missiles,  especially  when  much 
inflamed,  may  be  attended  by  paraplegia,  as  happened  in  the  following  case, 
which  Staff-surgeon  T.  P.  Matthew  declares  "  may  be  accepted  as  typical  of 
many  wounds  of  this  region : — " 

"  Maurice  Garvey,  aged  19,  was  wounded,  on  8th  June,  by  what  he  supposed  to  be 
a  spent  ball,  which  struck  him  on  his  back  about  opposite  the  seventh  dorsal  vertebra. 
On  admission  to  his  regimental  hospital,  there  was  immense  swelling  of  the  back,  and 
complete  loss  of  motion  of  both  lower  extremities,  but  not  of  sensation.  The  swelling 
in  great  measure  subsided  in  a  few  days,  under  the  use  of  fomentations,  when  two  wounds 
were  discovered,  giving  the  idea  of  entrance  and  exit  of  a  ball,  but  no  injury  of  the 
bones  of  the  spinal  column  could  be  detected.  The  wound  healed  under  simple  dress- 
ings, but  the  paralysis  continued,  and  he  was  transferred  to  the  Castle  Hospital,  on 
24th  October.  Here,  under  the  impression  that  the  persistent  paralysis  might  be  due 
to  chronic  inflammation  of  the  theca  vertebralis,  he  was  twice  put  under  the  influence 
of  calomel,  with  diuretics,  and  upon  each  occasion  with,  it  was  thought,  marked  bene- 
fit. Subsequently  strychnine  was  given,  in  suflicient  quantity  to  produce  convulsive 
spasms  of  the  affected  limbs.  This  did  not  seem  productive  of  any  good,  and,  after  per- 
sistence in  its  use  for  three  weeks,  it  was  omitted.  He  very  slowly  improved,  however^ 
and  on  26th  January,  was  invalided  to  England,  having  got  comparatively  fat,  and 
able  to  stand  upon  the  affected  limbs,  and  even  walk  a  few  paces  with  the  help  of 
crutches."^ 

Was  the  motor  paralysis,  which  presented  itself  in  this  case,  due  to  ex- 
tension of  the  inflammatory  process  which  arose  in  the  injured  tissues  of  the 
back,  and  caused  immense  swelling  inwardly  until  it  reached  the  theca  verte- 
bralis, etc.,  or  was  it  due  to  concussion  of  the  spinal  cord?  This  question 
no  one  can  authoritatively  decide,  although  the  fact  that  mercurials  and 
diuretics  proved  markedly  beneficial  on  two  occasions,  decidedly  favors  the 
idea  that  there  was  a  secondary  spinal  meningitis. 

2>ea^?ne?y^.— Flesh-wounds  of  the  back  made  by  small-arm  missiles  should 
be  carefully  explored  at  the  outset,  and  all  foreign  bodies,  including  spent 
balls,  frao;ments  of  clothing  and  of  equipments,  and  all  coagula,  should  be 
promptl/  extracted.  If  there  be  arterial  hemorrhage— whether  primary, 
intermediary,  or  secondary— it  must  be  suppressed  by  exposing  to  view  the 
wounded  vessel  at  the  place  of  injury,  and  ligaturing  it  on  each  side  of  the 
aperture  in  its  walls.  The  occurrence  of  septicaemia,  pyemia,  and  gangrene, 
must  be  obviated  as  far  as  possible  by  applying  antiseptic  lotions,  such  as  a  ten- 
per-cent.  solution  of  alcohol  in  water,  to  which  two  per  cent,  of  carbolic  acid 
has  been  added,  with  a  view  to  increase  its  efficacy.  Drainage  tubes  should 
be  inserted  in  all  wounds  where  the  purulent  matter  exhibits  a  tendency  to 
stagnate,  or  does  not  readily  flow  away.  Pain  and  constitutional  irritation 
should  be  subdued  by  administering  opiates  and  sedatives.    A  nourishing 


»  Med.  and  Surg.  History  of  the  British  Army  in  the  Crimea,  vol.  ii.  p.  337. 


280 


INJURIES  OF  THE  BACK. 


diet  should  generally  be  allowed ;  and,  not  unfrequently,  wine,  bitter  ale, 
porter,  or  alcoholic  liquors  should  also  be  prescribed.  But  the  most  impor- 
tant of  all  the  points  concerned  in  treating  this  group  of  injuries,  consist  in 
promptly  removing  all  foreign  bodies,  in  dressing  the  wounds  antiseptically, 
and  in  draining  them  thoroughly  by  passing  appropriate  velvet-eyed  India- 
rubber  tubes  of  suitable  size  into  them  deeply,  or  completely  through  them, 
which  is  still  better.  When  arterial  bleeding  occurs  in  this  group  of  injuries, 
to  such  an  extent  as  to  constitute  surgical  hemorrhage,  the  wounds  should 
not  be  stuffed  with  plugs  soaked  in  ferric  persulphate  or  perchloride  solutions, 
neither  should  these  liquids  be  injected  into  them,  for  both  proceedings  are 
worse  than  useless  in  such  cases ;  on  the  contrary,  the  bleeding  vessel  should 
be  promptly  exposed  to  view  at  the  place  of  injury,  by  enlarging  the  wound 
itself  or  by  direct  incisions,  and  then  it  should  be  tied  with  two  ligatures, 
one  of  them  being  applied  on  each  side  of  the  aperture  in  its  tunics ;  and, 
finally,  it  should  be  completely  divided  midway  between  the  ligatures,  so 
that  both  ends  may  retract,  and  thus  considerably  lessen  the  liability  to  return 
of  the  hemorrhage.  Instructions  on  this  point  of  treatment  are  by  no  means 
idle  or  unnecessary,  for  during  the  late  civil  war  (as  has  already  been  stated) 
no  less  than  thirty-three  fatal  cases  of  secondary  hemorrhage  from  flesh- 
wounds  of  the  back,  inflicted  by  small-arm  missiles,  were  reported  by  our 
military  surgeons.^ 

It  is  advisable,  however,  to  add  that  parenchymatous  hemorrhages  from 
flesh-wounds  of  the  back,  when  due  to  occlusion  by  coagulated  blood  (throm- 
bosis) of  the  veins  proceeding  from  the  injured  part,  or  to  any  other  cause, 
must  sometimes  be  treated  by  covering  the  raw  or  granulating  surface  from 
which  the  blood  is  exuding,  with  compresses  of  lint  thoroughly  wetted  w^ith 
a  solution  of  persulphate  or  perchloride  of  iron ;  but  arterial  hemorrhages 
must  not  be  treated  in  this  manner. 


Sprains,  Twists,  and  "Wrenches  of  the  Back. 

The  several  bones  which  compose  the  vertebral  column,  that  is,  the  true 
vertebrse  themselves,  together  with  the  sacrum  and  coccyx,  are  united  to  each 
other,  and  to  the  bones  that  lie  in  contact  with  them,  by  ninety-nine  joints  or 
articulations.  All  of  these  joints  are  more  or  less  susceptible  of  motion.  In 
some  of  them,  however,  the  degree  of  mobility  is  but  slight,  as  for  instance, 
in  the  sacro- coccygeal  articulation  ;  in  others,  it  is  very  considerable,  as  for 
example  in  the  occipito-atloid  and  atlo-axoid  articulations.  The  several 
bones  which  constitute  the  vertebral  column  are  likewise  strongly  bound 
together  by  ligaments,  a  considerable  proportion  of  which  are  elastic.  A 
brief  enumeration  of  these  ligaments  may  aid  us  materially  to  comprehend 
the  eflects  of  sprains,  wrenches,  and  jars  of  the  vertebral  column :  (1)  The 
lenticular  disks  of  intervertebral  substance^  interposed  between  the  bodies  of  all 
the  vertebrae  from  the  axis  to  the  sacrum,  perform  not  only  the  oflice  of  liga- 
ments, but  they  also  have  elastic  properties,  which  enable  them  to  act  in  a 
manner  not  very  unlike  that  of  India-rubber  bufters,  when  placed  between 
the  cars  of  a  railway  train,  in  obviating  the  injurious  eflects  of  jars  and 
shocks  upon  the  vertebral  column  itself,  and  upon  the  organs  contained  in  the 
spinal  canal.  (2)  Tiie  anterior  and  posterior  common  ligaments  likewise  bind 
together  the  bodies  of  the  vertebrae.  (3)  The  ligamenta  subflava  gird  together 
the  arches  of  each  pair  of  vertebrae,  from  the  axis  to  the  sacrum.  These  liga- 
ments are  also  elastic ;  and  by  means  of  their  elasticity,  they  counteract  the 

'  Med.  and  Surg.  History,  etc.,  Second  Surgical  Vol.,  p.  432, 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


281 


efforts  of  the  flexor  muscles  of  the  trunk,  so  tliat  in  maintaining  an  uprio-ht 
position  ot  the  vertebral  column,  they  lessen  considerably  the  expenditurJ'of 
muscular  force  by  their  automatic  work.  (4)  The  capsular  lujaiacKt^  and 
synovial  membranes  hold  together  the  articular  processes  of  tlie  vertebra\ 
(5)  The  inter-spinous  and  supra-spinoas  ligaments  fasten  together  the  spinous 
processes  in  the  dorsal  and  lumbar  regions.  (6)  The  intcr-transversc  ligaments 
connect  the  transverse  processes  of  the  lower  vertebrje  with  each  other. 

Furthermore,  the  ligamenta  sitbflava  are  in  direct  relation,  by  both  surfaces 
with  the  meningo-rachidian  veins;  and,  internally,  they  are  separated  froin 
the  dura  mater  of  the  spinal  cord  by  these  veins  and  some  loose  connective 
and  adipose  tissue.  A  laceration  of  these  ligaments  would  probably  be 
attended  by  a  rupture  of  these  veins.  Again,  the  posterior  common  ligament 
IS  in  relation  by  its  anterior  surface,  not  only  with  the  intervertebral  sub- 
stances and  the  bodies  of  the  vertebrae,  but  also  with  the  vena^  basam  vertebra- 
rum.  It  IS  in  relation  by  its  posterior  surface  with  the  dura  mater  of  the  spi- 
nal cord,  some  loose  connective  tissue  and  numerous  small  veins  alone  beincr 
interposed.  A  laceration  of  the  posterior  common  lij^ament  would  probably 
be  attended  by  a  rupture  of  these  veins,  wdth  a  rupture  of  the  vense  basum 
vertebrarum,  and  a  considerable  injury  of  the  spinal  dura  mater.  Indeed 
the  anatomical  relations  of  the  ligamenta  subflava  and  the  posterior  common 
ligament  are  such  that  traumatic  spinal  meningitis,  as  well  as  hemorrhage 
from  the  contiguous  veins,  might  readily  result  from  a  traumatic  lesion  in- 
volving either  of  them. 

Violent  strains  and  forcible  flexures,  and  strong  twists  or  wrenches  of  the 
back,  produce  injuries  of  the  joints  and  ligaments  of  the  vertebral  column, 
and  of  the  adjacent  parts,  both  soft  and  hard,  which  are  strictly  analogous  to 
the  ,  lesions  that  result  from  the  same  kinds  of  hurt  when  they  affect  the 
joints  of  the  extremities.  The  lesions  which  are  met  with  in  the  back  in 
consequence  of  these  forms  of  injury,  vary  from  a  slight  laceration  of  some 
fibres  of  the  vertebral  ligaments,  and  of  the  contiguous  connective  tissue,  and 
lesser  bloodvessels,  on  the  one  hand,  all  the  way  up  to  a  very  extensive  tear- 
ing through  or  detachment  of  the  vertebral  ligaments,  with  a  correspondino-lv 
extensive  rupturing  of  the  contiguous  muscles,  tendons,  connective  tissue, 
and  bloodvessels,  on  the  other.  Indeed,  the  lesions  which  result  from  severe 
sprains  and  twists,  or  wrenches  of  the  vertebral  column,  differ  only  in  decree 
from  those  which  attend  dislocations  of  the  vertebrae.  But,  according  to  the 
observations  of  Mr.  Hilton,  "the  most  frequent  lesion  in  injury  to  the  spine 

a  partial  severance  of  the  vertebra  from  the  intervertebral  substance 
Ihis  view  receives  support  from  the  fact  that  the  junction  of  a  more  to  a  less 
elastic^  body  is  the  weakest  spot,  and,  therefore,  receives  the  full  eflfect  of  a 
srrain. 

_  The  or  phenomena  which  attend  these  accidents  are  pain  in  the 

injured  parts,  and  mabihty  to  move  them,  with  tumefaction  and  tenderness 
under  pressure  ui  the  same  region  ;  and,  not  unfreqnentlv,  subcutaneous 
ecchymosis  appears  m  the  swelling.  These  symptoms,  however,  all  vary  in 
degree  and  extent  aceordmg  to  the  amount  of  the  injury  that  has  been  sns- 
;i,  i"g  ™ay  or  may  not  be  attended  by  eccliymosis ;  and  some- 

times the  latter  does  not  make  its  appearance  for  several  days.  The  tenderness 
under  pressure  is  usually  not  restricted  to  the  spinous  processes  of  one  or  two 
nLa^""  jertebr*  (which  circumstance,  if  it  were  present,  would  excite  a  sus- 
picion that  vertebral  tracture  existed),  but  is  equally  noticeable  over  several 
contiguous  spinous  processes.  At  the  same  time,  on  tracing  the  tips  of  these 
spinous  processes,  they  are  found  to  be  in  a  normally  strai|ht  line,  and  on  a 

'  On  Rest  and  Pain,  Am.  ed.,  pp.  47,  48.  n  Ibid.,  p.  48,  foot-note. 


282 


INJURIES  OF  THE  BACK. 


proper  level.  So  much  at  present  concerning  the  immediate  effects  of  these 
accidents. 

Among  the  remote  effects  of  the  lesions  of  the  back,  especially  when  they 
have  been  neglected  or  improperly  treated,  are  permanent  lameness  of  the 
back  from  chronic  inflammation  of  the  injured  joints,  and  curvature  of  the 
spinal  column  from  vertebral  caries.  Mr.  Hilton  thinks  that  severances  of 
the  vertebrae  from  the  intervertebral  substances,  when  inadequately  treated, 
are  particularly  liable  to  give  rise  to  vertebral  caries.^ 

Among  the  possible  consequences  of  sprains  or  wrenches  of  the  vertebral 
column,  spinal  meningitis  must  likewise  be  mentioned.  The  following  state- 
ment concerning  a  case,  hi  which  a  wrench  of  the  back  was  received  while 
on  board  of  a  street  railway  car,  has  recently  been  printed,  on  apparently 
good  authority,  in  a  prominent  morning  paper  in  isTew  York : — 

"  As  one  turns  into  Sixteenth  Street  off  Union  Square,  on  the  west  side,  one  notices 
the  tan-bark  laid  thickly  in  front  of  a  handsome  house  in  the  middle  of  the  block.  Here 
lies  G.  G.,  the  popular  soubrette  of  the  Theatre  Comique.  She  stopped  a  car  a  few 
weeks  ago,  and  the  conductor  started  it  before  she  had  fairly  got  on,  giving  her  such  a 
wrench  and  start  that  she  felt  at  the  time  a  severe  pain  in  her  back.  From  that  day 
to  this  she  has  been  unable  to  move,  lying  dangerously  ill  with  spinal  meningitis."^ 

Sprains,  Twists,  and  Wrenches  in  the  Cervical  Region. — I^o  other  cases 
of  spinal  injury  or  disease  are  so  immediately  dangerous  to  life  as  those  in  which 
the  upper  part  of  the  cervical  region  is  the  seat  of  injurj^,  but  especially  the 
first  and  second  cervical  vertebrae,  or  the  space  between  them ;  for,  when 
spinal  paralysis  results  from  injury  or  disease  of  this  part  of  the  cervical 
region,  the  nerves  which  cause  the  respiratory  muscles  to  act  are  likewise 
paralyzed,  and  then  complete  stoppage  of  the  respiratory  movements,  or 
death,  instantly  ensues.  Mr.  Hilton  has  reported  a  number  of  cases  which 
give  so  much  information  of  very  great  value  to  both  surgeons  and  patients 
concerning  this  group  of  injuries,  especially  about  their  symptoms,  conse- 
quences, and  treatment,  that  my  work  were  but  illy  done  should  I  omit  to 
mention  them.  Concerning  a  case  where  death  from  pressure  upon  the  spinal 
marrow  was  impending,  which  ultimately  ended  in  recovery,  he  says : — 

"  In  1850,  I  was  requested  by  Dr.  Addison  to  see,  w^ith  him,  a  young  woman,  suffer- 
ing from  injury  in  the  upper  part  of  the  spine,  the  result  of  an  accident.  I  found  her 
almost  pulseless,  with  great  distress  in  breathing,  loss  of  voice,  inability  to  swallow, 
and  nearly  complete  paralysis  of  the  arms  and  legs.  She  had  had,  from  the  early  part 
of  her  illness,  severe  pains  spread  over  the  back  of  her  head  and  neck,  increased  on 
pressing  the  head  downward  upon  the  spine.  Her  symptoms  had  gmdually  arrived  at 
this  stage  of  danger,  without  benefit  of  medical  treatment.  1  might  here  say,  that  the 
difficulty  of  breathing  and  deglutition  had  so  greatly  increased  of  late,  that  it  was 
thought  necessary,  or  to  her  advantage,  to  lift  her  up  more  and  more  in  the  bed  ;  but 
the  change  of  posture  seemed  only  to  add  to  her  distress  in  breathing  and  swallowing. 
These  were  the  difficulties  for  which  my  assistance  was  requested.  She  was  then 
propped  up  in  bed  by  pillows  at  her  back,  with  her  head  inclined  somewhat  forward, 
or  dropping  upon  the  chest.  As  the  impediment  to  swallowing  was  almost  an  insur- 
mountable difficulty,  I  was  desired  to  examine  the  throat,  but  I  could  not  discover 
anything  wrong  in  it.  It  was  our  opinion  that  her  life  was  in  imminent,  or  perhaps, 
instant  danger.  She  was  paralyzed,  and  could  not  swallow  ;  her  voice  was  excessively 
feeble,  and  her  pulse  not  very  perceptible  ;  she  scarcely  breathed  at  all,  and  was  not 
quite  conscious.  It  was  evident  that  something  must  be  done  without  delay.  Believ- 
ing that  her  symptoms  resulted  from  the  odontoid  process  of  the  second  vertebra  press- 
ing upon  the  spinal  marrow,  close  to  the  medulla  oblongata,  I  advised  that  she  should 
be  made  to  lie  down  immediately.     On  saying  to  her,  'You  must  lie  down  in  bed,'  she 


1  Ibid.,  p.  48. 


2  N.  Y.  Sun,  June  4,  1882. 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


283 


replied,  in  the  smallest  possible  voice,  '  Then  I  shall  certainly  be  killed  ;  I  can't  get 
my  breath.*  Seeing  there  was  no  time  for  contention,  I  told  her  our  opinion  was,  tiiat, 
if  not  placed  longitudinally  in  bed,  she  would  in  all  probability  die  in  a  very  few 
minutes.  Being  paralyzed,  or  nearly  so,  she  could  ofFer  no  resistance  to  my  purpose; 
and  1  shall  never  forget  the  weight  of  the  responsibility,  when  I  took  hold  of  her, 
desired  the  pillows  to  be  removed  from  her  back,  and,  supporting  her  head  and  shoul- 
ders in  my  arms,  slowly  placed  her  upon  her  back,  nearly  flat  upon  the  bed,  with  her 
head  upon  a  thin  pillow,  some  additional  support  to  tlie  hollow  of  her  neck,  and  two 
sand-bags,  one  on  each  side  of  her  head,  to  prevent  any  lateral  or  rolling  motion.  Here 
was  a  patient  in  the  greatest  possible  danger,  and  1  do  not  hesitate  to  express  tlie 
opinion,  that,  if  the  head  had  fallen  forward,  say  half  an  incli,  she  would  liave  died 
in  an  instant.  Her  sense  of  suffocation  was  soon  relieved  by  the  horizontal  position, 
and  she  remained  lying  down  during  six  months  uninterruptedly,  at  tlie  end  of  which 
time  all  the  serious  symptoms  had  disappeared.  She  was  then  allowed  to  move  about 
the  ward,  with  caution  ;  and,  a  few^  months  afterward,  left  the  hospital,  well,  with  the 
exception  of  a  stiff  neck,  most  probably  depending  on  anchylosis,  or  bony  union,  be- 
tween the  atlas  and  the  axis.  In  this  case,  nothing  but  complete  rest  was  employed  as 
a  remedy ;  rest  was  the  only  element  of  success  in  the  treatment,  and  I  think  it  is  a 
very  striking  example  of  its  power  to  prolong  life,  by  enabling  Nature  to  repair  her 
injuries  undisturbed."^ 

In  this  case,  the  sprain  or  wrench  of  the  joints  between  the  atlas  and  the 
axis  was  followed  by  chronic  inflammation  of  these  joints,  of  a  destructive 
character,  which,  happily,  terminated  in  a  cure  by  anchylosis,  under  the 
benign  influence  of  prolonged  rest.  The  severe  pain  over  the  back  of  the 
head  and  neck,  which  helped  to  mask  the  vertebi^al  lesion,  for  some  time, 
was  due  to  irritation  of  the  occipitalis  major  and  minor  nerves,  and,  perhaps, 
of  other  branches  of  the  anterior  and  posteiior  cervical  plexuses  of  nerves' 
also.  ' 

Mr.  Hilton  continues  in  a  most  instructive  vein : — 

"  I  will  now  direct  your  attention  to  another  case  of  diseased  cervical  vertebrae  (also 
caused  by  a  hurt),  which  terminated  in  sudden  death.  It  is  that  of  a  little  child,  five 
years  and  five  months  old,  seen  by  me  in  1841.  She  was  a  small,  delicate,  unhealthy 
girl.  She  had  been  accustomed  to  ride  a  good  deal  in  the  country,  with  her  mother, 
in  an  open  carriage,  and  was  thought,  in  that  way,  to  have  caught  a  cold  in  the  back 
of  the  neck,  which  became  gradually  stiff  and  swollen,  accompanied  by  pains  in  the 
head  and  neck.  These  pains  were  believed  to  be  rheumatic,  and  the  treatment  em- 
ployed had  reference  only  to  that  impression,  which  was  supposed  to  be  supported  by 
some  pain  experienced  in  the  limbs,  with  cramps  and  stiffness  in  walking.  She  fre- 
(luently  suffered  from  fever  and  loss  of  appetite,  and  had  been  under  medical  treatment 
during  many  weeks,  the  symptoms  slowly  increasing  in  severity.  The  mother  told  me 
afterward  that  she  had  thought  her  an  obstinate  child,  and  that  she  sometimes  threat- 
ened to  punish  or  to  shake  her  well  because  she  would  not  take  her  food.  I  have  no  doubt, 
if  she  had  done  so,  she  would  have  killed  the  child.  Upon  careful  examination,  I  thouo-ht 
I  made  out  the  case  to  be  one  of  disease  between  the  first  and  second  cervical  vertebrfe, 
or  thereabouts.  I  say  thereabouts,  because  the  parts  were  too  much  swollen,  and  too  pain- 
ful, to  admit  of  a  more  accurate  local  investigation.  There  was  pain  at  the  back  part  of 
the  head,  in  the  course  of  the  great  occipital  nerve ;  pain  behind  the  ear,  in  the  course 
of  the  great  auricular,  and  of  the  small  occipital ;  pain  in  the  higher  part  of  the  neck, 
on  rotation  of  the  vertebrae  upon  each  other ;  and  pain  in  the  same  vertebrje,  probably 
the  first,  second,  and  third,  by  pressing  the  bones  upon  each  other.  She  had  some  diffi- 
culty in  deglutition,  and  the  voice  had  lately  changed  its  character,  and  become  more 
feeble,  indicating  that  the  pneumogastric  nerves,  and  possibly  the  spinal  accessorv, 
were  involved  in  the  mischief.  Thus,  having,  in  common  with  the  sum-eon  in  attend- 
ance,  recognized  the  real  nature  of  the  case,  directions  were  given  that  the  child  should 
be  placed  upon  her  back,  with  her  head  resting  upon  a  thin  pillow,  and  some  additional 


»  Op.  cit.,  pp.  60,  61 


284 


INJURIES  OF  THE  BACK. 


support  to  the  nape  of  the  neck,  each  side  of  the  head  to  be  supported  by  sand-bags,  so 
as  to  prevent  any  lateral  or  rotary  movement  in  the  neck.  It  was  plain  that,  if  the  life 
of  the  child  was  to  be  prolonged  or  saved,  it  could  only  be  accomplished  by  a  long-con- 
tinued rest  to  the  spine ;  and,  for  the  purpose  of  securing  easy  rest  to  the  little  patient, 
a  water-bed  was  sent  from  London,  and  the  child  was  safely  placed  upon  it,  with  the 
sand-bags  extending  from  the  shoulders  to  beyond  the  head.  In  about  a  fortnight  the 
nurse  specially  appointed  to  attend  the  child,  finding  that  her  rest  at  night  was  now  so 
calm  and  quiet,  that  she  was  so  free  from  pain  and  fever,  that  her  appetite  and  power 
of  swallowing  were  so  much  improved,  as  well  as  her  temper,  and  thinking  she  was  alto- 
gether so  much  better,  and  willing,  no  doubt,  to  mark  her  own  penetration,  as  well  as 
to  please  the  mother  by  telling  her  in  the  morning  what  had  been  done  by  her  little 
charge — this  meddlesome  and  officious  woman,  instead  of  giving  the  child  her  breakfast, 
as  usual,  without  disturbing  her  head  or  neck  in  the  least  degree,  desired  the  child  to 
sit  up  to  breakfast.  The  child  did  so ;  the  head  fell  forward,  and  she  was  dead.  The 
post-mortem  examination  proved  that  disease  existed  in  the  articulations  between  the 
first  and  second  cervical  vertebrae,  that  the  bones  were  loose,  and  that,  when  the  head 
with  the  atlas  fell  forward,  pressure  had  been  made  upon  the  spinal  marrow,  close  to 
and  below  the  medulla  oblongata,  at  the  point  of  decussation,  so  that  the  child  was 
killed  almost  instantly,  as  in  pithing  animals.  This  was  a  case  in  which  both  the  sur- 
geon and  nature  were  completely  thwarted.  The  local  disease  was  considered  at  the 
time  to  be  dependent  upon  a  constitutional  or  a  scrofulous  cause  ;  but  I  have  since  under- 
stood that  it  was  the  result  of  a  blow  given  to  the  little  girl  by  her  brother,  who  struck 
her  with  something  he  had  picked  up  in  the  room.  It  was  not  constitutional ;  there 
was  no  visceral  disease  of  any  kind."^ 

In  this  case,  then,  there  was  a  destructive  inflammation  of  the  joints 
between  the  atlas  and  the  axis,  arising  from  a  blow  upon,  or  a  wrench  of, 
these  joints,  and  the  real  character  of  the  lesion  was,  for  a  long  time,  over- 
looked ;  but,  in  all  probability,  it  would  have  been  cured,  as  the  preceding 
case  was  cured,  by  proper  and  long-continued  rest,  had  nature  and  the  sur- 
geon not  been  thwarted  by  the  misadventure.  Moreover,  the  morbid  con- 
dition of  the  atlo-axoid  articulations,  which  was  revealed  by  the  autopsy,  in 
this  case,  sheds  a  flood  of  light  upon  the  pathogenesis  of  the  preceding  case, 
and  frees  it  from  all  obscurity  or  doubt.  Thus,  the  history  of  this  case  is 
the  complement  of  that  of  the  preceding  case,  and  fully  elucidates  it. 

Mr.  Hilton  also  relates  the  case  of  a  lady,  aged  about  30,  who  had  a  disease  of  the 
spine  affecting  the  occipitalis  major  and  minor  nerves,  the  third  cervical  nerves,  and 
the  nerves  forming  the  left  axillary  plexus,  that  was  caused  by  a  blow  on  the  left  side 
of  the  head  with  a  bolster,  or  cushion,  which  forcibly  displaced  it  laterally,  and  thus 
strained  or  wrenched  the  joints  of  the  first,  second,  and  third  cervical  vertebrae.  She 
fell  upon  the  carpet,  and  was  unconscious  for  some  little  time.  She  had,  as  reported 
to  herself,  a  sort  of  struggling  fit.  On  recovery,  she  was  put  to  bed  ;  and,  in  a  day  or 
two,  nothing  remained  of  the  accident,  excepting  some  tenderness  in  the  upper  part  of 
the  neck  ;  but,  soon  afterward,  the  symptoms  about  to  be  described  came  on.  When 
Mr.  Hilton  first  saw  her,  some  nine  or  ten  months  after  the  injury,  "  she  had  pains  on  the 
left  side,  at  the  back  of  the  head,  and  at  the  posterior  part  of  the  external  ear ;  pain  over 
the  clavicle  and  shoulder  (all  on  the  left  side)  ;  pain,  with  loss  of  power,  in  the  left  arm  ; 
pain  deep  in  the  neck,  on  pressing  the  head  directly  downward  upon  the  spine,  and  on 
rotating  the  head ;  some  fulness  and  tenderness  on  pressure  about  the  first,  second,  and 
third  cervical  vertebrae,  especially  on  the  left  side.  She  could  not  take  walking  exer. 
cise  in  consequence  of  the  increasing  severity  of  all  the  symptoms.  She  had  almost 
sleepless  nights,  and  her  appetite  was  very  poor.  It  was  obvious  that  there  existed 
some  disease  or  injury  of  the  spine  affecting  the  occipital  nerves,  the  third  cervical 
nerves,  and  the  nerves  forming  the  left  axillary  plexus.  As  far  as  I  [Mr.  Hilton]  could 
interpret  the  case,  rest  appeared  to  be  the  proper  remedy.  The  patient  maintained, 
almost  uninterruptedly,  the  recumbent  position,  during  nearly  three  months,  two  sand- 


'  Ibid.,  pp.  61,  62. 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


285 


bags  being  placed  one  on  each  side  of  tlie  head.  The  only  medicine  employed  was  one- 
sixteenth  of  a  grain  of  bichloride  mercury  twice  a  day,  during  about  two  months.  At  the 
expiration  of  three  months  the  patient  had  lost  all  pain  and  tenderness,  and  had  regained 
the  use  of  the  arm,  neither  did  pressure  nor  rotation  of  tiie  liead  induce  pain.  The  ful- 
ness  in  the  neck  had  also  disappeared."^  To  conclude  tlie  case,  this  lady  left  town,  and, 
afterward,  reported  herself  quite  well,  being  perfectly  cured. 

The  wrench  of  the  vertebral  column,  in  this  example,  appears  to  have  been 
attended  with  cerebral  concussion,  caused  by  the  same  blow  on  the  head  which 
produced  the  sprain  of  the  neck,  and  there  was  loss  of  consciousness  for  some 
little  time.  She  was  placed  in  bed,  but  she  was  not  kept  there  long  enough 
for  the  injured  joints  connecting  the  first,  second,  and  third  cervical  vertebrae 
together  to  become  sound  again.  The  consequence  was,  that,  as  soon  as  she 
got  up  and  began  to  go  around,  the  inflammation  in  the  sprained  joints 
mcreased,  the  contiguous  sensory  nerves  became  irritated  thereby,  and  pains 
appeared  m  the  parts  to  which  they  were  distributed,  that  were  mistakenly 
considered  to  be  rheumatic  pains ;  and  so  the  poor  lady  went  on  for  nine 
months,  constantly  under  treatment  for  rheumatism  and  hysteria,  but  gettino- 
worse  the  whole  time.  Eest,  that  is,  enforced  quietude  of  the  injured  articu- 
lations, was  the  sole  means  of  importance,  which  finally  secured  her  recovery  ; 
and  the  same  means,  had  it  been  applied  to  her  case  at  the  outset,  for  only  a 
few  weeks,  would  have  saved  her  from  a  year  of  intense  suiFering. 

"  The  next  case  is  that  of  a  surgeon,"  writes  Mr.  Hilton,  "  who  was  in  the  yacht  of 
another  gentleman.  Running  along  from  one  part  of  the  ship  to  another,  he  struck  his 
head  against  the  top  of  a  door,  and  was  thrown 

backward  with  great  force.    Very  shortly  after-  Fig.  857. 

ward  he  had  pain  in  the  distribution  of  the  occi- 
pital nerves  at  the  back  part  of  the  head  and  the 
back  of  the  neck.  [See  Fig.  857,  «,  b.]  Six 
weeks  from  that  time  (he  still  continued  in  the 
yacht),  having  experienced  some  increase  of 
pain,  and  heard  and  felt  a  grating  sensation  in 
his  neck,  he  was  somewhat  alarmed,  and  came  to 
me,  suffering  from  pains  indicating  disease  of  the 
second  or  third  cervical  vertebra.  He  was  ulti- 
mately cured  by  lying  down — that  is,  by  rest. 
On  the  8th  of  February  last  he  came  to  me  per- 
fectly well,  and  says  he  was  quite  cured  by  rest. 
Time  will  not  permit  me  to  dwell  on  the  details 
of  this  surgeon's  case."' 

In  order  to  illustrate  the  varieties  in 
strains  of  the  neck,  together  with  the 
symptoms  and  treatment  of  recent  cases, 
the  following  examples  must  be  briefly 
presented : — 

A  young  carpenter,  while  stepping  backward.      Showing,  a,  the  portion  of  the  scalp  supplied 

tripped  on  a  heap  of  planks,  and  fell  upon  his  occipitalis  major  nerve;  &,  the  portion 

back.  His  shoulders  were  received  on  the  planks  •    ^"pp^^^^^     ^''^  occipitalis  minor  nerve  ;  c,  the 

but,  his  head  and  neck  projecting  beyond  them,     j'^;;^;j;^PP"^^  by  the  auriculo-temporal  nerve. 

the  neck  was  abruptly  bent  backward  with  much 

force.  Swelling  at  the  back  of  the  neck,  from  occiput  to  scapula,  so  ^reat  to  be 
visible  at  a  distance,  appeared  soon  after  tlie  accident.  He  was  unabTe  to  keep  his 
head  erect ;  and  before  attempting  to  do  so,  placed  a  hand  on  each  side  to  steady  it 
He  was  placed  m  bed.  At  the  end  of  a  montii,  having  been  provided  with  an  artificial 
support,  he  was  made  an  out  patient.^ 

•  Ibid.,  pp.  54,  55.  t  ^^^^^  ^     55  5g 

8  Holmes's  System  of  Surgery,  2d  ed.,  vol.  ii.  p.  359.       '      '     '  * 


286 


INJURIES  OF  THE  BACK. 


Again,  a  shoemaker,  aged  32,  while  stooping,  tripped  and  rolled  over,  with  his  head 
under  him.  His  neck  received  thereby  a  twist  that  caused  much  pain.  He  lay  motion- 
less, flat  on  his  back,  for  ten  minutes,  being  without  the  power  to  move  both  arms  and 
legs,  and  having  a  sense  of  numbness  and  of  pricking  throughout  the  body.  In  trying 
to  stand,  his  legs  gave  way  under  him,  as  if  he  were  intoxicated.  Sensation,  also,  was 
impaired  but  not  lost.  Within  twelve  hours,  however,  both  motor  power  and  sensation 
were  restored  ;  and  the  paralysis  did  not  return.  He  complained  of  acute  pain  in  the 
neck,  which  was  aggravated  by  the  slightest  movement  of  the  head  ;  and  he,  therefore, 
kept  the  head  perfectly  still.  He  lay  in  bed,  on  his  back,  with  his  neck  sunk  on  to  a 
low  soft  pillow,  and  propped  up  by  sand-bags.  On  examination,  the  chief  tenderness 
was  found  at  the  fourth  cervical  vertebra ;  and  there  a  deeply  seated  swelling  was  per- 
ceived. For  treatment,  absolute  rest  of  the  neck  was  enforced,  and  tincture  of  iodine  ap- 
plied. In  a  month  he  was  allowed  to  leave  his  bed,  with  his  head  supported  by  a  plastic 
shield  extending  from  the  shoulders  to  the  occiput.  He  could  then  perform  the  nodding, 
but  not  the  rotatory,  movements  of  the  neck.  In  nine  weeks,  all  the  cervical  movements 
seemed  quite  restored ;  but,  for  precaution's  sake,  he  was  kept  in  hospital  three  weeks 
longer.  He  returned  to  his  trade,  and  called  several  times  afterward  to  show  that  he 
was  well.^ 

Finally,  a  little,  ricketty  girl,  of  3  years,  having  a  large  head,  was  admitted  to  hos- 
pital, late  one  evening,  with  paralysis  of  the  upper  and  lower  extremities.  She  had 
fallen  out  of  bed,  that  morning,  head-foremost,  and  was  insensible  for  a  few  minutes. 
During  the  day,  it  was  remarked  that  she  did  not  get  upon  her  feet,  nor  move  her  legs ; 
and  that  she  did  not  use  her  hands.  When  examined,  motor  power  was  found  to  be 
lost  in  both  upper  and  lower  extremities.  She  showed  no  signs  of  pain  when  the  skin 
was  pricked  anywhere  below  the  upper  part  of  the  chest.  Reflex  movements  were 
excited  in  the  lower  extremities  when  the  skin  of  the  abdomen,  and  it  alone,  was 
pricked  ;  and  then  the  child  gave  a  slight  cry  of  pain  ;  respiration  natural ;  bladder  and 
rectum  not  aflected.  She  uttered  cries  whenever  the  neck  was  moved,  or  the  back  of 
it  was  pressed  on  by  the  fingers ;  and,  after  it,  seemed  pleased  to  keep  the  head  at  per- 
fect rest  on  a  pillow.  For  three  days  no  change  in  the  symptoms  was  observed  ;  on 
the  fourth  day  there  were  visible  signs  of  improvement ;  on  the  fifth,  it  was  discovered 
that  she  could  freely  move  both  upper  and  lower  extremities,  and  that  motion  of 
the  head  had  ceased  to  give  pain.  There  was  no  further  trouble,  and  she  remained 
quite  well.^ 

The  main  point  in  the  treament  of  recent,  as  well  as  in  that  of  old  cases, 
in  which  the  articulations  of  the  cervical  vertebrae  have  been  sprained  or 
wrenched,  is  to  maintain  them  in  a  state  of  complete  immobility  and  relaxa- 
tion until  the  cure  is  complete.  To  this  end,  the  patient  must  be  made  to  lie 
continuously  in  bed,  on  the  back,  with  only  a  thin  pillow  under  the  head, 
and  barely  enough  support  under  the  nape  of  neck  to  keep  it  from  sinking. 
Besides,  to  keep  the  head  straight,  and  to  prevent  its  rolling  from  side  to 
side,  sand-bags,  that  are  sufficiently  long  and  heavy  to  fulfil  the  indica- 
tions, must  be  so  placed  upon  the  patient's  pillow,  one  on  either  side  of  the 
neck  and  head,  as  to  give  both  of  the  parts  a  complete  lateral  support.  In- 
deed, I  do  not  know  of  any  other  mechanical  expedient,  of  a  simple  nature, 
which  answers  this  purpose  as  well  as  sand-bags,  made  of  bed-ticking,  of  a 
length  sufficient  to  extend  beyond  the  head,  and  about  three-fourths  filled  with 
dry  sand.  One  of  them  is  to  be  placed  with  care  on  each  side,  close  to  the 
neck  and  head,  and  is  to  be  accurately  moulded  thereto,  so  as  to  keep  the  head 
entirely  straight,  and  to  render  all  lateral  or  rotatory  movements  of  the  parts 
impossible. 

Sprains,  Twists,  and  Wrenches  in  the  Dorsal  Region.-— The  dorsal  por- 
tion of  the  vertebral  column,  when  compared  with  the  cervical  and  lumbar 
portions,  is  characterized  by  a  relatively  much  greater  rigidity  and  want  of 


'  Ibid.,  p.  359. 


2  Ibid.,  pp.  359,  360. 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


2S7 


flexibility  or  capacity  for  movement  n[»oii  each  otlier  of  the  several  bones 
that  compose  it,  at  the  articulations  ])y  which  they  are  linked  too;ether.  The 
injuries  caused  by  sprains  and  twists,  or  wrenches,  in  this  region  are,  there- 
fore, somewhat  analogous  to  those  produced  by  enormously  powerful  blows, 
and  their  deleterious  effects  are  apt  to  be  restricted  to  the  articulations 
w^hich  connect  two  contiguous  vertebrse,  instead  of  being  dispersed  or  dif- 
fused so  as  to  affect  the  articulations  of  many  adjoining  ])ones,  as  is  usually 
the  case  with  similar  injuries  in  the  more  flexible  parts  of  the  vertebral  col- 
umn, the  cervical  and  lumbar  regions. 

There  is  a  traumatic,  as  well  as  a  rheumatic,  "  crick"  in  the  back,  which 
is  not  unfrequently  caused  by  lifting,  or  attempting  to  lift,  a  heavy  weight 
while  in  a  stooping  position,  and  is  located  in  the  dorsal  region.  The  victim, 
while  exerting  his  strength  to  the  uttermost  in  this  position,  suddenly  feels 
"  something  give  way"  in  his  back,  and  is  soon  seized  by  cramping  pains  in 
the  affected  part,  which  are  aggravated  by  all  attempts  to  produce  motion 
therein  ;  so  that  he  carefully  abstains  from  making  such  attempts  himself, 
fi.nd  is  only  too  glad  if  the  injured  part  be  allowed,  by  the  exigencies  of  life, 
to  remain  in  a  state  of  absolute  quietude.  In  such  cases,  the  muscular  fibres 
belonging  to  the  strained  part  are  sometimes  lacerated  to  a  considerable  ex- 
tent, and  the  effusions  of  blood  and  of  inflammatory  products  into  the  injured 
muscular  and  connective  tissue  may  cause  tumefactions,  possibly  with  sub- 
cutaneous ecchymoses  also,  which  can  readily  be  felt  and  seen  externally. 
For  such  cases,  the  best  plan  of  treatment  consists  in  the  enforcement  of  abso- 
lute quietude  as  long  as  the  soreness  continues,  with  the  external  use  of  a 
mildly  stimulating  liniment,  and  the  internal  administration  of  opiates, 
whenever  necessary  to  allay  the  pains. 

^  Sprains  and  wrenches  of  the  dorsal  part  of  the  vertebral  column  are  some- 
times  caused  by  alighting  on  the  dorsal  region  in  falls,  or  when  thrown  from 
the  saddle  while  on  horseback.  They  are  also  produced,  occasionally,  in 
military  life,  by  the  trampling  of  horses  upon  the  backs  of  men  w^ho  have 
suddenly  been  dismounted,  or  have  been  thrown  down  to  earth  by  other 
means,  in  battles  or  in  sham-fights. 

The  vertebral  ligaments  and  joints  may  likewise  be  sprained  or  wrenched 
by  the  impact  of  powerful  blows  on  the  dorsal  region,  no  matter  what  the 
nistrument  may  be  that  inflicts  them.  In  respect  to  treatment,  no  additional 
directions  are  required. 

The  natural  curvature  of  the  dorsal  part  of  the  vertebral  column,  the 
convexity  of  which  looks  backward,  undoubtedly  exerts  considerable  in- 
fluence in  the  way  of  lessening  the  injurious  eflects  upon  the  vertebral 
ligaments  and  articulations,  of  violent  blows  on  the  dorsal  region.  This  cir- 
cumstance probably  explains  why  it  is  that  heavy  blows  on  tSis  part  of  the 
back  are  so  seldom  attended  w^ith  strains  or  wrenches  of  the  vertebral 
column,  that  prove  troublesome  to  manage,  or  even  require  a  surgeon's  care. 
The  principal  eftect  of  strong  blows,  etc., "when  received  on  the  convexity  of 
the  vertebral  arch  in  the  dorsal  region,  is  to  compress  the  intervertebral 
substances,  and  the  articulations  in  general,  which  enter  into  the  formation 
of  the  arch;  and,  therefore,  they  usually  do  comparatively  little  harm  to  the 
spme.  But  a  much  more  powerful  blow— one,  for  instance,  that  falls  but 
little  short  of  dislocating  or  fracturing  a  dorsal  vertebra,  and  so  comes  very 
near  to  breaking  down  the  dorsal  arch — may  readily  detach  the  correspond- 
ing intervertebral  substance,  to  greater  or  less  extent,  from  the  bone,  and 
thus  cause  an  inflammation  which  may  prove  destructive  to  the  injured  bone 
and  cartilage,  especially  if  the  lesion  chance  to  pass  unrecognized,  or  happen 
to  be  inadequately  treated.  It  is  not  improbable  that  caries  of  the  dorsal 
vertebrae  sometimes  begins  in  this  way. 


288 


INJURIES  OF  THE  BACK. 


The  mechanical  effects  of  falls,  however,  are  widely  different  from  those  of 
blows  on  the  dorsal  portion  of  the  vertebral  column,  especially  when  the 
victim's  back  happens  to  alight  upon  some  solid  body  of  comparatively  small 
dimensions,  whose  upper  surface  is  considerably  raised  above  the  surrounding 
ground — for  instance  the  stump  of  a  tree,  or  a  block  of  wood,  etc.;  for,  in 
such  a  case,  when  the  further  descent  of  the  back  is  stopped  by  striking 
against  the  solid  body,  the  downward  movements  of  the  head,  neck,  and 
upper  extremities  on  the  one  hand,  and  those  of  the  abdomen,  pelvis,  and 
lower  extremities  on  the  other,  are  not  arrested  at  the  same  instant  of  time  as 
that  of  the  dorsal  region ;  and',  therefore,  the  weight  and  impetus  of  these 
parts  simultaneously  press  downward,  with  great  energy,  upon  both  the  upper 
and  lower  ends  of  the  arch  formed  by  the  dorsal  vertelbrse,  and  on  the  concave 
side  thereof,  in  such  a  manner  that  the  intervertebral  substances  and  bodies  of 
the  dorsal  vertebrae  are  in  the  line  of  extension,  and  the  spinous  processes  of 
these  vertebra  in  that  of  compression.  It  is  obvious  that  a  comparatively 
slight  fall  upon  the  dorsal  region,  occurring  in  this  waj^  may  badly  stretch 
or  strain  the  anterior  and  posterior  common  ligaments  of  the  spine,  and  may 
also  separate  to  a  considerable  extent  the  intervertebral  substances  from  the 
bones.  It  is  highly  probable  that  caries  of  the  dorsal  vertebrse,  in  consequence 
of  falls  upon  the  back,  not  unfrequently  originates  in  this  manner ;  and  that 
comparatively  trifling  accidents  of  this  sort  may,  under  favoring  circum- 
stances, suffice  to  produce  this  result. 

Sprains,  Twists,  and  Wrenches  in  the  Lumbar  Region. — The  vertebral 
column  is  sprained  and  twisted,  or  wrenched,  in  the  lumbar  region,  more  fre- 
quently than  in  any  other  part  thereof  Such  lesions  of  the  lumbo-vertebral 
articulations  are  sometimes  produced  in  attempting  to  lift  great  weights  while 
in  a  stooping  position  ;  and  by  the  impact  of  blows  and  falls  upon  the  lum- 
bar reo-ion  itself,  quite  analogous  to  those  in  the  dorsal  region  which  have  just 
been  cfiscussed.  More  often,  however,  they  are  caused  by  accidents  in  which 
the  vulnerating  force  is  indirectly  applied  to  the  lumbar  region  ;  for  instance, 
by  alighting  on  the  buttocks  in  falling  from  a  height,  or  by  the  falling  of  a 
heavy  weight  upon  the  head  or  upper  part  of  the  body,  while  it  is  in  an 
erect  posture,  the  lower  extremities  being  firmly  planted  on  the  ground. 
Many  years  ago,  a  good  example  of  the  first-mentioned  kind  of  accident  came 
under  my  observation  : — 

A  young  farmer,  aged  about  20,  accidentally  slid  down  from  a  steep  hay-mow,  and 
then  falling  about  fourteen  feet,  struck  the  ground  upon  his  buttocks.    He  received 
thereby  a  violent  jar  in  the  lumbo-sacral  region.    His  head  and  shoulders  sank  back- 
Avard  to  the  earth,  where  he  lay  for  some  time,  unable  to  arise,  barely  able  to  move  his 
legs  a  little  (they  also  felt  benumbed),  and  suffering  terribly  from  pains  in  both  lumbar 
regions.    At  first,  he  thought  his  "back  was  broke."    However,  after  he  had  lain  wet 
wilh  cold  sweat  for  some  httle  time,  he  began  to  feel  less  faint,  or  a  little  stronger,  and 
found  himself  able  to  move  his  lower  extremities  rather  better.    The  pains,  too,  gradually 
abated,  and  then  turning  himself  partly  over,  he  tried  to  make  his  way  to  the  house  by 
crawling  on  his  belly  ;  but  these  efforts  increased  the  lumbar  pains  so  much  that  he  was 
compelled  to  desist.    After  lying  quite  still,  a  little  longer,  he  found  that  the  paral}^sis 
of  his  lower  extremities  was  considerably  lessened,  and  that  possibly  he  might  arise. 
After  many  efforts  he  succeeded  in  doing  so,  his  legs,  meanwhile,  having  given  way 
under  him  several  times  like  those  of  a  drunken  man.    He  walked  with  the  feeble  and 
uncertain  steps  of  an  intoxicated  person,  from  the  weakness  of  his  lower  limbs  ;  but 
after  much  effort,  he  succeeded  in  getting  to  the  house,  a  distance  of  about  two  hundred 
yards,  without  any  assistance.    He  was  immediately  placed  in  bed.    There  was  con- 
siderable swelling  across  the  loins,  and  much  tenderness  was  discovered  by  pressing 
upon  the  lumbar  spinous  processes.    Tenderness  was  also  discovered  in  and  around  the 
bodies  of  the  last  three  lumbar  vertebrae,  on  pressing  upon  them  through  the  front  wall 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


•280 


of*  the  abdomen.  There  was  no  displacement  of  the  bodies  or  spinous  processes  of  tiie 
vertebra^.  For  several  days,  the  loins  were  fomented  with  a  strong  decoction  of  chamo- 
mile flowers  and  wormwood.  His  favorite  posture  in  bed  was  that  of  lying  upon  the 
side  (it  did  not  seem  to  matter  w^hich  side),  with  his  body  semi-flexed,  and  knees  drawn 
up.  For  many  days  he  was  reluctant  to  make  any  change  whatever  in  his  posture, 
because  of  the  excruciating  pains  in  the  lumbar  region,  which  every  little  twist  or 
flexure  of  the  injured  articulations  of  the  spine,  and  every  contraction  of  the  lumbar 
muscles,  gave  rise  to.  As  continuous  confinement  to  bed  was  enforced,  tiie  first  im- 
portant evidence  that  he  was  recovering  was  noted  when  he  began  to  move  himself 
about  in  bed,  of  his  own  accord.  On  discontinuing  the  fomentations,  a  large  belladonna 
plaster  was  applied  to  the  loins.  He  was  confined  to  bed  just  lour  weeks,  and  the  com- 
plete rest  of  the  injured  parts,  thus  secured,  was  the  chief  means  relied  upon  to  promote 
his  recovery.  He  wore  belladonna  plasters,  and  complained  of  feeling  lame  and  weak 
in  the  lumbar  region  for  a  long  time  afterward  ;  but,  in  the  end,  he  perfectly  recovered. 

In  this  case,  the  articulations  of  the  lumbar  vertebrse  were  wrenched  in  a 
peculiar  manner.  The  young  man's  buttocks,  in  falling  from  a  height  of  fully 
fourteen  feet,  struck  the  ground  with  great  force.  At  that  instant,  the  lower 
part  of  the  spinal  column  was  suddenly  compelled  to  support  the  weight  and 
impetus,  or  momentum,  of  all  parts  of  the  body  situated  above  the  loins,  the  first 
effect  of  which  was  to  compress  the  intervertebral  substances,  to  be  followed, 
however,  in  an  instant  afterward,  by  a  violent  bending  of  the  spinal  column 
backward,  at  the  peculiar  curvature  formed  by  the  lumbar  vertebrae  on  top 
of  the  sacral  curvature.  The  greatest  part  of  the  strain,  therefore,  fell  upon 
the  articulations  of  the  last  three  lumbar  vertebrpe  ;  and,  at  the  same  time, 
the  intervertebral  substance  and  the  bodies  of  these  vertebrae  were  in  the  line 
of  extension.  In  this  way,  the  anterior  and  posterior  common  ligaments  of 
the  spine,  and  the  intervertebral  substances,  in  the  lumbar  region,  together 
with  the  psoas  muscles,  were  all  severely  stretched ;  and  this  circunistance 
accounts  for  the  fact  that  much  tenderness  under  pressure  was  discerned  on 
examining  the  lumbar  vertebrae  through  the  front  wall  of  the  abdomen.  The 
nature  of  the  lesion  also  explains  why  it  was  that  the  attempt  to  crawl  on 
the  belly  caused  so  much  increase  of  the  pains  in  the  injured  part ;  for,  on 
elevating  the  shoulders  in  order  to  execute  the  movements  which  constitute 
crawling,  the  injured  vertebral  ligaments  and  muscles  were  again  put  on  the 
stretch. 

A  good  illustration  of  the  last-mentioned  kind  of  accident,  in  which  the 
vulnerating  force  is  indirectly  applied  to  the  lumbar  region,  was  lately  under 
my  care : — 

E.  B.  C,  aged  about  60,  while  walking  in  the  second-story  hall  of  an  old  house, 
January  21,  1882,  entirely  oblivious  of  danger,  was  suddenly  struck  on  top  of  the  head 
by  a  mass  of  plastering,  estimated  to  weigh  over  two  hundred  pounds,  that,  having 
become  loosened,  had  fallen  down  from  the  ceiling,  which  itself  was  rather  lofty,  being 
about  sixteen  feet  high.  The  blow  on  the  head,  of  course,  was  exceedingly  violent ; 
it  gave  him  a  scalp-wound  two  and  one-half  inches  long  over  the  right  parietal  bone,  with 
severe  concussion  and  contusion  of  the  brain.  His  body  was  also  bent  forward,  and 
doubled  up,  by  the  force  of  the  blow  on  the  head  and  the  weight  or  momentum  of  the  falling 
mass  of  plastering,  so  that  he  was  instantly  crushed  down  to  the  floor,  where  he  lay  stunned 
for  some  little  time.  The  forcible  bending  forward  and  doubling  up  of  his  body  took 
place  at  the  loins  ;  and  thus  the  lumbar  muscles  and  the  articulations  of  the  first,  second, 
and  third  lumbar  vertebrae  were  badly  strained.  Obviously,  the  structures  of  the  fore- 
part of  his  spinal  column  suffered  powerful  compression  at  the  place  of  forcible  flexure, 
while  those  at  the  back-part  thereof  were  subjected  to  violent  elongation  and  over- 
stretching. The  cerebral  lesion  masked  to  a  great  extent  the  subjective  symptoms  of 
the  lumbar  lesions,  for  a  considerable  time  ;  but,  objectively,  there  soon  arose  a  swell- 
ing across  the  injured  loins  which  attained  the  thickness  of  a  man's  hand,  was  very 
tender  under  pressure,  and  lasted  a  long  time.  Tiie  quietude  and  other  remedial  mea- 
VOL.  IV. — 19 


290 


INJURIES  OF  THE  BACK. 


sures  that  the  cerebral  contusion  demanded,  were  sufficient  to  relieve  the  lumbar  lesions 
also,  so  that  no  special  medication  was  ordered  for  the  lumbar  region  until  April  12, 
when  a  large  belladonna  plaster  was  prescribed,  giving  much  relief.  His  recovery,  how- 
ever, was  not  complete  (as  to  the  loins)  until  the  1st  of  June. 

Usually,  considerable  swelling  across  the  loins  soon  follows  such  injuries 
of  the  lumbar  region  as  have  just  been  described.  Subcutaneous  ecchymosis 
may  or  may  not  attend  the  tumefaction.  Sometimes  the  ecchymosis  does  not 
appear  until  several  days  after  the  accident.  On  tracing  the  spinous  processes 
with  the  fingers,  their  positions  are  found  to  be  the  same  as  in  the  normal 
state.  On  examining  the  bodies  of  the  lumbar  vertebrse  through  the  anterior 
wall  of  the  abdomen,  no  displacement  is  detected.  Tenderness  under  pres- 
sure, in  such  cases,  is  usually  observed  over  a  considerable  space.  Oftentimes 
the  patient,  with  evident  difficulty,  and  much  exhibition  of  pain  and  weak- 
ness in  the  loins,  will  endeavor  to  place  his  vertebral  column  in  an  erect 
position ;  if  his  eflbrts  be  successful,  and  no  deformity  be  presented,  it  may 
confidently  be  assumed  that  there  is  no  fracture.  The  posture  which  patients 
having  lumbar  sprains  generally  assume  in  bed,  is,  as  described  above,  that 
of  lying  on  one  side,  with  the  trunk  semi-flexed,  and  the  knees  drawn  up  ; 
and,  for  many  days,  they  are  usually  reluctant  to  make  any  change  of  posi- 
tion, from  dread  of  the  pains  and  sjDasms  in  the  injured  muscles,  which  all 
attempts  at  movement  are  liable  to  excite.  When  such  patients  begin  to 
move  themselves  about  in  bed,  of  their  own  accord,  they  furnish  the  best 
possible  evidence  of  progress  toward  recovery. 

The  treatment^  as  shown  above,  does  not  differ  essentially  from  that  of 
sprained  joints  in  general.  The  most  important  point  is  to  enforce  absolute 
quietude  of  the  injured  parts  for  a  sufficient  length  of  time.  Commonly,  it 
requires  from  four  to  six  weeks'  confinement  to  bed  for  recovery  to  take 
place.  If  the  bowels  be  at  all  confined,  a  mercurial  purge  may  be  adminis- 
tered with  advantage.  If  there  be  febrile  movement  of  a  sthenic  character, 
saline  drinks  may  be  given  with  benefit,  and  the  diet  should  be  low  while  it 
continues.  Should  the  lumbar  pains  or  the  muscular  spasms  prove  trouble- 
some, they  may  be  quieted  by  exhibiting  opium  in  the  form  of  Dover's  powder. 
The  diet  must  be  nourishing  in  asthenic  cases,  and  in  all  others  likewise 
after  the  acute  stage  has  been  passed.  Fomentations  with  decoction  of  poppies, 
applied  to  the  injured  loins,  also  appear  to  do  good.  But  those  which  consist 
of  a  strong  decoction  of  chamomile  and  wormwood  (mentioned  above),  are 
perhaps  still  better.  At  a  later  period,  camphorated  oil,  or  camphorated 
soap-liniment,  should  be  used  instead  of  fomentations.  The  patient,  when 
about  to  leave  his  bed,  should  be  furnished  with  a  riding-belt  stiffened  with 
additional  whalebone.  (Shaw.)  At  the  same  time,  a  large  belladonna  plaster 
can  generally  be  applied  with  benefit. 

Inflammation  of  the  Vertebral  Articulations  arising  from  Sprains, 
Twists,  or  Wrenches. — From  such  injuries,  an  inflammation  of  the  over- 
stretched or  lacerated  ligaments,  tendons,  muscles,  and  connective  tissue, 
more  or  less  severe  according  to  the  nature  of  the  case,  soon  ensues.  This 
appearance  of  inflammatory  reaction  in  the  damaged  tissues  is  a  necessary 
consequence  of  the  original  lesions.  Its  occurrence  should,  therefore,  be 
anticipated,  and  its  treatment  should  likewise  be  provided  for  by  the  sur- 
geon from  the  very  outset  of  the  case.  Moreover,  this  traumatic  inflamma- 
tion may,  in  general,  be  completely  controlled  by  patiently  applying  the 
principles  and  methods  of  treatment  just  enunciated.  But  when  the  presence 
of  traumatic  inflammation  in  the  vertebral  joints  happens,  from  any  cause,  to 
be  unrecognized,  or,  if  recognized,  \o  be  made  light  of,  and  when,  therefore, 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


291 


Fig.  858. 


the  disorder  receives  no  treatment  whatever,  or  at  best  is  very  inadequately 
treated,  then  the  inflammatory  process  is  quite  liable  to  become  chronic  and 
suppurative  in  character,  and,  in  the  end,  to  destroy  the  vertebral  articula- 
tions involved,  just  in  the  same  way  as  the  joints  of  the  extremities  are  de- 
troyed  by  disease  under  similar  circumstances.  It  is  this  chronic  or  consecu- 
tive disorder  of  the  vertebral  articulations,  that  not  unfrequently  results  from 
sprains  and  twists,  or  wrenches,  of  the  vertebral  column,  which  we  have  now 
to  consider.  It  is,  perhaps,  more  often  met  with  in  cases  where  the  symptoms 
of  injury  originally  are  not  severe,  than  in  cases  where  they  are  strongly 
marked ;  for,  in  the  latter  instance,  the  severity  of  the  symptoms  themselves 
will  be  apt  to  secure  that  thoroughness  and  sufficiently  long  continuance 
of  treatment  which  is  indispensable  for  recovery.  However  this  may  be,  it 
nevertheless  is  certain  that  this  disorder  not  unfrequently  appears  in  cases 
where  the  symptoms  of  vertebral  injury  have  been  originally  by  no  means 
severe ;  and  sometimes,  too,  in  cases  where  the  symptoms  of  vertebral  injury 
have  been  comparatively  slight  at  the  outset,  so  that  the  disastrous  conse- 
quences have  unexpected!}^  ensued.  When  the  articulations  of  the  spine  that 
have  been  damaged  by  sprains,  etc.,  are  occupied  by  chronic  inflammation, 
they  are  liable  to  exhibit  at  first  gradually  increasing  tumefaction  and  indura- 
tion ;  then  indolent  suppuration,  like  that  which  takes  place  in  other  joints 
that  are  similarly  aflected,  and,  finally,  ulceration  of  the  cartilages  and  caries 
of  the  vertebrae. 

Among  the  earliest  symptoms  in  these  cases,  not  unfrequently,  are  pains, 
located  not  in  the  spine  itself,  but  in  the  parts  supplied  by  the  terminal 
branches  of  the  sensory  nerves  which  issue 
from  the  vertebral  column  at  the  seat  of  the 
lesion,  and  give  rise  to  the  pains,  because 
their  filaments  are  irritated  by  the  inflamma- 
tory process  going  on  in  the  intervertebral 
foramina  through  which  they  pass.  Several 
examples  have  already  been  presented  where 
disease  of  this  sort,  situated  between  the  first 
and  second  cervical  vertebrae,  was  attended 
by  pains  located  on  the  back  part  of  the  head, 
behind  the  ears,  etc.,  because  the  occipitalis 
major  and  minor  nerves  with  the  auricularis 
magnus  were  irritated  in  this  manner  within 
the  spinal  column  (see  Fig.  857).  In  such 
cases,  the  pains  due  to  the  spinal  disease  are 
apt  to  be  mistaken  tor  rheumatic  pains,  and 
to  be  maltreated  accordingly.  In  like  man- 
ner, pains  at  the  pit  of  the  stomach  may  be 
caused  by  diseases  ot  the  dorsal  vertebrae, 
which  irritate  the  sixth  and  seventh  dorsal 
nerves  (see  Fig  858).  Mr.  Hilton  presents 
two  examples  which  well  illustrate  this  point. 
Both  patients,  however,  made  good  recove- 
ries, by  adopting  rest  as  the  chief  remedial 
agent,  and  without  applying  anythmg  to  the 
dorsal  region.*  Mr.  Hilton  also  points  out  that 
these  pains  are  almost  always  symmetrical, 
that  is,  alike  on  both  sides  ot  the  median  plane,  when  they  arise  from  disorders 
in  the  lower  cervical,  dorsal,  or  lumbar  vertebrae,  whilst  they  often  are  uni- 


Side  view  of  the  chest  and  abdomen, 
showingr  the  course  of  the  sixth  and  seventh 
dorsal  nerves.  (Hilton.) 


Op.  eit.,  pp.  48-50. 


292 


INJURIES  OF  THE  BACK. 


lateral,  or  one-sided,  when  caused  by  disorders  betweeii  the  occiput  and  the 
atlas,  or  between  the  atlas  and  the  a^is.  The  most  probable  explanation  of 
this  peculiarity  is,  that  a  spinal  disorder  occurring  between  the  occiput  and 
the  atlas,  or  between  the  atlas  and  the  axis,  may  be  confined  to  only  one  of 
the  joints  between  these  bones,  whilst  a  disorder  of  the  lower  cervical,  dorsal, 
or  lumbar  vertebrae,  generally  involves  the  bodies  of  the  vertebrae  or  the  in- 
tervertebral substances,  entirely  or  completely.^  I  have,  however,  lately  seen 
a  case  wherein  pains  of  this  sort,  that  were  caused  by  chronic  inflammation 
following  a  wrench  of  the  lumbar  vertebrae,  appeared  on  one  side  only. 

The  following  case,  which  is  related  by  Mr.  Hilton,  illustrates  the  symp- 
toms of  this  lesion,  when  it  involves  the  eighth  and  ninth  dorsal  vertebrae, 
in  a  most  useful  manner : — 

It  is  that  of  a  moderately  robust  little  girl,  aged  4^  years,  who,  while  enjoying  good 
health,  fell  down  out  of  bed  upon  her  back,  a  distance  of  about  two  feet.  But  nothing 
appears  to  have  been  thought  of  it  at  the  time,  though  she  at  once  began  to  lose  flesh, 
and  her  face  become  anxious.  About  three  months  afterwards,  she  began  to  complain 
of  symmetrical  pains  in  her  belly,  was  easily  fatigued  also,  and  stooped  a  little  in  walk- 
ing. Her  fall  upon  the  back  having  been  forgotten,  she  was  treated  for  the  abdominal 
affection  by  several  surgeons,  but  rapidly  grew  worse  instead  of  better.  She  became 
much  reduced  in  flesh  and  strength,  and  unable  to  walk  about,  from  spasmodic  pinching 
pain  in  the  abdomen,  which  "  doubled  her  up."  In  a  -short  time,  however,  having 
been  kept  quiet  in  bed,  she  recovered  her  flesh  and  strength,  so  as  to  be  enabled  to  walk 
about  a  little  without  pain.  But,  quickly,  all  the  untoward  symptoms  again  super- 
vened ;  the  abdomen  became  large  and  tumid,  the  bowels  irregular,  with  pain  in  the 
belly,  as  if  a, cord  were  drawn  tightly  around  the  abdomen  and  tied.  Another  surgeon 
was  now  consulted,  who  declared  the  mesenteric  glands  affected.  The  urine  was  phos- 
phatic  and  ammoniacal.  She  was  allowed  to  go  about  as  usual.  In  a  short  time  the 
alteration  and  unsteadiness  of  gait  became  more  marked,  and,  the  other  symptoms  con- 
tinuing, she  was  taken  to  London  for  advice.  Disease  of  the  eighth  and  ninth  dorsal 
vertebrae  was  detected,  with  slight  projection  backward,  or  angular  curvature.  Her  tall 
upon  the  back  h?ld  recently  been  remembered.  Uninterrupted  rest  in  the  recumbent 
posture  was  ordered,  with  no  medicine,  and  the  child  completely  recovered  in  four  or  five 
months.^ 

It  is  apparent  that  in  this  ease  the  real  cause  was,  for  a  long  time,  entirely 
overlooked  ;  that  the  abdominal  symptoms  were  treated  as  depending  on 
Bome  error  in  the  abdominal  viscera,  when  they  w^hoUy  depended  on  the 
spine  ;  and  that  the  spinal  condition  itself  was  meanwhile  altogether  ignored. 
"Nevertheless,  almost  all  the  symptoms  which  attend  chronic  inflammations 
of  the  veYtebral  joints,  in  consequence  of  neglected  sprains  and  wrenches, 
were  present  in  this  case.  For  example,  there  were  pains  in  the  belly, 
which  w^ere  due  to  irritation  of  the  sensory  filaments  of  the  ninth  pair  of 
dorsal  nerves.  There  were  also  cramps  or  muscular  spasms  in  the  belly, 
which  were  caused  by  irritation  of  the  motor  filaments  of  the  same  pair  of 
nerves,  during  their  passage  through  the  intervertebral  foramina.  Besides, 
there  was  paraplegia  (incomplete),  which  probably  resulted  from  compression 
of  the  spinal  cord.  The  urine,  too,  became  phosphatic  and  ammoniacal,  and 
the  bowels  tympanitic,  in  consequence  of  accompanying  myelitis.  More- 
over, the  appearance  of  angular  curvature  of  the  spine,  at  the  seat  of  mjury, 
served  to  show  exactly  what  joint  was  sprained,  and  the  nature  of  the  dis- 
order which  invaded  the  bodies  of  the  contiguous  Vertebrae  in  consequence  of 
the  articular  lesions.  By  adding  to  this  account  of  the  symptoms,  a  state- 
ment that  tenderness  under  pressure  and  some  swelling  of  the  soft  parts  were 
found  over  the  eighth  and  ninth  dorsal  vertebrae,  which  without  doubt  was 


1  Ibid.,  pp.  51,  52. 


«  Ibid.,  pp.  52,  53. 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


293 


the  case,  a  complete  picture  of  the  symptoms  pertaining  to  the  disorder  in 
question  is  presented.  So  much,  then,  for  the  symptoms  which  are  liable  to 
result  from  traumatic  spinal  arthritis,  when  it  becomes  chronic  and  advances 
unchecked  for  some  considerable  time ;  or  until  caries  of  the  bodies  of  the 
contiguous  vertebrae  ensues. 

Caries  of  the  vertebrae,  however,  Avill  not  be  specially  discussed  in  this 
article,  as  it  will  be  fully  dealt  with  elsewhere.  Inflammation  of  the  verte- 
bral joints  is  here  considered  only  in  so  far  as  it  is  a  consequence  of  sprains 
and  twists  or  w^renches  of  these  jomts,  and  in  so  far  as  it  becomes  necessary 
for  surgeons  to  thoroughly  understand  the  symptoms,  final  results,  and  treat- 
ment of  these  hurts,  in  order  to  recognize  their  importance,  and  take  care  of 
them  in  such  a  manner  as  to  save  patients  from  the  great  evils  which,  Avhen 
neglected,  they  are  liable  to  cause.  To  this  end  I  have  presented  the  fore- 
going examples  and  observations  that  illustrate  these  forms  of  injury,  and 
the  principles  which  should  guide  their  treatment.  It  is  necessary,  still,  to 
point  out  briefly  some  direful  consequences  of  these  lesions  which  have  not 
yet  been  mentioned,  and  which  are  as  follows:  (1)  The  consecutive  inflamma- 
tion may  extend  to  and  destroy  the  spinal  nerves  that  are  contiguous  to  the 
injured  articulations,  and  thus  cause  permanent  paralysis  of  the  parts  w^hich 
they  supply.  (2)  The  consecutive  inflammation  may  spread  from  the  joints 
of  the  spine  to  the  theca  vertebralis,  and  thus  induce  spinal  meningitis. 
What  then  is  chiefly  to  be  apprehended  is,  that  the  product  of  this  meningeal 
inflammation,  on  being  eft  used  into  the  spinal  arachnoid  cavity,  may  c"om- 
press  the  spinal  cord  so  as  to  arrest  its  functions,  and  thereby  cause  paraplegia, 
or  even  death.  (3)  The  consecutive  inflammation  may  spread  still  further 
toward  the  centre,  and  attack  the  spinal  cord  itself,  thereby  causing  spinal 
myelitis,  and,  in  this  manner,  paralysis  witi!  a  fatal  result.  Happily,  how- 
ever, there  is  not  the  same  risk  that  an  inflammation  which  involves  the 
bones  of  the  vertebral  column  will  spread  inward,  and  successively  attack  the 
spinal  meninges  and  the  spinal  cord,  as  there  is,  in  cases  where  the  cranial 
bones  are  inflamed,  that  the  inflammatory  process  will  spread  inward  and  suc- 
cessively attack  the  cerebral  meninges  and  the  cerebral  substance ;  for,  in  the 
head,  the  dura  mater,  being  flrmly  adherent  to  the  cranium,  performs  the 
office  of  an  internal  periosteum,  whilst,  in  the  spine,  not  only  does  each  verte- 
bra possess  a  distinct  periosteum,  but  the  theca  vertebralis,  or  spinal  dura 
mater,  is  also  comparatively  free,  being  attached  by  a  very  loose  connective 
tissue  only  to  the  walls  of  the  spinal  canal.  Whilst  the  cranium,  the  cerebral 
meninges,  and  the  brain  itself,  are  formed  in  close  connection  with  each  other, 
the  vertebral  column,  the  spinal  meninges,  and  spinal  cord  are  formed  in  loose 
array ;  and,  therefore,  an  inflammation  cannot  extend  itself  from  one  structure 
to  another,  through  contiguity,  in  the  latter  organs,  with  anything  like  the 
same  facility  that  it  can  in  the  former. 

After  long  and  wide  experience,  Mr.  Hilton  concludes :  "  I  have  generally 
found  that  almost  all  these  diseases  of  the  spine  are  the  result  of  slight  acci- 
dents overlooked."^  It  has  been  shown  in  the  preceding  pages,  that  slight 
falls  upon  the  back,  especially  on  the  dorsal  region  thereof,  and  where  the 
intervertebral  substances  and  bodies  of  the  vertebrae  are  situated  in  the  line 
of  extension,  and  the  laminae,  spinous  processes,  etc.,  in  that  of  compression, 
may  be  attended  by  detachment  (more  or  less  extensive)  of  the  intervertebral 
substances  from  the  vertebral  bodies,  and  that  these  lesions,  if  overlooked  or 
maltreated,  can  lead  to  all  the  evil  results  that  have  been  mentioned  above. 
The  importance  of  continuous  rest  in  bed,  as  a  remedial  measure,  in  such 
cases,  cannot  be  over-estimated,  and  must  not  be  forgotten. 


1  Ibid.,  p.  52. 


294 


INJURIES  OF  THE  BACK. 


HEMATURIA  FROM  CONTUSIONS  AND  SpRAiNS  OF  THE  Back.  —  Traumatic 
lesions  of  the  kidneys,  with  bloody  urine,  occur  so  frequently  in  cases  where 
severe  contusions  and  strains,  or  wrenches,  are  sustained  in  the  lumbar  regions, 
that  a  pretty  full  account  of  them  is  necessary  in  this  place. 

The  source  of  the  hemorrhage,  in  these  cases,  it  is  seldom  difficult  to  deter- 
mine ;  for,  when  blood  is  found  intermingled  with  the  urine,  after  such 
injuries  of  the  loins,  it  may  generally  be  inferred  with  safety  that  one  (at 
least)  of  the  kidneys  is  also  injured.  When,  however,  slender,  cylindrical, 
pale  pieces  of  fibrin,  or  dark-colored  coagula  having  a  similar  shape,  are  seen 
in  the  urine,  the  surgeon  may  be  sure  that  the  blood  has  come  from  the 
kidney,  for  these  clots  have  been  moulded  in  the  ureter  and  then  have  been 
washed  down  therefrom  by  the  urine.  Moreover,  when  blood  is  passed  inti- 
mately blended  with  the  urine,  but  without  coagula,  in  cases  of  lumbar  injury, 
it  has  likewise,  in  all  probability,  a  renal  origin. 

It  will  be  remembered  that  the  kidneys  are  two  dense  and  rather  brittle 
glands  which  lie  close  to  the  sides  of  the  spinal  column  from  the  first  to  the 
third  lumbar  vertebrae  inclusive,  and  outside  of  the  peritoneum;  that  they  are 
surrounded,  and  held  in  place  with  considerable  firmness,  by  connective  tissue 
containing  much  fat ;  that  the  right  kidney  lies  rather  lower  than  the  left ; 
and  that  each  of  them  projects  downward  below  the  last  rib,  and,  behind,  is 
covered  by  the  quadratus  lumborum  muscle.  Hence,  all  violent  flexures  of 
the  upper  1  umbo- vertebral  articulations  from  sprains  or  wrenches  are  liable 
to  be  attended  by  corresponding  bends  and  breaks  of  the  kidneys ;  hence, 
also,  the  impact  of  powerful  blows  on  the  lumbar  muscles  may  readily  be 
transmitted  through  these  muscles  to  the  kidneys  themselves,  with  enough 
force  to  contuse  or  even  tear  those  organs.  Finally,  the  renal  lesion  in  these 
cases,  whether  consisting  merely  of  contusion,  or  of  slight  rupture,  or  of 
extensive  laceration  of  the  renal  substance,  is  usually  attended  by  hsematuria. 

But,  when  the  kidneys  contain  calculi,  and  when  they  are  congested,  as,  for 
example,  in  the  first  stage  of  Bright's  disease,  or  when  their  texture  has 
become  weakened,  as,  for  instance,  in  chronic  parenchymatous  nephritis,  com- 
paratively slight  injuries  of  the  lumbar  region  may  be  attended  by  heematuria. 

The  clinical  features  or  characteristics  of  the  above-mentioned  forms  of 
renal  injury  can  best  be  presented  by  the  narration  of  some  examples.  In 
military  life,  the  blow  on  the  lumbar  region  which  causes  the  mischief,  may 
result  from  the  explosion  of  a  shell,  as  happened  in  the  following  instances, 
two  in  number,  which  w^ere  reported  during  the  late  civil  war : — 

J.  H.  P.,  Co.  K,  142d  Pennsylvania  Vols.,  aged  20,  was  struck  on  the  left  lumbar 
region,  July  2,  1863,  at  Gettysburg,  by  a  large  fragment  of  shell,  which  caused  a  grave 
contusion  with  ecchymosis,  but  without  abrasion  of  the  skin.  There  was  shock,  and 
much  pain  and  tenderness  at  the  injured  part,  and  the  urine  was  scanty  and  bloody. 
The  pain  extended  along  the  course  of  the  ureter,  and  there  was  retraction  of  the  tes- 
ticle with  smarting  at  the  orifice  of  the  urethra.  There  was  much  difficulty  in  micturi- 
tion, and  occasionally  tubular  clots  of  blood  were  passed,  after  wdfich  the  urine  flowed 
in  a  stream,  with  great  relief.  The  patient  was  also  suffering  from  diarrhoea.  He  was 
treated  with  hot  fomentations  applied  to  the  injured  part,  and  with  chalk  mixture  and 
spirit  of  nitric  ether,  until  the  11th,  when  he  had  rallied  sufficiently  to  be  transferred 
to  the  Satterlee  Hospital,  at  Philadelphia.  There  he  was  treated  wnth  infusion  of 
buchu,  together  with  counter-irritation  applied  to  the  loins ;  and,  as  soon  as  the  irrita- 
bility of  his  bowels  permitted,  he  was  placed  on  nourishing  diet,  with  ferruginous  medi- 
cines, and  bitter  tonics.  The  haematuria  disappeared  after  the  third  week  from  the 
reception  of  the  injury.  The  patient  gradually  convalesced,  and,  on  December  31, 
1863,  was  transferred  to  the  Invalid  Corps.^ 


»  Med.  and  Surg.  History  of  the  War  of  the  Rebellion,  Second  Surgical  Vol.,  pp.  20,  21. 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


21)5 


This  example  aftbrds  a  good  clinical  illustration  of  the  traumatic  lesion  of 
the  kidneys,  by  which  powerful  blows  on,  or  violent  contusions  of,  the 
lumbar  regions,  are  not  unfrequently  accompanied.  The  renal  symptoms 
were  very  clear.  They  w^ere  shock,  pain  in  the  bruised  and  torn  kidney, 
which  extended  downw^ard  along  the  course  of  the  corresponding  ureter,  with 
retraction  of  the  testicle  on  the  same  side,  and  smarting  at  the  urethral 
orifice.  The  urine  was  bloody,  and,  at  times,  contained  also  coagula  which 
had  been  moulded  in  the  ureter.  At  such  times  the  act  of  urination  was 
very  difiicult,  and  the  difficulty  lasted  until  the  coagula  had  passed  through 
the  urethral  canal.  Their  voidance  was  always  followed  by  copious  urina- 
tion, and  by  a  sense  of  great  relief.  The  hsematuria  continued  for  three 
weeks,  but  the  patient  gradually  recovered. 

From  the  nature  of  the  vulnerating  force,  from  the  presence  of  shock, 
from  the  intensity  and  persistency  of  pain  in  the  injured  kidney  and  its  ex- 
cretory duct,  etc.,  from  the  long  continuance  of  hsematuria,  and  from  the 
severity  of  the  renal  symptoms  in  general,  it  is  but  just  to  infer  that  the  renal 
lesion  in  this  case  w^as  extensive,  and  probably  consisted  of  laceration  as  well 
as  contusior^  of  the  renal  parenchyma.  jSTotwdthstanding,  the  patient  slowly 
regained  his  health.  This  pohit  is  of  much  practical  importance;  for,  aside 
from  other  considerations,  the  happy  result  helps  to  show  that  rupture  of  the 
kidney  is  an  accident  from  which  recovery  is  more  common  than  it  is  from 
a  similar  lesion  of  any  other  important  viscus. 

The  next  case  belongs  to  the  same  category  as  the  last : — 

Lieutenant  H.  T.  Burrows,  Co.  C,  7th  Maryland  Vols.,  was  struck  May  5,  1864, 
by  a  fragment  of  shell,  on  the  left  lumbar  region.  He  was  treated  during  one  week  at 
the  second  division  hospital  of  the  Fifth  Corps,  in  the  field.  Severe  pain  and  difficult 
micturition,  with  haematuria,  led  to  the  belief  that  laceration  of  the  left  kidney  had 
resulted.  On  the  1 2th,  this  officer  was  sent  to  Washington,  and  there  was  treated  in 
quarters.    He  recovered ;  and,  on  June  8,  he  was  placed  on  court-martial  duty.^ 

Besides  the  examples  just  related,  there  were  also  observed,  during  the  late 
civil  w^ar,  a  number  of  cases  of  recovery  in  wdiich  there  was  reason  to  sus- 
pect the  existence  of  laceration  of  the  kidney,  or,  at  least,  of  severe  contusion 
of  its  substance.  Unfortunately,  they  are  not  reported  with  fulness  or  pre- 
cision of  detail."^  Taking  these  cases,  however,  for  what  they  are  worth,  they 
will  serve  to  increase  considerably  the  aggregate  of  instances  in  which  trau- 
matic lesions  of  the  kidneys,  attended  with  h?ematuria,  and  caused  by  lumbar 
contusions,  have  eventuated  in  cure;  and,  for  this  reason,  I  have  thought  it 
worth  while  to  mention  them. 

Mr.  Shaw  refers  to  the  case  of  a  woman  who  had  been  bruised  in  the  loins,  from  the 
falling  in  of  the  roof  of  her  dwelling ;  and  who,  it  was  claimed,  had  sustained  a  renal 
lesion  thereby.®    Albuminuria  also  was  present. 

When  great  strains  or  wrenches  of  the  vertebral  articulations  in  the  lumbar 
region  are  caused  by  alighting  upon  the  feet  in  falling,  the  kidney  may  be 
extensively  ruptured  at  the  same  time,  as  happened  in  the  following  instance 
reported  by  Dr.  Anders : — 

A  well-built  lad,  aged  15,  fell  from  the  second  floor  ot  a  house  to  the  ground,  with- 
out becoming  insensible.  He  said  that  he  struck  the  ground  first  with  his  feet,  and 
then  with  his  right  hip.  No  external  mark  of  injury,  excepting  a  slight  purplish  spot 
over  the  right  trochanter.  No  fracture  of  any  kind,  and  no  symptom  of  concussion  of 
ihft  brain  or  spinal  cord.    He  could  not  walk  very  well,  but  was  able  to  move  his 


I  Ibid.,  p.  21.  «  Ibid.,  p.  20. 

*  Holmes's  System  of  Surgery,  2d  edition,  vol.  ii.  p  363,  foot-note 


296 


INJURIES  OF  THE  BACK. 


extremities  freely  when  lying  in  bed.  Pulse  60,  and  small ;  sensibility  not  decreased. 
He  freely  passed  bloody  urine.  He  complained  of  severe  pain  in  the  abdomen,  espe- 
cially in  the  left  renal  region,  but  nothing  abnormal  could  be  detected  by  inspection  or 
palpation.  The  microscope  showed  the  urine  to  contain  a  large  number  of  red  blood- 
corpuscles.  Well-marked  symptoms  of  internal  hemorrhage  appeared  and  increased  ; 
and,  at  11  A.  M.  next  day,  he  died  in  consequence  of  inward  bleeding.    During  the 

night  the  urine  was  very  little  bloody.    In  the  morning  it  was  quite  clear.  Autopsy  

A  darli-blue  tumor  of  the  size  of  a  child's  head,  extending  from  the  iliac  fossa  to  above 
the  tenth  rib,  and  covering  the  three  superior  lumbar  vertebrae,  was  found  in  the 
abdominal  cavity.  It  consisted  of  coagulated  blood,  wherein  the  left  kidney,  which 
had  been  torn  into  two  distinct  halves,  was  found  imbedded.  The  rupture  was  trans- 
verse, extending  from  the  anterior  superior  part  of  the  organ  to  the  posterior  inferior, 
througli  the  capsule  and  the  parenchyma.  The  pieces  of  the  kidney  were  about  two 
inches  distant  from  each  other,  and  entirely  separated  from  their  adhesions.  The  left 
ureter  was  torn  across,  and  was  attached,  to  the  length  of  two  inches,  to  the  lower  frag- 
ment ;  the  corresponding  renal  vein  and  artery  were  in  the  same  condition.  The  right 
kidney  was  perfectly  sound.  The  peritoneum  was  not  ruptured.  No  fluid  was  con- 
tained in  the  abdominal  cavity,  and  no  blood  in  the  bladder.^ 

In  this  case,  the  left  kidney,  together  with  the  accompanying  ureter,  renal 
vein,  and  renal  artery  were  torn  completely  across,  while  all  the  other  organs 
were  unaffected ;  and  the  force  which  caused  this  immense  laceration  had 
been  indirectly  applied. 

The  rationale  of  the  h?ematuria  was  probably  as  follows :  The  blood  being 
still  liquid,  for  some  hours  after  the  accident,  flowed  down  through  the 
severed  ureter  into  the  bladder,  and  this  sanguinolent  flow  continued  until 
the  ureter  itself  became  plugged  by  tlie  formation  of  coagulum.  Then  the 
urine  which  was  secreted  by  the  right  kidney  remained  clear,  that  is,  un- 
stained with  blood,  and  in  that  condition  was  discharged  in  the  morning 
before  the  patient  died. 

But,  the  lacerations  of  the  kidneys  which  result  from  falling  upon  the  feet, 
buttocks,  or  back,  etc.,  are,  for  the  most  part,  also  attended  with  lacerations 
of  other  important  viscera,  as  was  observed  in  the  following  instance  recorded 
by  Professor  Fayrer : — 

The  patient,  a  Hindoo,  aged  25,  fell  from  a  tamarind  tree,  and  fractured  both  arms. 
He  was  brought  to  the  hospital,  and  appropriately  treated  ;  but  the  wounds  did  not  do 
well,  and  he  died  in  consequence  of  tetanus,  sixteen  days  after  the  event.  There  was 
no  indication  of  internal  mischief  beyond  a  complaint  of  pain  in  the  epigastrium  on  the 
day  after  the  accident,  when  uniformly  bloody  urine,  without  any  clots,  was  passed. 
Next  day,  the  urine  was  also  bloody,  but  there  was  nothing  more  till  death.  Autopsy. — 
At  the  upper  end  of  the  left  kidney  was  a  rupture  running  into  the  hilus,  where  the 
areolar  tissue  was  infiltrated  with  blood.  A  great  part  of  this  kidney  was  softened. 
There  was  some  coagulated  blood  over  the  kidney  and  left  side  of  the  pelvis,  but  no 
peritonitis.  Two  ounces  of  blood  clots  lay  in  the  great  omentum.  The  spleen  had  two 
ruptures  in  its  posterior  edge,  the  upper  one  being  very  deep.  The  liver  had  a  super- 
ficial rent  on  the  posterior  margin  of  its  right  lobe,  and  two  others  on  the  under  surface. 
The  liver  was  also  studded  with  light-gray  pyaemic  patches,  which  Professor  Fayrer 
attributed  to  emboli  from  the  ruptured  spleen.  The  heart  and  great  vessels  were  found 
to  contain  coagula.^ 

In  the  example  just  presented,  hsematuria  appeared  on  the  second  day,  and 
constituted  a  prominent  symptom.  It  was  also  the  form  of  hsematuria  that 
characterizes  renal  injury,  when  no  coagala  are  voided  in  the  urine.  It  lasted, 
however,  oidy  two  days,  although  it  was  caused  by  a  rupture  at  the  upper 

'  Med.  News  and  Abstract,  January,  1880,  pp.  41,  42  ;  also  Brit.  Med.  Journal,  Oct.  18,  1879. 
2  Med.  Times  and  Gazette,  May  18,  1867  ;  also,  New  Sydenham  Society's  Biennial  Retrospect, 
18G7-8,  p.  187. 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


297 


end  of  the  left  kidney,  which  extended  into  the  hihis.  The  patient  died  six- 
teen days  after  the  injury,  of  tetanus  ;  and,  at  the  autopsy,  a  great  part  of  tlie 
torn  kidney  w/ds  found  to  be  softened. 

Sometimes,  the  liquid  voided  by  urination,  in  these  cases  of  renal  injury 
consists  of  almost  pure  blood,  as  was  specially  noted  in  the  followii^j-  in- 
stance : —  * 

Private  Henry  Greene,  Co.^  H,  9th  Cavalry,  entered  hospital  at  6  P.  M.,  December 
15,  1870,  at  Fort  Quitman,  Texas,  having  been  run  over  by  a  wagon  at  8  A.  M.,  while 
on  his  way  to  Fort  Quitman  from  Eagle  Springs.  It  was  thought  that  both  wheels  of 
one  side  had  passed  over  his  right  hip  and  tliorax.  The  patient  was  sufferinc>-,  when 
admitted,  from  shock  and  extreme  depression.  His  extremities  were  cold,  "and  he 
was  almost  pulseless  at  the  wrist.  But  he  was  perfectly  conscious ;  the  beatin^r  of  his 
heart  was  feeble  but  regular,  and  104  per  minute ;  respiration  44.  Death  from  shock 
and  internal  hemorrhage  ensued  at  7.30  A.  M.  of  the  following  day,  "  the  patient  hav- 
ing passed,  through  tlie  night,  a  quantity  of  nearly  pure  blood  from  the  bladder  " 
Autopsy,  ten  hours  after  death — "  A  large  effusion  of  blood  into  the  abdominal  cavity 
was  found,  and  a  longitudinal  rupture  of  the  right  kidney,  througliout  nearly  its  entire 
extent.  The  bladder  was  normal  and  empty."  The  liver  also  was  ruptured  throucrh 
almost  the  whole  of  its  antero-posterior  diameter,  following  the  junction  of  tlie  riHit 
with  the  left  and  quadrate  lobes,  to  within  an  inch  of  its  anterior  margin.  The  sternum 
was  fractured  at  the  junction  of  its  upper  and  middle  third.  The  eighth  rib  (rio-ht), 
too,  was  fractured  two  inches  in  front  of  its  an«-le.i  ° 

Dr.  Roddick  reported  the  following  case  in  which  pure  blood  was  passed,  and  ex- 
hibited the  specimen.  A  healthy  woman,  aged  60,  had  fallen  down  a  long  flio-ht  of 
stairs,  and  was  picked  up  insensible.  There  was  no  wound,  but  on  recovennor"  con- 
sciousness she  complained  of  great  pain  in  the  riglit  loin  ;  vomiting  began,  and,  m  spite 
of  all  treatment,  continued  to  the  end.  The  bowels  became  tympanitic  and  refused  to 
act.  Pure  blood  was  passed  from  the  bladder  during  the  first  twenty-four  hours  ;  sub- 
sequently, the  urine  was  mixed  with  blood,  and  on  the  fourth  day  it  was  nearly  clear. 
Rupture  of  the  kidney  was  diagnosed,  and  ileus  was  suspected  on  account  of  the  obstruc- 
tion of  the  bowels  and  their  great  distension,  though  no  tumor  could  be  felt.  Rectal 
injections  were  employed  without  any  benefit.  At  the  autopsy  a  large  clot  of  blood 
was  found  surrounding  the  right  kidney,  which  presented  a  laceration  on  the  border 
extending  into  the  pelvis  of  the  organ.  The  kidneys  were  firm  and  slightly  o-ranular! 
The  bowels  were  distended  but  not  obstructed ;  it  was  thought  that  perhaps  the  laro-e 
blood  clot  might  have  pressed  upon  the  ascending  colon  and  produced  the  obstruction.^ 

Prognosis— ll^m^tmAd  from  contusions  and  sprains,  or  wrenches,  of  the 
lumbar  region  is,  in  most  instances,  not  a  very  dangerous  symptom  ;  for 
usually  It  disappears  in  the  course  of  a  few  days,  without  leaving  any  trace 
of  organic  disease  of  the  renal  tissue  behind.  Concerning  hcTmaturia  from  this 
cause,  Le  Gros  Clark  says  that  among  the  many  cases  he  has  witnessed,  he  has 
never  had  reason  to  suspect  that  nephritis  or  organic  disease  followed  in  any 
On  the  same  point  Mr.  Shaw  remarks:  "  When  such  an  important  gland  as 
the  kidney  has  been  crushed  and  broken,  to  such  an  extent  that  hemorrhage 
goes  on  from  a  rent  in  it  for  several  days,  it  might  be  thought  probable  that 
the  damage  w^ould  be  followed  by  ulterior  bad  results,  especially  that  inflam- 
ination— nephritis— would  ensue.  But  extensive  observation  negatives  this 
view ;  general  experience  shows  that  when  patients  recover  from  the  imme- 
diate effects  of  haematuria  brought  on  by  sprain  of  the  spine,  thev  are  not 
more  prone  than  others  to  renal  complaints."*  In  regard  to  h^ematuria  from 
sprain  of  the  back,  Mr.  Bryant  observes :  "  It  is  not  generally  a  very  serious 

1  Circular  No.  3,  S  G.  O.,  August  15,  1871. 
8  Medical  News,  November,  18,  1882. 
8  British  Medical  Journal,  October  3,  1868. 
♦  Loc.  cit.,  pp.  362,  363. 


298 


INJURIES  OF  THE  BACK. 


symptom,  unless  the  kidney  is  ruptured ;  as  a  rule,  it  disappears  gradually, 
and  no  evidence  remains  that  organic  renal  disease  is  ever  the  consequence.'  ^ 

Concerning  the  symptoms  smd  prognosis  when  rupture  of  the  kidney  is  pre- 
sent, Mr.  Bryant  also  says  :  "  When  not  very  severe,  and  uncomplicated  with 
other  injuries,  such  cases  usually  do  well.  It  [that  is,  rupture  of  the  kidney] 
is  generally  known  by  an  attack  of  heematuria  and  local  pain  following  a  blow 
on  the  lumbar  region.  The  hsematuria  may  be  but  slight  and  passing,  or 
not  show  itself  until  the  second  day.  It  may  cease  also  after  the  lapse  of  two 
or  three  days,  when  it  is  probable  that  only  a  contusion  of  the  kidney  has 
taken  place ;  for,  in  more  severe  injuries,  the  bleeding  may  last  fifteen  days 
or  even  more.  At  times  clots  will  be  passed,  assmning  the  shape  of  the  ure- 
ter, and  I  have  before  me  the  notes  of  some  half  dozen  cases  in  which  these 
symptoms  were  present,  and  from  which  recovery  took  place.  These  clots, 
however,  at  times  give  rise  to  retention  of  urine  by  blocking  up  the  urethra. 
Retraction  of  the  testicle  is  an  occasional  symptom,  and  so  is  pain  in  the 
course  of  the  ureter.  This  paragraph  sums  up  so  clearly  and  so  tersely  the 
symptoms,  etc.,  of  rupture  of  the  kidney  from  contusions  and  strains,  or 
wrenches,  of  the  lumbar  region,  as  they  severally  presented  themselves  in  the 
examples  related  above,  that  I  have  quoted  it  in  full. 

It  should,  however,  he  noted  that  in  one  of  these  examples  (it  was  recorded 
by  Professor  Fayrer),  although  the  hematuria  did  not  appear  until  the  second 
dav,  and  lasted  only  two  days,  the  autopsy  revealed  a  rupture  at  the  upper 
end  of  the  left  kidney  which  extended  into  the  hilus,  instead  of  a  renal  con- 
tusion ;  but  it  is  probable  that  such  a  limitation  of  the  haematuria  is  rather 
exceptional  than  otherwise,  in  cases  where  the  rupture  is  so  extensive. 

In  the  last  two  of  the  illustrative  cases  presented  above,  the  urinary  dis- 
charge was  observed  to  consist  of  pure  or  nearly  pure  blood.  isTevertheless, 
the  loss  of  blood  from  hsematuria,  when  caused  by  contusions  and  sprains  of 
the  back,  is  rarely  so  great  as,  j^er  se,  to  endanger  life.  Mr.  Shaw,  however, 
relates  one  case  where  there  was  good  reason  for  alarm : — 

The  patient  was  a  young  man.  Although  the  sprain  was  not  very  severe,  the  renal 
hemorrhage  was  uninterrupted,  and  unusually  profuse,  during  the  first  four  days ;  it 
nearly  ceased  for  two  days ;  then  it  returned,  and  continued  for  two  days,  with  its 
former  profusion ;  it  now  ceased  for  one  day ;  it  appeared,  however,  on  the  next  day, 
the  tenth,  in  great  quantity ;  but  then  it  ceased  permanently.  The  patient,  meanwhile, 
had  become  blanched  and  excessively  weak.^ 

In  this  case,  the  large  quantity  of  blood  that  was  discharged  from  the  r^n- 
nary  oro;ans,  together  with  the  rapid  appearance  of  the  signs  of  acute  anae- 
mia, clearly  indicated  the  danger.  So,  likewise,  in  all  those  rather  infrequent 
cases  of  h^ematuria  where  the  prognosis  is  not  favorable,  the  general  symp- 
toms Avill  sufficiently  indicate  the  peril.  The  proofs  of  strong  shock  and 
great  depression  may  present  themselves.  If  the  liver  or  spleen  be  also  rup- 
tured extensively,  there  will,  too,  be  unmistakable  signs  of  mternal  hemor- 
rhage.   Besides,  the  torn  viscus  may  exhibit  considerable  tenderness  under 

pressure.  .       ^  ^    -,  .  -,  ^  a 

Wounds  of  the  cortical  or  secretory  portion  of  the  kidney  are  represented 
to  be  less  dangerous  than  wounds  of  the  tubular  or  excretory  portion  of  the 
gland.  (Agnew.)  It  is  probable  that  this  proposition  is  also  applicable  to  the 
lesions  of  the  kidney  which  are  caused  by  contusions  and  sprains  of  the  back. 

Treatinent. — Hsematuria,  when  very  profuse,  should  be  combated  by  admin- 
istering the  fluid  extract  of  ergot,  in  half-drachm  doses,  three  or  four  times  a 

I  Practice  of  Surgery,  p.  205,  Am.  ed.  1879.  «  Ibid.,  p.  432. 

8  Loc.  cit.,  p.  362. 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


299 


day,  together  with  gallic  acid,  in  ten-grain  doses,  at  the  same  intervals.  In 
some  sthenic  cases,  however,  it  may  be  advisable  to  give,  instead  of  these 
remedies,  the  acetate  of  lead,  in  styptic  doses  of  two  grains,  every  hour  or  two, 
until  relief  is  obtained.  But,  generally,  the  emj^loyment  of  ergot  and  gallic 
acid  should  be  preferred. 

Pain  in  the  injured  kidney  and  ureter,  etc.,  is  to  be  combated  with  opium 
or  morphia ;  but,  at  the  same  time,  these  narcotics  must  be  exhibited  with 
caution.  Rest  in  bed  should  be  enjoined,  together  with  a  milk  diet.  When 
coagula  form  in  the  bladder,  and  cannot  be  spontaneously  passed  by  the 
urethra,  causing  retention  of  urine,  they  should  be  broken  down  by  injecting 
w^arm  w^ater  through  a  large-sized  catheter. 

The  medico-legal  relations  of  hjematuria  from  contusions  and  sprains  of  the 
back  still  remain  to  be  considered.  Mr.  Shaw  relates  the  case  of  a  gentleman 
who  claimed  in  a  law  court  compensation  from  a  railway  company,  for 
Bright's  disease  resulting  from  injuries  received  in  a  railway  collision.  The 
injuries  consisted  of  a  bruise  over  the  right  ilium  and  side  of  the  loins. 
On  the  following  day  he  observed  blood  mixed  with  his  urine ;  and,  for  four 
days,  he  continued  to  pass  blood.  At  this  time  his  urine  was  found  to  con- 
tain albumen,  and  it  continued  to  be  albuminous  from  the  date  of  the  acci- 
dent to  that  of  the  trial,  a  period  of  eleven  months.  The  medical  witnesses 
for  the  plaintiff  held  that  the  albuminuria,  that  is,  the  parenchymatous 
nephritis,  had  been  caused  by  the  injury  of  the  right  kidney  that  was  inflicted 
in  the  collision.  The  medical  witnesses  for  the  defence  (Mr.  Shaw  was  one 
of  them)  "  expressed  a  strong  opinion  that  the  plaintiff'  was  suffering  from 
the  disease  when  he  met  with  the  accident,  and  that  the  injury  could  not 
have  brought  it  on."^  But,  to  say  "  that  the  injury  could  not  have  brought 
the  disease  on,''  in  this  case,  is  tantamount  to  asserting  that  a  traumatic  lesion 
of  the  kidney,  which  manifests  itself  by  heematuria  appearing  on  the  day  fol- 
lowing the  accident  and  continuing  for  four  days,  cannot  give  rise  to  a  struc- 
tural disease  of  the  kidney  of  an  inflammatory  character.  Such  an  assertion 
cannot  reasonably  be  maintained ;  for  Professor  Fayrer,  in  the  case  of  the 
Hindoo,  related  above,  who  had  h?ematuria  beginning  on  the  day  follqw- 
ing  the  accident,  and  lasting  only  two  days,  and  who  died  in  consequence  of  ^ 
tetanus  sixteen  days  after  the  injury,  found  at  the  autopsy  that  there  w^as  a 
rupture  of  the  left  kidney  extending  into  the  hilus,  and  that  a  great  part  of 
this  kidney  was  softened,  that  is,  had  become  the  seat  of  a  structural  disease, 
and  had  undergone  a  structural  change,  such  as  is  not  unfrequently  produced 
by  the  inflammatory  process ;  or,  in  other  words,  that  the  rupture  of  the 
kidney  had  been  attended  by  traumatic  nephritis.  There  is,  therefore,  no 
reason  for  doubting  that,  in  at  least  occasional  instances,  the  injury  of  the  kid- 
ney w^hich  causes  h«ematuria,  gives  rise  also  to  Bright's  disease.  In  the  case 
just  mentioned,  the  jury,  notw^ithstanding  the  medical  testimony  adduced  by 
the  defence,  awarded  heavy  damages  to  the  sufferer,"  and  it  may  well  be 
that  the  verdict  was  a  righteous  one. 

A  legitimate  inference  from  the  foregoing,  which  has  value  for  medico- 
legal uses,  IS,  that  although  some  surgeons  of  large  experience  have  never  seen 
a  case  in  which  heematuria  from  contusions  and  sprains  of  the  back  was  fol- 
lowed by  nephritis  or  by  organic  disease  of  the  kidney,  nevertheless,  such 
cases  do  sometimes  occur ;  and  that,  whenever  they  do  occur,  their  existence 
ought  to  be  recognized.  It  is  also  pretty  certain  that  Bright's  disease  does 
not  often  arise  from  renal  traumatism ;  but,  precisely  how  often,  future  expe- 
iience  alone  can  determine. 


I  Loc.  cit.,  p.  363. 


300 


INJURIES  OF  THE  BACK. 


Hemorrhage  into  the  Vertebral  Canal  from  Sprains,  Violent  Flex- 
ures, AND  Twists,  or  Wrenches,  of  the  Back. — This  accident  has  no  sur- 
o-ical  importance,  unless  paraplegia  more  or  less  complete  ensues.  In  the 
cases  where  it  occurs,  the  chief  proximate  cause  of  disability  and  danger  to  life 
is  the  compression  of  the  spinal  cord,  or  of  the  spinal  nerves  before  they  issue 
from  the  intervertebral  foramina,  which  the  extravasated  blood  occasions. 
As  in  the  cranium,  so  also  in  the  vertebral  column,  the  extravasated  blood 
which  compresses  the  nerve-tissue  may  be  eftused  iDetween  the  dura  mater 
and  the  bone,  that  is,  externally  to  the  dura  mater,  on  the  one  hand ;  or  in- 
ternally to  that  membrane,  that  is,  betw^een  it  and  the  nerve-structures,  on 
the  other.  We  are,  therefore,  liable  to  meet  with  both  extra-dural  and  intra- 
dural hemorrhages,  of  a  perilous  character,  in  the  vertebral  canal  as  well  as 
in  the  cranial  cavity. 

It  has  already  been  stated,  in  this  article,  that  the  ligamenta  subflava  are 
in  direct  relation  with  the  meningo-rachidian  veins,  and  that  laceration  or 
violent  stretching  of  those  ligaments  w^ould  pretty  certainly  be  attended^  by 
rupture  of  these  veins;  also,  that  the  posterior  common  ligament  is  in  relation, 
by  its  anterior  surface,  with  the  vence  basiim  vertebrarum,  and  by  its  posterior 
surface,  with  the  dura  mater  of  the  spinal  cord,  from  which  it  is  separated 
only  by  the  plexus  venosi  spinales  interni  or  longitudinal  spinal  sinuses,  with 
some  loose  connective  tissue  containing  fat,  and  that  laceration  of  this  liga- 
ment would  be  likely  to  be  attended  by  rupture  of  these  venous  plexuses  or 
sinuses,  and,  possibly,  by  rupture  likewise  of  the  dura  mater  of  the  spinal  cord. 
Moreover,  the  laceration  or  violent  stretching  of  these  ligaments  is  liable  to 
be  attended  by  rupture  of  the  arteries  which,  on  entering  the  vertebral 
canal,  come  into  relation  with  these  ligaments  as  well  as  with  the  interverte- 
bral disks,  namely,  the  rami  spinales.  The  arteries  which  may  be  ruptured 
are  numerous,  the  veins  are  not  provided  with  any  valves  which  could  pre- 
vent re2:urgitant  hemorrhage,  and  the  dura  mater  is  attached  but  very  loosely 
to  the  inner  surface  of  the  vertebral  canal.  Thus,  it  appears,  that  when  the 
vertebral  ligaments  are  much  torn  by  sprains,  violent  flexures,  and  twists,^  or 
wrenches  of  the  vertebral  column,  there  are  many  bloodvessels  from  which 
hemorrhage  may  occur  if  these  vessels  also  be  torn  open,  and  that  ample 
means  are  afforded  by  looseness  of  the  connective  tissue  for  the  extravasated 
blood  to  accumulate,  in  great  masses,  between  the  dura  mater  of  the  spinal 
cord  and  the  bone,  as  well  as  within  the  hollow  cylinder  or  sheath  which  is 
formed  by  the  dura  mater  itself. 

When,  in  such  cases,  the  hemorrhage  soon  ceases,  and  the  quantity  of  the 
extravasation  is  not  large,  it  is  probable  that  recovery  will  ensue ;  for  the 
effused  blood  will  be  more  or  less  completely  absorbed,  and  thus  the  spinal 
cord  will  be  more  or  less  completely  freed  from  compression.  But,  when  the 
hemorrhage  continues  unchecked,  the  paraplegia  arising  therefrom  will 
increase,  and  it  will  gradually  spread  upward  until  the  superior  extremities, 
too,  become  paralyzed  ;  and  finally,  the  functions  of  the  phrenic  nerves  wall 
likewise  be  suspended,  the  diaphragm  w^ill  no  longer  contract,  the  respiratory 
movements  wall  entirely  cease,  and  then  death  will  of  course  immediately 
result,  as  happened  in  the  following  example  which  occurred  in  the  practice 
of  Dr.  John  J.  Crane,  of  New  York,  and  in  w^hich  I  assisted  at  the  autopsy:— 

Mr.  S.,  an  actor,  aged  about  50,  sustained  a  violent  injury  in  the  root  of  his  neck, 
shoulders,  and  back,  from  being  thrown  thereon  while  wresthng,  on  a  Sunday  after- 
noon. Being  unable  to  arise  without  assistance,  he  was  picked  up  and  laid  upon  a 
bench  by  tliose  around.  Afterward  he  was  put  into  a  coach  ;  and,  being  held  in  a 
semi-recumbent  position,  he  was  carried  to  his  home.  Dr.  Crane  saw  him,  for  the  first 
time,  about  nine  o'clock  P.  M.  He  was  then  unable  to  move  his  lower  extremities, 
and  exhibited  all  the  symptoms  of  paralysis  from  spinal  injury,  so  far  as  they  were  cou- 


SPRAINS,  TWISTS,  AND  WRENCHES  OF  THE  BACK. 


301 


cerned.  His  urine,  however,  was  passed  voluntarily,  the  bladder  and  abdominal 
muscles  being  unaffected.    The  upper  extremities,  also,  were  not  paralyzed. 

On  the  following  morning  (Monday)  it  was  found  that  the  paralysis  had  reached  a 
higher  point,  that  there  was  retention  of  urine,  and  that  catheterization  was  necessary. 
Afterward,  the  paraplegia  continued  steadily  to  advance,  travelling  up  the  trunk, 
involving  the  upper  extremities,  involving  likewise  all  the  res[)iratory  muscles  excepting 
the  diaphragm,  and,  finally,  attacking  the  origin  of  the  phrenic  nerves,  when  he  imme- 
diately ceased  to  breathe.  He  died  on  Wednesday  night,  somewhat  more  than  three 
days  after  the  accident.  His  bowels  were  moved  only  once,  and  then  by  enema,  on 
Tuesday  morning.  He  complained  of  pain  only  in  the  lower  part  of  the  neck,  and 
exhibited  signs  of  severe  suffering  whenever  his  head  was  moved.  There  was  tender- 
ness under  pressure,  and  considerable  swelling  in  the  lower  and  back  part  of  the  cervical 
region.  But  no  displacement  or  irregularity  of  the  spinous  processes,  nor  of  any  other 
parts  of  the  vertebrae,  could  be  detected.    His  mind  was  clear  to  the  end. 

The  autopsy  revealed  a  very  extensive  effusion  of  blood  within  the  theca  vertebralis, 
which  distended  that  membrane  and  compressed  the  spinal  cord  throughout  almost  the 
whole  of  its  extent,  namely,  from  the  cauda  equina  up  to  the  superior  cervical  region. 
The  spinal  cord  itself  was  not  wounded.  The  theca  vertebralis  was  ruptured  to  the 
extent  of  about  one-third  of  its  circumference,  in  the  lower  part  of  the  cervical  region. 
The  ligaments  connecting  the  fifth,  sixth,  and  seventh  cervical  vertebrae  exhibited  much 
laceration.  A  fissured  fracture  also  passed  longitudinally  through  the  fifth,  sixth,  and 
seventh  cervical  vertebrae.  There  was  not  much  displacement  of  bone,  certainly  not 
enough  to  press  on  the  spinal  cord  in  any  way,  and  not  enough  to  be  cognizable  by 
external  examination.  The  blood  found  within  the  theca  vertebralis  was,  for  the  most 
part,  extravasated  from  the^  vessels  of  the  cord — that  is,  from  the  arterise  spinales, 
anterior  and  posterior  ;  but,  no  doubt,  some  blood  from  without  had  entered  the  cavity 
of  the  theca  vertebralis  through  the  ruptured  aperture  in  that  membrane,  it  was, 
however,  evident  that  the  paraplegia  had  slowly  crept  upward  in  this  man's  body,  just 
as  the  effused  blood  accumulated  in  the  thecal  cavity,  commencing  in  the  lower  end 
thereof ;  and,  that  death  had  resulted  from  compression  of  the  spinal  cord,  arising 
from  this  cause. 

In  the  very  instructive  case  which  has  just  been  related,  there  was  a  longi- 
tudinal fissuring  of  the  last  three  cervical  vertebrae,  as  well  as  such  a  lacera- 
tion of  the  ligamentous  tissue  and  neighboring  bloodvessels  as  is  often  found 
in  cases  of  sprains,  from  contusions  and  violent  flexures  of  the  vertebral 
column.  Still,  the  case  practically  belongs  to  the  same  category  as  sprains 
and  wrenches  of  the  vertebral  column,  because  several  vertebral  articulations 
did,  in  fact,  sustain  the  lesions  which  characterize  this  form  of  injury,  and 
examination  during  life  did  not  and  could  not  reveal  any  lesion  of  the  verte- 
bral column,  excepting  the  sprains  of  the  vertebral  joints.  Moreover,  if  in  this 
case  there  had  been  no  intra-thecal  hemorrhage,  and  no  compression  of  the 
spinal  cord,  or  had  the  effusion  of  blood  been  moderate,  and  had  it  been  fol- 
lowed by  absorption,  the  patient's  recovery  might  easily  have  ensued ;  and  had 
his  recovery  so  ensued,  the  fissures  in  the  last  three  cervical  vertebrse  Avould 
never  have  been  discovered,  and  the  injury  would  have  been  considered  as 
merely  a  sprain  or  wrench  of  the  back.  But,  at  all  events,  this  example 
illustrates  in  an  excellent  manner  the  clinical  historj^  that  is,  the  symptoms 
which  are  likely  to  present  themselves,  in  f^ital  cases  of  compression  of  the 
spinal  cord  from  the  extravasation  of  blood  within  the  spinal  dura  mater, 
where  life  is  prolonged  for  three  or  four  days. 

To  illustrate  compression  of  the  spinal  cord  from  hemorrhages  which  occur 
externally  to  the  spinal  dura  mater,  Mr.  Shaw  relates  at  much  length  the 
case  of  a  woman,  aged  60,  admitted  to  the  Middlesex  Hospital  under  his  care, 
in  March,  1841,  having  been  injured  in  the  back  by  falling  down  a  flight  of 
steps  shortly  before : — 


302 


INJURIES  OF  THE  BACK. 


No  irregularity  in  the  line  of  the  spine  could  be  perceived  ;  and,  although  she  sat  up 
for  examination,  there  was  no  particular  part  of  the  back  which  seemed  to  be  particu- 
larly weak.  Both  upper  extremities  and  the  right  lower  extremity  were  deprived  of 
voluntary  motion  ;  but  sensation  was  nearly  perfect,  for  she  spoke  only  of  a  little  numb- 
ness in  them.  Reflex  movements  could  not  be  excited  in  the  paralyzed  upper  extremi- 
ties, while  they  were  particularly  lively  in  the  paralyzed  lower  extremity.  The  breathing 
was  not  disturbed.  There  was  at  first  retention  of  urine  ;  and,  for  a  few  days,  incon- 
tinence ;  but  soon  afterward  she  regained  the  natural  control  over  urination.  The 
bowels  acted  regularly.  During  the  first  ten  days  no  perceptible  change  took  place  ; 
but  in  the  following  fortnight  a  slow  and  gradual  increase  of  power  over  the  paralyzed 
limbs  was  observed ;  after  that,  however,  all  progress  seemed  to  cease.  She  was  re- 
tained in  the  hospital  for  three  months;  but  her  subsequent  history  is  not  known. 
"  That  in  this  case,"  says  Mr.  Shaw,  "  the  blood  which  escaped  had  been  poured  into 
the  loose  space  intervening  between  the  osseous  walls  of  the  canal  and  the  theca  spinalis 
seems  most  probable ;  and,  also,  that  the  source  of  the  blood  was  the  venous  sinuses 
which  line  the  interior  of  the  canal  in  the  form  of  plexuses."     He  further  says: 

As  the  paralysis  was  partial,  three  alone  out  of  the  four  extremities  being  affected, 
and  motor  power  being  the  only  property  lost,  it  may  be  inferred  that,  if  blood  extrava- 
sated  external  to  the  theca  were  the  compressing  agent,  it  had  been  collected  in  the 
canal  in  unequal  quantities  at  different  parts.  Such  an  hypothesis  would  explain  how 
one  of  the  lower  extremities  escaped  being  deprived  of  its  motor  power."^ 

But,  inasmuch  as  there  was  no  autopsy  in  this  case,  the  conclusion  that 
intra-vertebral  hemorrhage  had  occurred  externally  to  the  theca  yertebralis 
must  be  held  to  be  unproved,  and  as  at  least  to  that  extent  uncertain. 

Dr.  Deville,  in  1843,  in  examining  the  body  of  a  man  who  had  died  in 
consequence  of  falling  from  a  great  height  on  to  the  pavement,  found,  on 
laying  upon  the  spinal  canal,  a  most  extensive  extravasation  of  blood,  com- 
pletely filling  up  this  canal  in  its  whole  length,  and  extending  upward,  even 
beyond  the  point  where  the  spinal  cord  had  been  cut  across,  when  the  brain 
was  taken  out.  'No  trace  of  injury  whatever  was  detected  in  the  cranial  con- 
tents. This  man,  when  admitted  to  hospital,  was  collapsed  and  perfectly 
insensible.  There  was  no  paralysis,  nor  muscular  spasm.  In  this  state  he 
lay  for  some  hours,  and  then  died.  Except  the  intra-vertebral  hemorrhage, 
no  cause  of  death  could  be  found.^ 

Mr.  Le  G-ros  Clark  mentions  a  remarkable  case  of  the  same  kind,  which 
was  narrated  to  him,  but  which  he  did  not  see: — 

A  man  was  violently  struck  on  the  back  by  a  chain-cable  ;  there  were  no  immediate 
symptoms  of  spinal  injury^,  but  a  paraplegic  condition  soon  supervened,  extending  rapidly 
upward  and  destroying  life  by  asphyxia.  The  theca  was  found  distended  with  fluid 
blood,  derived  from  a  ruptured  spinal  artery.  He  likewise  mentions  another  case  : 
A  man  was  injured  in  a  coUision  in  the  tunnel,  four  or  five  miles  from  Brighton.  He 
walked  this  distance  with  some  difficulty  into  the  town  ;  and,  within  twenty-four  hours, 
became  entirely  paraplegic.  He  slowly  recovered,  so  that,  at  the  end  of  two  years, 
he  was  able  to  walk  as  well  as  before  the  injury.  One  spot  on  the  back  was  always 
tender  ;  and,  at  times,  still  continued  so.^ 

The  close  resemblance  which  the  symptoms  that  presented  themselves  in 
this  case,  bore  to  those  that  were  observed  in  the  preceding  case,  indicates 
that  the  pathological  lesion  was  the  same  in  both  instances,  namely,  extrava- 
sation of  blood  within  the  spinal  dura  mater  from  ruptured  spinal  arteries, 
whereby  the  spinal  cord  was  compressed.  ^ 

The  symptoms  which  result  most  frequently  from  this  lesion  are  those  of 

1  Loc.  oil.,  pp.  364-366. 

2  Mem.  de  la  Soc.  de  Chirurg.  de  Paris,  t.  iii.  p.  180;  also  Holmes's  System  of  Surgery,  2d  ed., 
.vol.  11.  p.  300. 

»  British  Medical  Journal,  October  3,  1868. 


DISLOCATIONS  OF  THE  VERTEBRA.  303 

paraplegia,  coming  on  some  little  time  after  a  violent  contusion  or  sprain  of 
the  back,  the  paralysis  appearing  first  in  the  legs,  and  extending  upward  with 
more  or  less  rapidity,  according  to  the  nature  of  the  case.  At  all  events, 
these  are  the  phenomena  which  were  observed  in  both  of  the  instances  men- 
tioned by  Le  Gros  Clark,  as  well  as  in  that  Avhich  I  have  myself  recorded. 

Treatment— Should  the  surgeon  be  able  to  make  a  differential  diagnosis  in 
a  case  where  this  accident  has  occurred,  it  may  be  advisable  for  him  to  pre- 
scribe the  fluid  extract  of  ergot  in  doses  of  thirty  drops  every  four  hours,  or 
the  acetate  of  lead  in  doses  of  two  grains  every  hour  or  two,  with  a  view  to 
suppress  the  bleeding.  In  cases  where  the  hemorrhage  has  ceased,  it  will 
generally  be  advisable  to  administer  potassium  iodide  in  doses  of  ten  grains 
every  eight  hours  in  simple  syrup,  with  a  view  to  promote  absorption  of  the 
effused  blood.  Quiet  should  be  enjoined,  and  measures  should  be  employed 
to  prevent  the  occurrence  of  spinal  meningitis  and  myelitis. 


11.  mJURIES  OF  THE  VERTEBRAL  COLUMK 


Dislocations  of  the  Vertebra. 

The  traumatic  lesions  to  which  the  several  pieces  of  the  spinal  column  are 
exposed  consist,  (1)  of  pure  dislocation,  (2)  of  pure  fracture,  and  (3)  of  disloca- 
tion combined  with  fracture.  Experience  has  shown  that,  leaving  gunshot 
wounds  of  the  vertebrae  out  of  the  account,  pure  dislocation  occurs  quite  as 
frequently  as  pure  fracture,  and  that  dislocation  combined  with  fracture  is 
met  with  much  oftener  than  either  of  them ;  and,  perhaps,  almost  as  fre- 
quently as  both  conjoined.  For  instance.  Professor  Porta  found  in  27  cases, 
pure  dislocation  in  7,  dislocation  complicated  with  fracture  in  14,  with  6 
recoveries,  so  that  there  could  not,  by  any  possibility,  have  been  more  than  6 
examples  of  pure  fracture.  Dissection  was  practised  in  20  of  the  21  fatal 
cases,  that  is,  in  all  but  one.  The  fracture  complicating  the  dislocation  was 
often  so  slight  as  not  to  be  distinguishable  until  the  autopsy  revealed  it. 
Again,  Mr.  Bryant  found  in  17  cases  where  the  nature  of  the  injury  was 
verified  by  post-mortem  examination  at  Guy's  Hospital,  during  a  period  of 
five  years  while  he  was  ofliciating  as  surgical  registrar,  that  6  were  instances 
of  pure  dislocation,  3  of  pure  fracture,  and  8  were  examples  of  dislocation 
and  fracture  combined. 

Clear  views  on  this  subject  are  of  practical  importance,  because  pure  dis- 
locations of  the  spinal  column  are,  as  a  rule,  more  amenable  to  treatment 
than  corresponding  fractures  with  a  like  degree  of  displacement.  In  the 
latter  cases,  the  spinal  cord  is  apt  to  be  scratched  and  torn  by  the  sharp 
points  and  edges  of  the  fracture-splinters  and  fragments,  in  addition  to  beino- 
compressed  by  the  displacement  of  bone.  The  late  Dr.  D.  S.  Conant,  of  ]^ew 
York,  reported  a  case  of  fracture  of  the  twelfth  dorsal  and  first  lumbar  ver- 
tebrae,* in  which  the  patient  lived  six  days,  the  spinal  cord  being  divided  by 
a  splinter  from  the  first  lumbar  vertebra,  and  not  by  displacement  of  the 
vertebra  itself.  It  might  well  be  that  an  apparently  hopeless  case  of  spinal 
dislocation  could  be  saved  by  reducing  the  luxation,  while  a  case  of  fracture 
involving  the  same  part,  with  a  similar  amount  of  displacement  of  bone  and 
paralysis  of  body,  would  not  be  saved  by  a  like  proceeding ;  and  that,  too, 

'  American  Medical  Times,  1861,  pp.  359,  360. 


304 


INJURIES  OF  THE  BACK. 


because  of  the  injury  iiitiicted  upon  the  cord  by  the  splinters  and  fragments 
of  broken  bone.  Moreover,  in  certain  cases  of  cervical  dislocation  where  the 
reduction  proves  to  be  difficult,  although  it  is  indispensable  in  order  to  save 
the  patient  from  speedy  death,  the  surgeon  will  be  more  likely  to  persevere 
until  he  accomplishes  the  reduction  and  thus  frees  the  spinal  cord  from  in- 
jurious  compression,  if  his  mind  be  clear  in  respect  to  the  diagnosis,  than  he 
will  if  his  opinion  be  unsettled.  Many  cases  of  this  sort  have  already  been 
recorded,  some  of  which  have  been  saved  by  a  timely  reduction  of  the  dislo- 
cation, while  others  have  perished  from  the  lack  of  this  proceeding ;  and 
more  cases  of  the  same  sort  will  hereafter  be  met  with.  The  clearness  of 
view  and  accuracy  of  diagnosis  needful  for  their  proper  treatment,  are  nmch 
more  likely  to  be  attained  by  making  a  separate  study  of  vertebral  disloca- 
tions, than  by  considering  them  together  with  vertebral  fractures — that  is, 
than  by  discussing  the  traumatic  lesions  of  the  vertebrae,  en  masse,  as  practised 
by  most  writers  and  lecturers  on  surgery,  at  the  present  day,  in  England  and 
America — and,  therefore,  I  shall  not  follow  their  example. 

Until  a  recent  date,  yure  dislocations  of  the  vertebrae  were  held,  by  even 
the  best  informed  surgeons,  to  be  of  very  rare  occurrence  ;  and  some  of  equal 
eminence  positively  denied  that  dislocation  of  the  body  of  a  vertebra,  unat- 
tended with  fracture,  ever  occurred  at  all.  Among  the  latter,  Delpech  was 
specially  prominent.  Abernethy  likewise  taught:  "There  can  be  no  disloca- 
tion (of  the  vertebrae)  surgically  speaking — we  do  not  take  the  word  in  its 
etymological  sense  ;  in  surgical  language,  a  dislocation  is  a  displacement  of 
bone,  with  a  laceration  of  ligament  unaccompanied  with  fracture;  for  if  there 
be  a  fracture,  it  is  not  a  dislocation ;  but,  from  their  position,  if  one  vertebra 
be  knocked  in,  its  articular  surfaces  must  be  broken  "  (South).  Sir  A.  Cooper 
declared  that  he  had  never  seen  a  pure  dislocation  of  one  vertebra  upon 
another;  but,  at  the  same  time,  he  admitted  the  possibility  of  its  occurrence 
when  he  said :  "If  luxation  of  the  spine  ever  does  happen,  it  is  an  injury 
w^hich  is  extremely  rare."  In  England,  Mr.  Lawrence  was  the  first  to  dem- 
onstrate that  vertebral  dislocation,  unattended  by  fracture,  in  reality  did 
occur.    He  reported  the  following  example : — 

A  robust  porter,  aged  22,  while  "  carrying  a  heavy  barrel  on  the  back  of  his  head 
and  neck,  slipped  on  descending  some  steps,  and  fell  on  the  buttocks,  the  burden  resting 
on  the  head  and  upper  part  of  the  neck.  He  was  immediately  deprived  of  sensibility  in 
the  trunk  and  limbs,  and  of  all  power  over  the  voluntary  muscles  of  these  parts.  When 
brought  to  the  hospital  he  was  completely  insensible,  and  incapable  of  voluntary  motion 
below  the  neck."  The  respiratory  movements  were  performed  apparently  by  the  dia- 
phragm alone.  Priapism  was  noted.  On  the  next  day  "  there  was  pain  in  the  lower 
part  of  the  neck  ;  he  could  move  the  arms  very  slightly,  and  had  a  Httle  feeling  in  the 
front  and  upper  part  of  the  chest."  On  the  third  day  "  he  experienced  a  tingling 
sensation  in  the  hands,  and  was  sensible  to  impressions  on  the  upper  part  of  the  arms 
and  thighs."  On  the  morning  of  the  fifth  day,  very  early,  he  died  from  asphyxia  and 
exhaustion. 

Autopsy  "  No  displacement  or  inequality  could  be  discovered  by  external  examina- 
tion, when  the  body  was  laid  on  the  face.  After  cutting  away  the  muscles  from  the 
back  of  the  spine,  the  cartilaginous  surfaces  of  the  superior  articular  processes  of  the  Iffth 
cervical  vertebra  came  into  view.  They  were  exposed  in  consequence  of  the  inferior 
processes  of  the  fourth  vertebra  having  been  completely  dislocated  forwards,  and  re- 
maining fixed  in  their  unnatural  position.  The  yellow  ligaments  connecting  the  laminae 
of  the  two  vertebrae  [ligamenta  subflava]  were  torn  through,  and  the  bifid  apex  of  the 
fourth  spinous  process  lay  in  close  contact  with  the  basis  of  the  fifth.  On  the  front  of 
the  column  an  unusual  projection  was  observed,  but  the  anterior  longitudinal  liga- 
mentous expansion  [anterior  common  ligament]  was  entire.  The  body  of  the  fourth  was 
completely  detached  from  that  of  the  fifth  vertebra,  the  coimecting  fibro-cartilage  being 
torn  through,  and  the  body  of  the  former  projecting  by  its  whole  depth  in  front  of  the 


DISLOCATIONS  OF  THE  VERTEBRA. 


305 


latter.  In  consequence  of  this  displacement,  the  antero-posterior  diameter  of  the  ver- 
tebral canal  was  lessened  about  one-third."^ 

The  specimen  was  preserved,  I  believe,  in  the  museum  of  St.  Bartholo- 
mew's Hospital.  In  this  case,  then,  there  undoubtedly  occurred  "  a  displace- 
ment of  bone  with  a  laceration  of  ligament  unaccompanied  with  fracture;" 
or,  in  other  words,  there  Avas  unquestionably  a  pure  dislocation  of  the  fourth 
cervical  vertebra  forward  upon  the  tifth. 

The  French  surgeons  had  already  ascertained  that  the  atlas  might  be 
luxated  on  the  axis  without  fracture;  and  that,  occasionally,  a  luxation  of 
the  articular  process  on  one  side  (unilateral  dislocation)  occurred  among  the 
last  live  cervical  vertebrae.^  But  these  lesions  were  held  to  be  of  extremely 
rare  occurrence ;  and,  as  to  luxation  of  the  bodies  of  the  vertebrae  without 
fracture,  the  possibility  of  such  an  accident  was  scarcely  admitted.  On  the 
latter  point,  Boyer  says  :  "  If  we  examine  the  facts  upon  which  a  belief  of  the 
possibility  of  their  being  luxated  is  founded,  we  shall  find  that  the  posterior 
laminae  of  the  vertebrae  are  uniformly  broken,  often  crushed,  and  reduced  to 
splinters,  and  that,  almost  always,  when  the  bod}^  of  a  vertebra  is  luxated,  the 
separation  of  its  ligaments  tears  off  a  piece  of  the  bone  itself  Boyer  has 
been  blindly  followed  by  most  writers  on  spinal  injuries  since  his  day. 
(Ashhurst.) 

In  1865,  however.  Professor  Porta's  memoir  on  "Dislocations  of  the  Ver- 
tebrae" was  read  before  the  Royal  Lombard  Institution  of  Science  and 
Letters,  and  was  summarized  in  Omodei's  Annali  Universali  di  Medicina, 
whereby  the  chief  points  made  in  it  have  become  widely  known.  This 
memoir  is  founded  on  27  cases — 13  in  the  cervical,  10  in  the  dorsal,  and  4  in 
the  lumbar  region,  case  of  luxation  of  the  occiput  on  the  atlas,  nor  of 

the  atlas  on  the  axis  is  included.  There  were  only  six  recoveries.  ^Tecro- 
scopy  was  practised  in  20  out  of  the  21  fatal  cases.  Prof.  Porta  asserts  that 
dislocations  of  the  bodies  of  the  vertebrae,  which  all  authors  (including  Mor- 
gagni)  have  believed  to  be  rare,  are  common  enough,  and  met  with  every 
year  in  hospital  practice.  Experiments  on  the  spinal  column  removed  from 
the  body,  and  denuded  of  its  muscles,  show  that  by  vigorous  torsion  the 
intervertebral  cartilage  and  ligaments  can  always  be  torn,  and  this  dislocation 
be  thus  produced.  He  combats  the  opinion  of  Boyer  that  the  dislocation  is 
always  accompanied  by  fracture,  and  mentions  seven  cases  in  which  there 
was  no  such  complication.  Even  Avhen  fracture  does  accompany  the  luxation, 
the  complexion  of  the  accident  is  determined  by  the  luxation  and  the  extent 
of  its  displacement.  As  already  stated,  14  cases  were  complicated  with  frac- 
ture— 5  in  the  cervical,  6  in  the  dorsal,  and  3  in  the  lumbar  region.  He  regards 
the  concomitant  fracture  as  a  phenomenon  secondary  to  the  dislocation.''" 

In  1867,  Mr.  Bryant  published  some  statistics  of  spinal  injuries,^  in  order  to 
show  ihsitpure  dislocation  of  the  vertebrae  was  less  rare  than  was  usually  taught. 
During  a  period  of  five  years,  ending  in  1858,  while  he  officiated  as  surgical 
registrar  at  Guy's  Hospital,  46  cases,  of  spinal  injury  were  admitted ;  "and, 
among  the  46  cases,  there  were  24  examples  of  dislocation,  or  of  fracture,  or  of 
both  combined.  In  10  of  them,  the  dislocation,  or  the  fracture,  was  in- the 
cervical  region ;  in  14,  the  injury  was  in  the  dorsal  region.  Moreover,  the 
nature  of  the  lesion  was  verified  by  a  post-mortem  examination,  in  17  instances. 
Of  these,  6  were  pure  dislocations,  3  were  pure  fractures,  and  8  were  examples 
of  dislocation  combined  with  fracture,  as  already  stated.    Of  the  pure  disloca- 

1  Medico-Chirurg.  Trans.,  vol.  xiii.  part  2,  pp.  394-397.  1827. 

2  Boyer's  Surgery,  translated  by  Stevens,  vol.  ii.  pp.  230-234.    New  York,  1816. 

s  Ibid.,  p.  235.  *  New  Syd.  Soc.  Retrospect,  1865-1866,  pp.  281-283. 

^  Lancet,  April  6. 

VOL.  IV. — 20 


306 


INJURIES  OF  THE  BACK. 


tioiis,  5  occurred  in  the  cervical  and  1  in  the  dorsal  region.  The  nature  of  the 
lesion  was  verified  by  a  post-mortem  examination  in  every  one  of  the  10  cases 
in  which  a  cervical  vertebra  was  injured ;  and  thus,  pure  dislocation  was 
found,  beyond  question,  in  one-half,  or  50  per  c<ent.,  of  the  cervical  cases.  It 
was  found  in  2  between  the  fourth  and  fifth  vertebrje  of  the  neck ;  in  2 
between  the  fifth  and  sixth  ;  and  in  1  between  the  last  cervical  and  first  dorsal 
vertebrae.  In  each  of  the  other  5  cases  of  injury  to  the  cervical  portion  of  the 
spine,  the  lesion  consisted  of  dislocation  and  fracture  combined.  All  of  the 
examples  oi  pure  fracture  were  found  in  the  dorsal  region.  Three  examples 
of  dislocation  combined  with  fracture  were  also  found  in  this  region.  The 
instance  of  inire  dislocation  in  the  dorsal  region,  above  mentioned,  occurred 
between  the  eleventh  and  twelfth  vertebrae^  The  ligaments  normally  con- 
necting these  vertebrae  were  ruptured  at  all  the  joints  between  them,  and  the 
body  of  the  eleventh  was  thrown  forward.  In  the  remaining  7  cases  of  injury 
to  the  dorsal  portion  of  the  spine,  there  was  no  autopsy ;  but  the  lesions 
occurred  about  the  tenth,  eleventh,  and  twelfth  vertebrae. 

Professor  Porta's  memoir  and  Mr.  Bryant's  article  mark  the  commence- 
ment of  a  new  epoch  in  the  surgical  hfstory  of  vertebral  injuries.  Some 
forty  years  before,  Mr.  Lawrence  "had  demonstrated,  as  already  mentioned, 
that  the  body  of  a  vertebra,  as  well  as  an  articular  process,  could  be  disjointed 
from  its  fellow  without  being  attended  by  any  fracture.  They,  however, 
went  much  further,  and  demonstrated  that  pure"  dislocations  of  the  vertebrae 
were  not,  by  any  means,  extremely  rare  lesions;  that,  on  the  contrary,  they 
occurred  about  as  frequently  as  pure  fractures  of  the  vertebrae  in  civil  prac- 
tice, and  that  dislocations  combined  with  fractures  were  met  with  in  the 
spinal  column  at  large  much  oftener  than  either  of  these  lesions.  Mr.  Bryant 
went  further  still,  and  showed  that  pure  dislocations  Avere  mostly  found  in 
the  cervical  region,  but  seldom  in  the  dorsal  and  lumbar  regions. 

In  1867,  awakened  interest  in  this  neglected  branch  of  surgery  was  also 
manifested  in  America,  by  the  publication  of  Professor  Ashhurst's  instructive 
essay  on  Injuries  of  the  Spine,  with  an  analysis  of  394  cases,  the  clinical  his- 
tories of  which  he  had  examined.  His  investigations,  after  making  due  allow- 
ance for  all  possible  errors,  strongly  confirm  Mr.  Bryant's  conclusions  on  the 
last-named  point.  Of  these  394  cases  of  spinal  injury,  124  are  reported  as 
jjure  dislocations;  104  of  them  being  in  the  cervical  region,  17  in  the  dorsal, 
and  only  3  in  the  lumbar  region.  Xow,  admitting  that  in  some  of  these 
oases  reported  as  pure  dislocations  of  the  vertebrae,  there  must  also  have  been 
lesions  of  bone,  perhaps  quite  limited  in  extent,  but  still  constituting  frac- 
tures of  the  vertebrae  with  which  the  dislocations  were  complicated,  the  rela- 
tive proportions  would  not  be  destroyed,  nor  even  essentially  changed  (it  is 
probable),  for  an  error  of  this  sort  is  not  likely  to  occur  in  a  greater  percentage 
of  cases  in  one  of  the  spinal  regions  than  in  another.  But  enough  has  been 
said  to  indicate  that,  since  the  days  of  Delpech  and  Abernethy,  of  Baron 
Boyer  and  Sir  Astley  Cooper,  great  additions  have  been  made  to  the  stock 
of  our  knowledge  concerning  this  important  class  of  spinal  injuries. 

Here  it  may  be  well  to  say  that,  when  a  vertebra  is  dislocated,  the  ver- 
tebra itself,  together  with  the  part  of  the  spinal  column  resting  on  it,  is 
usually  moved  forward  upon  the  next  vertebra  below  it  and  the  rest  of  the 
column.  That  the  displacement  in  vertebral  dislocations  is  generally  anterior, 
results  from  the  fact  that  the  forces  causing  them  generally  act  from  behind, 
and,  having  ruptured  the  column,  they  drive  the  upper  part  of  it  forward,  in 
which  direction  this  part  is  also  drawn  by  its  own  weight  and  by  muscular 
action,  while  the  lower  part  remains  unmoved.  This,  Professor  Porta  verified 
in  17  out  of  26  cases,  and  anterior  displacement  was  doubtless  present  in  other 
instances.    Hence  tlte  upper  is  usually  considered  to  be  the  portion  of  the 


DISLOCATIONS  OF  THE  VERTEBRA. 


307 


spinal  column  that  is  dislocated.  I  shall  endeavor  to  note  any  exceptions  to 
this  rule  in  regard  to  the  displacement  in  spinal  dislocations  as  they  present 
themselves  in  the  following  pages. 

It  may  likewise  be  well  to  say  here  that  in  all  pure  dislocations  of  the  ver- 
tebrse,  certainly  in  all  of  them  that  are  bilateral  or  symmetrical,  the  inter- 
vertebral substance  is  torn  completely  through ;  if  it  were  otherwise,  the 
body  of  the  upper  vertebra  could  not  be  displaced  forward  nor  backward,  nor 
in  any  other  direction  upon  the  body  of  the  lower  vertebra. 

Also,  in  dislocations  of  the  cervical  vertebrae  complicated  with  fracture,  the 
intervertebral  substance  is  generally  torn  com[)letely  through,  and  the  frac- 
ture is  usually  found  in  the  spinous  process,  or  laminee,  or  pedicles  of  the 
dislocated  vertebra  itself,  but  not  in  the  body.  In  five  successive  examples 
of  dislocation  and  fracture  combined,  Mr.  Bryant  found  in  each  that  the  body 
of  a  vertebra  was  dislocated  forward  upon  the  one  below  ;  that  the  articular 
processes  were  displaced,  or  separated  from  each  other,  at  their  joints  ;  and 
that  in  each  there  was  a  fracture  through  the  spinous  process  or  laminae  of 
the  upper  or  dislocated  vertebra,  the  luxations  having  taken  place  at  the 
under  surfaces  of  the  third,  fourth,  fifth,  sixth,  and  seventh  cervical  vertebrae- 
respectively.^ 

Dislocations  in  the  Cervical  REGiON.^The  ginglymoid  articulation 
between  the  occipital  bone  and  the  atlas,  which  joins  the  cranium  to  the  ver- 
tebral column,  and  is  therefore  called  the  articulatio  capitis,  is  remarkably  stable 
and  difficult  to  unhinge  by  reason  (1)  of  the  cup-shaped  depressions  in  the 
transverse  processes  of  the  atlas  which  receive  the  condyles  of  the  occipital 
bone ;  (2)  by  reason  of  the  seven  ligaments,  some  of  which  are  very  strong, 
that  bind  the  atlas  to  the^  occipital  bone,  and  (3)  by  reason  of  the  narrow 
limits  to  w^hich  the  motions  of  the  joint  itself  are  restricted.  Hence,  Boyer 
declares  that  there  is  no  example  of  a  displacement  of  the  articular  surfaces 
of  the  occiput  with  the  vertebral  column,  in  consequence  of  external  violence. 
Even  the  large  carnivorous  animals,  which  prey  upon  the  smaller,  and  which 
have  occasion  to  make  very  violent  movements  of  the  head,  furnish  no 
example  of  this  kind.  In  falls  upon  the  head,  in  which  the  neck  is  strongly 
flexed,  although  several  cervical  vertebrae  may  be  broken,  the  occipital  bone 
is  never  luxated  upon  the  atlas.  In  the  bodies  of  persons  who  have  died  by 
hanging,  the  atlas  is  often  found  luxated  upon  the  axis,  but  the  occiput  is 
never  found  luxated  upon  the  atlas.  I^evertheless,  dislocation  of  the  occipital 
bone  from  the  atlas  has  been  described  ;  it  is,  however,  extremely  rare.  For 
instance:  (1)  Lassus  observed^  the  case  of  a  man,  injured  by  a  mass  of  hay 
falling  on  the  back  of  his  neck,  who  was  stunned  and  paralyzed,  and  had 
convulsions  of  the  upper  extremities.  He  lived  six  hours.  Dislocation  of 
the  occiput  from  the  atlas,  and  rupture  of  the  vertebral  artery  and  vein  were 
found.  (Ashhurst.)  (2)  Paletta  described ^  the  case  of  a  peasant  man,  aged 
forty,  who  fell  head-foremost  from  a  tree,  and  was  paralyzed.  He  lived  five 
days.  Fracture  of  the  fourth  cervical  vertebra  and  dislocation  of  the  occiput 
from  the  atlas  were  found.  (Ashhurst.)  (3)  Bouisson  mentions^  the  case  of  a 
boy,  aged  sixteen,  who  was  crushed  under  a  cart,  and  taken  out  dead.  Dis- 
location forward  of  the  atlas  on  the  occiput  was  found.  The  medulla  was 
compressed,  but  not  crushed.  (Ashhurst.)  (4)  A  case  in  which  dislocation  of 
the  occipital  bone  from  the  atlas  and  axis  occurred,  is  noted  in  St.  Bartho- 
lomew's Hospital  Eeports,  vol.  x.  p.  313.   (5)  Dariste  is  credited^  with  a  case 

»  New  Syd.  Soc.  Retrospect,  1867-68,  pp.  275,  276. 

2  Pathologie  Chirurgicale,  t.  ii.  3  Exercitationes  Pathologicse. 

Revue  Medico-Chirurg.  de  Paris,  t.  ii. 
5  American  Journal  of  the  Medical  Sciences,  0.  S.,  vol.  xxiii. 


308 


INJURIES  OF  THE  BACK. 


of  incomplete  luxation  of  the  occiput  on  the  atlas ;  cause  not  stated.  The 
patient  was  relieved,  and  lived  more  than  one  year.  Death  resulted  from 
other  causes — tubercle  of  the  brain.  (Ashhurst.)  Dariste  exhibited  the  speci- 
men to  the  Anatomical  Society  of  Paris. 

Dislocation  behveen  Occiput  and  Atlas — In  respect  to  the  direction  of  the  dis- 
placem.ent  in  dislocations  at  the  summit  of  the  spinal  column,  involving  the 
articulation  with  the  head,  it  seems  that  the  occipital  bone  may  be  displaced 
backward,  as  well  as  forward,  upon  the  atlas,  for  in  Bouisson's  case  it  is  stated 
that  the  atlas  was  found  dislocated  forward  on  the  occiput — that  is,  the  occi- 
pital bone  was,  in  reality,  found  to  be  dislocated  backward  on  the  atlas  and 
the  whole  spinal  column. 

In  regard  to  the  consequences  of,  this  dislocation,  whatever  be  its  direction, 
it  is  worthy  of  remark  that,  while  Bouisson's  subject  died  immediately, 
Lassus's  patient  lived  six  hours,  Paletta's  five  days,  and  Dariste's  more  than 
a  year,  death  in  the  end  resulting  from  another  lesion.  But,  it  is  well  known 
that  any  injury  of  the  spinal  cord  above  the  origin  of  the  phrenic  nerves,  that 
is,  above  the  third  cervical  vertebra,  which  arrests  the  functions  of  the  cord — 
for  instance,  severe  compression  or  crushing  of  the  cord — always  causes  instant 
death.  This  result,  however,  was  noted  in  only  one  case.  It  is  therefore 
evident  that  the  degree  of  compi^ession  of  the  cord,  or  the  amount  of  the  dis- 
placement of  the  luxated  bones  which  caused  the  compression,  was  materially 
less  in  the  other  cases,  and  very  much  less  in  two  of  them.  This  circumstance 
directs  our  attention  to  the  fact  that  the  foramen  spinale  is  much  wider  in  the 
atlas  than  it  is  in  the  other  vertebrae :  that  the  foramen  magnum  of  the  occi- 
pital bone  is  almost  equal  to  it  in  extent ;  and  that,  therefore,  a  good  deal  of 
displacement  of  the  bones  may  occur  in  disjointings  at  the  articulation  of  the 
head,  without  causing  much  compression  of  the  spinal  cord. 

In  regard  to  the  etiology  of  the  luxations  which  are  met  with  at  the 
occipito-atloid  articulation,  an  inspection  of  the  above-mentioned  examples 
indicates  that  the  application  of  great  force,  in  such  a  way  as  to  bend  the 
head  on  the  atlas  far  forward  or  backward,  is  requisite  for  their  causation. 
This  force  may  be  directly  applied,  for  instance,  by  means  of  a  crushing 
weight  striking  on  the  neck,  and,  perhaps  on  the  head  also,  as  was  noted  in 
the  observations  of  Lassus  and  Bouisson ;  or  it  may  be  indirectly  applied 
through  the  cranium — for  example,  by  falling  head-foremost  from  a  great 
height  and  striking  thereon,  as  happened  in  Paletta's  case.  But  a  disloca- 
tion of  the  occipital  bone  from  the  atlas  has  never  been  caused,  as  far  as 
known,  by  stretching  the  head  and  neck,  however  great  the  extending  force 
may  have  been,  although  the  experiment  has  often  been  made  in  executing 
the  death-sentence  on  criminals  by  hanging.  Even  in  those  cases  in  which  the 
head  has  been  torn  completely  off  from  the  trunk,  from  laceration  of  the 
neck  by  the  rope,  the  vertebral  ligaments,  it  is  believed,  have  always  given 
way  at  some  point  other  than  the  occipito-atloid  articulation — at  some  point 
where  the  ligaments  are  less  able  to  withstand  the  stretching. 

Spontaneous  luxation,  however,  may  occur  at  the  occipito-atloid  articula- 
tion, in  consequence  of  the  destruction  or  extreme  weakening  of  its  ligaments 
by  disease.  Boyer  mentions  an  example  which  he  had  seen  at  La  Charite,  and 
refers  to  a  case  related  by  Daubenton,  the  specimen  from  which  was  placed 
in  the  king's  cabinet.  Sandifort  has  described  five  specimens,  found  in  the 
museum  at  Ley  den.  Mr.  Hilton  has  presented  a  very  instructive  case  of  the 
same  sort,  illustrated  with  two  wood-cuts.^  In  these  cases,  the  ligaments  con- 
necting the  first  vertebra  to  the  occipital  bone  must  have  been  destroyed  by 


'  Op.  cit.,  pp.  56-58. 


DISLOCATIONS  OF  THE  VERTEBRA. 


309 


ulceration;  or,  at  least,  must  have  become  so  much  softened  as  to  have  quite 
lost  their  consistence  and  strength. 

Dislocation  of  the  atlas  upon  the  axis  very  often  occurs.  The  neck  is  dis- 
jointed at  the  atlo-axoid  articulation  more  frequently  than  it  is  at  the  junc- 
ture of  any  two  cervical  vertebrae  beside  them.  The  considerable  variety 
and  wide  extent  of  the  movements  of  the  head  and  neck,  which  are  executed 
at  the  triple  articulation  between  the  atlas  and  axis,  and  the  peculiarities  in 
the  anatomical  structure  thereof  which  enable  these  difierent  movements, 
particularly  the  rotatory  ones,  to  be  performed,  nmch  increase  the  chances 
for  dislocation  to  occur  at  this  compound  vertebral  joint,  notwithstanding  the 
remarkable  strength  of  the  apparatus  itself.  Moreover,  in  almost  every 
instance  where  sudden  death  is  caused  by  the  luxation  of  a  cervical  vertebra, 
the  displacement  of  bone  which  crushes  or  fatally  compresses  the  spinal  cord 
is  found  within  the  spinal  foramen  of  the  atlas  or  axis.  But,  generally,  in 
such  cases,  it  is  found  within  the  spinal  foramen  of  the  former,  and  there  the 
act  of  crushing  or  strongly  compressing  the  spinal  cord  is  effected  by  the 
odontoid  process  of  the  latter. 

Dislocation  of  the  first  upon  the  second  vertebra  is  alw^ays  forward,  and 
may  be,  or  may  not  be,  complicated  with  fracture ;  but,  even  when  compli- 
cated w^ith  fracture,  the  dislocation  is  usually  the  more  important  lesion,  inas- 
much as  it  generally  is  the  bone  displaced  by  the  dislocation,  which  presses 
the  cord  from  behind  against  the  odontoid  process  in  front,  and  thus  places 
life  in  sudden  periL  The  special  consideration,  however,  of  fracture  as  a 
complication  in  such  cases  is,  for  the  moment,  deferred. 

Dislocation  of  the  atlas  upon  the  axis,  without  fracture,  that  is,  joure  dislo- 
cation of  the  first  upon  the  second  vertebra,  also  not  unfrequently  occurs.  It 
appears  with  probably  about  the  same  frequency  as  dislocation  combined 
with  fracture  of  the  same  bone.  In  the  first  variety  of  pure  dislocation  occur- 
ring at  the  atlo-axoid  articulation,  that  is  to  be  noticed  in  this  place,  the 
atlas  is  thrust  or  displaced  forward  because  the  transverse,  accessory,  and 
lateral  ligaments  have  all  been  simultaneously  ruptured  by  external  violence, 
and  nothing  remains  to  hold  the  odontoid  process  in  contact  with  the  articular 
fossa,  intended  for  its  reception,  on  the  anterior  arch  of  the  atlas.  To  pro- 
duce this  variety  of  dislocation  the  expenditure  of  great  force  is  obviously 
required.  The  following  example  will  materially  aid  in  illustrating  this  acci- 
dent : — 

Lieut.  J.  Alman,  Troop  I,  4th  Cavalry,  was  killed,  March  17,  1868,  in  a  collision 
between  a  row-boat,  which  was  carrying  him  to  Jefferson,  Texas,  and  a  steamboat.  He 
was  struck  by  the  paddles  of  the  wheel  and  carried  under.  His  body  was  once  thrown 
to  the  surface  by  the  eddies  of  the  water,  and  then  sank.  Every  effort  was  made  to 
secure  his  remains,  but  without  avail,  until  the  sixth  day  after  the  disaster,  when  the 
body,  in  a  very  advanced  stage  of  decomposition,  rose  to  the  surface.  An  autopsy 
revealed  a  dislocation  of  the  atlas  upon  the  second  cervical  vertebra,  with  rupture  of 
the  transverse  ligaments,  and  the  odontoid  process  impinging  upon  the  spinal  marrow.^ 

In  this  case,  the  strength  of  the  odontoid  process  was  greater  than  that  of 
the  transverse  and  other  ligaments  combined.  Hence,  when  the  triple  articu- 
lation to  which  they  belonged  was  subjected  to  a  great  strain,  they  gave  way 
and  allowed  dislocation  forward  of  the  atlas  to  occur,  with  crushing  of  the 
spinal  cord  against  the  odontoid  process  of  the  axis.  The  strength  which  the 
odontoid  process  manifested  in  this  case  does  not  appear  to  have  been  excep- 
tional ;  for  Dr.  Stephen  Smith,  after  making  numerous  experiments  that  bear 
on  this  point,  comes  to  the  following  conclusions :  (1)  In  a  healthy  condition 


1  Circular  No.  3,  S.  G.  0.,  August  17,  1871. 


310 


INJURIES  OF  THE  BACK. 


of  parts,  the  odontoid  process  has  greater  strength  than  either  the  anterior 
arch  of  the  atlas,  or  the  transverse  ligament.  (2)  The  odontoid  process  is 
less  liable  to  be  fractured  by  external  violence  than  the  body  of  the  axis  at 
the  insertion  of  the  process.  (3)  The  odontoid  process  is  not  fractured  by 
being  driven  against  the  transverse  ligament  or  anterior  arch  of  the  atlas.^ 

Again,  it  appears  that  the  ligaments  of  the  atlo-axoid  articulation  may 
be  broken  in  detail,  as  it  were,  or  one  after  another,  by  violently  turning  or 
rotating  the  head  to  one  side,  and  that  dislocation  forward  of  the  atlas  may 
in  this  way  be  produced.  In  a  violent  rotation  of  the  head  to  one  side,  the 
alar  or  check  ligaments  of  the  odontoid  process  are  put  upon  a  stretch,  and 
twisted  around  this  process.  The  momentum  of  the  head  is  opposed  by  these 
ligaments  alone,  and,  if  at  this  time  the  head  be  inclined  to  either  side,  one 
of  the  alar  or  check  ligaments,  more  tense  than  the  other,  yields  first,  and 
thus  renders  the  rupture  of  both  more  easy.  When  the  alar,  check,^  or 
odontoid  ligaments  are  once  broken,  rupture  of  the  transverse  and  other  liga- 
ments easily  follows.  It  is  not  improbable  that  the  dislocation  in  the  follow-, 
ing  instance  was  produced  in  this  manner  by  a  pow^erful  blow  in  the  face : — 

A  man,  named  Carter,  was  killed  in  a  brawl,  on  the  ni<?ht  of  July  18,  1882.  The 
blow  was  planted  fairly  in  his  face  by  his  assailant's  fist.  He  dropped  to  the  ground  as 
if  felled  by  an  axe,  and  did  not  move  afterward.  An  autopsy  showed  that  death  had 
resulted  immediately  from  dislocation  of  the  spinal  column,  and  injury  of  the  spinal 
cord,  at  the  junction  of  the  atlas  and  axis,  the  lesion  being  identical  with  that  caused  by 
hanging.^ 

Such  a  blow,  planted  on  the  man's  cheek  while  his  head  w^as  already  turned 
in  the  opposite  direction,  might,  by  rotating  his  head  with  great  force  still 
further  in  the  same  direction,  readily  break  the  odontoid  or  check  ligaments 
first,  and  then  the  transverse  and  the  other  ligaments  successively.  Owing 
to  the  skull  being  articulated  at  its  base,  near  the  middle,  on  the  summit  of 
the  cervical  portion  of  the  vertebral  column,  imaginary  lines  drawn  from  the 
point  of  junction  to  the  farthest  convexities  on  the  skull's  periphery,  will 
represent  levers,  which  will  act  on  the  axis  of  motion  in  the  cervical  vertebrae, 
with  power  commensurate  to  their  different  lengths.  (Shaw.)  In  the  case  just 
mentioned,  the  portion  of  the  head  intervening  between  the  malar  prominence 
of  the  cheek  and  the  occipito-atloid  articulation  w^ould  constitute  a  lever, 
through  which  the  blow^  on  the  cheek  would  act  with  greatly  augmented 
force  upon  the  axis  of  motion  in  the  cervical  vertebrae ;  and,  in  this  way,  the 
odontoid  and  the  other  ligaments  belonging  to  the  atlo-axoid  articulation 
would  be  successively  ruptured,  and  the  atlas  would  be  dislocated  upon  the 
axis,  as  it  were,  by  powerfully  twisting  the  neck  by  means  of  force  applied 
to  the  face. 

So,  too,  Louis,  the  famous  French  surgeon,  in  endeavoring  to  distinguish, 
among  those  who  had  died  by  hanging,  the  suicide  from  the  victim  of 
assassination,  found  that  those  who  were  merely  suspended  by  a  rope  died 
simply  from  strangulation,  while  those  who,  after  being  swung  off  from  the 
gallows,  had  their  necks  tvnsted,  had  also  the  first  cervical  vertebra  luxated 
upon  the  second.  Moreover,  the  hangman  at  Lyons  having  reduced  the  prac- 
tice of  his  infamous  profession  to  its  elemental  principles,  always  produced 
disjointing  of  the  neck  by  sitting  on  the  shoulders  of  the  culprit,  and  rotating 
the  head  and  bending  it  to  one  side  until  he  heard  the  crack  which  informed 
him  that  he  had  effected  dislocation  of  the  atlas  upon  the  axis.  (Boyer.) 

But  traction  (direct)  of  the  head,  especially  when  combined  with  rotation^ 
is  peculiarly  dangerous  in  children,  on  account  of  its  liability  to  cause  luxa- 


1  Am.  Journal  of  the  Med.  Sciences,  October,  1871.  ^  New  York  Sun,  July  22,  1882. 


DISLOCATIONS  OF  THE  VERTEBRiE. 


811 


tion  of  the  first  vertebra  upon  the  second.  Several  cases  are  reported  vvliere 
children,  in  turning  somersaults,  dislocated  the  first  upon  the  second  vertebra  ; 
and  Marjolin  states  that  in  very  young  persons  the  odontoid  process  is  so  short 
that  it  may  pass  behind  the  transverse  ligament,  without  rupturing  the  latter. 
(Ashhurst.)  In  young  subjects,  the  odontoid  process  being  yet  incompletely 
developed,  and  the  odontoid  ligaments  being  proportionally  longer  and  less 
firm,  traction  directly  applied  to  the  head  with  rotation,  may  stretch  and 
break  these  ligaments  and  their  accessories,  so  as  to  permit  the  odontoid  pro- 
cess to  pass  under  the  transverse  ligament  and  crush  the  spinal  cord,  without 
rupturing  that  ligament.  J.  L.  Petit  saw  a  child,  aged  (i  or  7,  lifted  up  by 
a  man  (in  order  to  see  London,  according  to  the  vulgar  saying),  who  took 
hold  of  the  forehead  and  back  part  of  the  head.  The  cliild  struggled,  became 
agitated,  and  died.  Although  no  anatomical  examination  was  made,  there  is 
little  doubt  that  the  atlas  was  luxated  upon  the  axis.  (Boyer.) 

An  infant,  8  days  old,  Avas  instantly  killed  by  violence  from  its  mother ; 
Maschka  reports  that  the  second  cervical  vertebra  was  found  dislocated.^ 
This  case  probabl}"  belongs  to  the  same  category  as  those  mentioned  in  the 
last  paragraph ;  and  in  it,  likewise,  dislocation  occurred  between  the  atlas 
and  the  axis,  because  the  odontoid  process  was  so  short,  from  want  of  develop- 
ment, that  it  passed  under  the  transverse  ligament,  as  soon  as  the  odontoid 
or  check  ligaments  had  been  ruptured. 

The  etiology  of  luxation  at  the  juncture  of  the  atlas  and  axis  can  be  further 
illustrated  by  referring  to  12  examples  of  it  that  are  mentioned  in  Professor 
Ashhurst's  tables.^  Of  these,  it  was  caused,  in  four  instances,  by  falling  from 
a  height  and  alighting  on  the  head  ;  in  two  instances,  by  suicidal  hanging  ;  in 
one  instance,  by  the  fall  of  a  bundle  of  hay  upon  the  head  ;  in  one  instance, 
by  blows  on  the  back  of  the  neck  ;  in  one  instance,  by  muscular  action  ;  while 
in  three  cases,  the  form  of  the  injury  is  not  stated.  It  is  worthy  of  remark 
that  there  is  no  mention,  in  Professor  Ashhurst's  tables,  of  any  instance  where 
this  lesion  was  caused  by  the  hanging  of  criminals  according  to  law,  although 
it  is  well  known  that  this  lesion  is  often  present  in  such  cases.  The  probable 
reason  for  this  absence  of  mention  is  the  fact  that  such  cases  are  but  seldom 
reported  in  the  medical  journals.  Hospital  reports,  likewise,  but  seldom 
contain  any  examples  of  luxation  of  the  atlas  upon  the  axis,  because  the 
victims  of  this  accident  generally  do  not  survive  long  enough  to  get  into  a 
hospital. 

But,  dislocation  at  the  juncture  of  the  first  and  second  cervical  vertebrae 
sometimes  occurs  spontaneously^  in  consequence  of  disease  having  destroyed 
the  ligaments  of  the  threefold  articulation.  I  have  already  mentioned  a 
remarkable  example  of  this  sort  (page  284)  which  was  recorded  by  Mr. 
Hilton.^  In  such  cases,  the  head  and  the  atlas  together  fall  forward ;  and 
thus  the  spinal  cord  may  be  crushed  or  strongly  compressed  by  the  latter 
against  the  odontoid  process  of  the  axis  which  remains  fixed.  In  this  way, 
Mr.  Hilton's  patient  was  almost  instantly  killed.  Duverney  met  with  a  case 
in  which  the  atlas  had  fallen  forward  so  far,  in  consequence  of  the  destruc- 
tion by  disease  of  the  atlo-axoid  ligaments,  that  the  odontoid  process  was 
approximated  to  the  posterior  arch  of  the  atlas  b}^  two-thirds  of  the  diameter 
of  its  foramen  spinale.  (Boyer.) 

Furthermore,  dislocation  of  the  atlas  upon  the  axis,  whether  caused  by 
injury  or  by  disease,  does  not  prove  immediately  fatal  unless  the  displacement 
of  the  former  be  so  great  that  its  posterior  arch  crushes,  or  strongly  com- 
presses, the  spinal  cord  against  the  odontoid  process  of  the  latter.    In  cases 


1  New  Syd.  Soc.  Year-Book,  1859,  p.  427. 

2  Op.  cit.,  pp.  72-121.  8  Op.  cit.,  pp.  61,  62. 


312 


INJURIES  OF  THE  BACK. 


where  the  displacement  of  bone  is  not  so  great  as  to  seriously  compress  the 
cord,  however,  life  may  be  prolonged  for  many  hours  or  many  days,  and  even 
recovery  may  take  place.    For  example : — 

A  mason,  aged  60,*  fell  head-foremost  from  a  height.  He  suffered  from  shock,  and 
there  was  unnatural  mobility  of  his  head.  He  survived  the  accident,  however,  twenty 
hours.  An  autopsy  showed  dislocation  forward  of  the  atlas  on  the  axis  ;  no  fracture  ; 
the  spinal  cord  was  compressed  by  the  odontoid  process.  (Ashhurst.)  Again,  a  boy, 
aged  15,^  was  injured  by  blows  on  the  back  of  the  neck,  but  paralysis  did  not  supervene 
until  lour  months  afterward.  One-half  of  a  month  later  still,  death  ensued.  An  autopsy 
revealed  dislocation  forward  of  the  atlas,  with  compression  of  the  spinal  cord.  (Ash- 
hurst.) Moreover,  in  two  cases  mentioned  in  Professor  Ashhurst's  tables,  where  "  dis- 
location or  displacement  of  the  atlas"  was  diagnosticated,  reduction  by  extension,  etc., 
proved  successful;  and  in  one  case  of  '"dislocation  of  the  odontoid  process"  recovery  also 
is  stated  to  have  taken  place.^ 

In  the  case  of  a  female  patient,  aged  45,  where  there  was  at  least  subluxation  of  the 
atlas  from  disease  of  the  atlo-axoid  articulation,  Mr.  Hilton  says:  "The  head  was 
inclined  to  fall  forward,  and,  indeed,  she  found  it  impossible  to  keep  it  up  without  arti- 
ficial support  of  some  kind.  On  pressing  the  head  directly  downward  upon  the  spine, 
and  attempting  to  rotate  the  head  upon  the  spine,  she  could  not  bear  it.  She  became 
nearly  pulseless  and  fainted,  and  the  limbs  tremulous  and  agitated.  We  immediately 
placed  her  upon  the  floor  of  the  room.  I  thought  she  was  dead,  but  she  very  slowly 
recovered."* 

S'till,  this  patient,  in  the  end,  regained  good  health  after  many  months  of 
treatment,  which  consisted  mainly  in  absolute  rest  of  the  spine  in  bed  with 
two  large  half-filled  bags  of  sand  placed,  one  on  each  side  of  the  head  and 
neck,  to  prevent  any  lateral  movement  of  the  head,  and  a  small,  firm  pillow 
put  under  the  neck,  to  remedy  the  displacement  of  the  atlas  by  raising  the 
axis  to  the  same  level,  thereby  freeing  the  spinal  cord  from  the  impingement 
upon  it  of  the  odontoid  process  of  the  axis.  The  last-mentioned  point  in  the 
treatment  is  of  very  great  importance.   Concerning  it  Mr.  Hilton  observes : — 

"  The  patient  was  placed  with  her  back  flat  on  her  bed.  This  position  brought  on 
extreme  difficulty  in  her  breathing.  Whilst  she  was  still  in  the  recumbent  position,  and 
breathing  with  difficulty,  I  placed  my  hand  underneath  the  neck,  and  lifted  upward 
and  forward  that  part  of  the  spine.  The  sense  of  suffocation  became  at  once  dimin- 
ished (I  had  observed  the  same  circumstance  before  in  another  patient  who  had  disease 
of  the  highest  part  of  the  spine),  and  I  had  therefore  a  small,  firm  pillow  put  under- 
neath the  neck,  which  supported  it  very  perfectly.  This  is  a  very  important  fact, 
because  I  think  I  have  known  at  least  two  persons  who  were  destroyed  in  consequence 
of  this  little  point  not  having  been  attended  to."^ 

Considerable  space  has  been  devoted  to  this  example  because  of  its  intrinsic 
value  in  showing  what  the  plan  of  treating  this  lesion  should  be,  in  cases  of 
injury  where  life  is  not  immediately  destroyed,  as  well  as  in  cases  of  disease. 

1  Journal  de  Chirurgie,  1844.  2  Revue  Medico-Chirurg.,  t.  xii. 

3  The  two  instances,  that  are  barely  mentioned  above,  in  which  traumatic  dislocation  of  the 
atlas  was  successfully  treated  by  reduction,  deserve  additional  notice  :  (1)  A  man,  aged  60 
(Malgaigne,  Traits  des  Fract.  et  des  Luxations,  t.  ii.),  was  injured  by  a  bundle  of  hay  falling  on 
his  head.  His  head  was  bent  forward  so  that  his  chin  touched  the  sternum,  but  there  was  no 
paralysis.  A  dislocation  of  the  atlas  was  diagnosticated.  Malgaigne  (Senior)  reduced  the  dis- 
location by  making  extension,  and  the  man  recovered.  Two  years  afterward  his  head  could  not 
be  turned.  (2)  A  lad,  aged  16  (Journ.  Complementaire,  t.  xxxvi.),  fell  backward  from  a  ladder, 
with  a  sack  of  flour  over  his  head.  He  was  unconscious,  almost  pulseless,  and  paralyzed. 
There  was  abnormal  mobility  of  the  head,  and  a  prominence  in  front  and  to  the  left  of  the 
point  of  abnormal  mobility.  A  displacement  of  the  atlas  was  diagnosticated.  Ehrlich  effected 
reduction  by  applying  extension  and  pressure.  The  success  of  his  efforts  was  marked  by  an 
audible  sound.    Recovery  ensued. 

<  Op.  cit.,  pp.  56-60.  «  Ibid.,  p.  58. 


DISLOCATIONS  OF  THE  VERTEBRA. 


313 


Dislocation  forward  of  the  axis  upon  the  third  cervical  vertebra^  without  fi-ac- 
ture,  carrying  the  atlas  and  the  head  forward  with  the  axis,  has  been  i-eported 
in  a  few  instances.  In  the  following  example,  where  pure  luxation  of  the 
second  upon  the  third  cervical  vertebra  was  found,  partial  paralysis  of  the  left 
arm  and  forearm  was  noted,  while  the  lower  extremities  and  the  bladder 
were  entirely  free  from  paralysis  ;  but  death  suddenly  occurred  on  the  fourth 
day  :— 

The  case  was  that  of  a  man,  aged  34.^  On  the  patient's  admission  to  hospital,  there 
were  observed  paralysis  of  the  left  deltoid  muscle,  and  impaired  power  ol*  supination  of 
the  left  forearm,  showing  involvement  of  the  left  circumflex  and  musculo-spiral  nerves. 
All  the  movements  of  the  lower  extremities,  liowever,  were  perfect,  and  the  patient  iiad 
complete  control  over  the  bladder.  But  he  became  restless,  and  threw  his  limbs  about ; 
and  died  suddenly  on  the  fourth  day,  while  struggling  and  kicking.  At  the  autop si/ 
a  dislocation  of  the.  second  from  the  third  cervical  vertebra  was  found,  with  very 
extensive  extravasation  of  blood  behind  the  pharynx  and  oesophagus,  uncomplicated 
with  fracture.  Mr.  Erichsen  remarks  on  the  great  rarity  of  the  case.  Tliere  were  no 
head-symptoms,  and  there  was  also  no  general  paralysis.  Stress  is  laid  on  the  absence 
of  any  hyper^sthetic  Hne  during  life,  as  indicating  that  the  lesion  was  a  dislocation 
rather  than  a  fracture,  because  the  broken  sharp  edges  of  bone  in  a  fracture  would  irri- 
tate the  spinal  nerves  in  contact  with  them,  and  thus  cause  hypera3sthesia  in  the  tract 
supplied  by  the  irritated  nerve-fibres. 

It  is  not  improbable  that  this  man's  sudden  death  was  caused  by  sudden 
compression  of  the  spinal  cord,  resulting  from  a  sudden  increase  in  the  dis- 
placement forward  of  the  second  cervical  vertebra,  which  was  occasioned  by 
the  restlessness  and  tossing  of  the  patient  himself.  In  treating  such  a  case, 
confinement  to  bed  in  the  recumbent  posture  trom  the  outset,  with  a  small, 
firm  pillow  placed  under  the  neck,  and  a  large,  half-filled  bag  of  dry  sand 
moulded  to  each  side  of  the  head  and  neck,  as  recommended  by  Mr.  Hilton 
in  treating  luxations  of  the  upper  cervical  vertebrpe  from  disease,  would  be  of 
inestimable  value,  and  would  probably  lead  to  the  patient's  recovery  as  w-dl 
as  prevent  the  occurrence  of  sudden  death. 

Another  example  of  this  accident  may  be  briefly  reported  as  follows :  

A  man,  aged  50,^  fell  backward  from  a  fence  and  struck  upon  his  head,  sustaining 
thereby  a  dislocation  of  the  second  from  the  third  cervical  vertebra.  His  head  was 
thrown  back,  and  there  was  paralysis,  but  no  pain.  Attempts  at  reduction  failed  ;  and, 
in  forty-eight  hours,  he  died.  (Ashhurst.) 

Pure  luxations  at  the  juncture  of  the  second  and  third  cervical  vertebrje 
are  extremely  rare  ;  and  I  have  found  only  the  two  examples  just  presented. 
One  reason  why  these  cases  very  seldom  come  under  treatment,  possibly  is 
the  fact  that  the  vertebral  displacement  is  very  liable  to  cause  instant  death, 
at  the  time  of  the  accident,  by  strongly  compressing  or  crushing  the  spinal 
cord  above  the  origin  of  the  phrenic  nerves.  But,  in  the  exarnptes  which  do 
come  under  treatment,  it  may  sometimes  be  a  remedial  measure  of  very  great 
importance  to  eftect  a  reduction  of  the  displacement,  especially  if  the  paralysis 
be  extending  or  threatening  to  become  complete  paraplegia.  In  such  a  case, 
the  efi:brts  at  reduction  should  be  persisted  in  until  they  achieve  success. 

The  next  case  is  of  interest  mainly  because  it  shows  that  death  by  hanging 
may  be  attended  with  luxation  at  the  juncture  of  the  second  and  third  cervi- 
cal  vertebrae,  as  well  as  with  fracture  of  the  second  : — 

Mahon^  found  in  a  female  criminal,  on  whom  the  death-sentence  had  been  executed 
by  hanging,  that  the  axis  was  fractured,  and  that  the  intervertebral  cartilage  between 
the  axis  and  the  third  cervical  vertebra  was  ruptured.  (Ashhurst.) 


'  Lancet,  August  1,  1874.  Some  remarks  thereon  by  Mr.  Erichsen  are  also  presented. 
2  Boston  Med.  and  Surg.  Journal,  vol.  x.  3  Med.  Lecrale,  t,  iii. 


314 


INJURIES  OF  THE  BACK. 


Dislocations  of  the  last  Jive  cervical  vertebrce  (that  is,  of  any  vertebra  from  the 
third  to  the  seventh  inclusive)  from  violence,  without  fracture,  frequently 
come  under  the  care  of  surgeons.  For  example,  of  36  fatal  cases  of  injury 
of  the  cervical  vertebrae  extracted  from  the  records  of  Guy's  Hospital  prior 
to  1878,  11  were  examples  of  pure  dislocation,  all  of  them  below^  the  third 
cervical  vertebra  ;  and  the  remaining  25  were  instances  of  dislocation  combined 
wdth  fracture.*  Pure  dislocation  below  the  third  cervical  vei'tebra  is  there- 
fore met  wdth  in  about  30  percent,  of  all  the  cases  in  which  traumatic  lesions 
of  the  cervical  vertebrse  occur;  and,  in  the  rest  of  them,  the  dislocation  is 
generally  combined  with  fracture. 

Again,  of  these  11  examples  of  pure  dislocation,  4  ^vere  found  betw^een  the 
fourth  and  fifth  cervical  vertebrae ;  2  between  the  fifth  and  sixth ;  3  between 
the  sixth  and  seventh  ;  and  2  between  the  seventh  cervical  and  the  first  dorsal 
vertebra.  In  6  of  them,  the  displacement  was  so  great  as  to  crush  the  spinal 
cord.  In  5,  there  was  no  marked  paralysis  as  a  direct  result  of  the  injury, 
although  secondary  paral3^sis  subsequently  appeared,  from  stretching  or  other 
injury  of  the  cord,  and  proved  fatal.  In  none  of  them  was  there  even  the 
smallest  trace  of  fracture. 

Death  generally  ensued  within  seventy-two  hours  in  those  cases  of  cervical 
dislocation  where  the  spinal  cord  was  injured  enough  to  cause  paraplegia ; 
and,  in  a  majority  of  the  instances,  within  forty-eight  hours.  For  example, 
28  of  the  36  fatal  cases  observed  at  Guy's  Hospital  died  in  less  than  seventy- 
two  hours,  and  20  in  less  than  forty-eight  hours ;  8  only  survived  the  former 
period,  and  in  them  no  symptoms  of  paralysis  resulted  immediately  from  the 
accident.  (Bryant.) 

In  every  one  of  these  cases  of  cervical  dislocation,  the  upper  vertebra  w^as 
thrown  forward  upon  the  lower,  and  the  intervertebral  cartilage  connecting 
them  w^as  ruptured.  In  the  luxations  that  occur  among  the  last  five  cervical 
vertebrae,  then,  as  well  as  in  those  that  have  already  been  described,  the  dis- 
placed bone  carries  with  it  the  whole  of  that  portion  of  the  spinal  column 
which  is  placed  above  it,  no  single  vertebra  being  simultaneously  dislocated 
from  those  above,  as  well  as  from  those  below  it.  When  spinal  symptoms 
result  in  these  cases,  the  cord  is  generally  found  to  be  injured  by  the  displaced 
bone ;  in  some  instances  it  is  crushed,  in  others  bruised,  and  in  others  merely 
compressed. 

The  following  case,  wdth  the  accompanying  wood-cut  (Fig.  859),  will  afibrd 
a  good  illustration  of  the  disjointings  w^hich  are  met  with  among  the  last  fi.ve 
cervical  vertebrae : — 

Private  John  F.,  Co.  B,  2d  Infantry,  a  powerful,  muscular  German,  aged  o5,  was 
badly  hurt  by  falling  on  his  head  while  attempting  to  turn  a  somersault,  on  February  10, 
1866.  Instead  of  alighting  upon  his  feet,  his  head  struck  the  earth,  and  he  rolled  over 
upon  his  side  and  lay  motionless  ;  face  pale,  respiration  sighing,  pulse  slow  and  full. 
Examination  showed  that  sensation  and  power  of  motion  were  alike  wanting  from 
the  neck  downward.  The  walls  of  his  chest  were  motionless,  and  respiration  was 
effected  by  the  diaphragm  alone.  He  moved  his  head  freely  from  side  to  side,  but 
could  not  raise  it.  On  lifting  his  head  from  the  table,  so  much  distress  ensued  that  the 
effort  was  abandoned,  and  he  was  turned  partly  upon  his  side,  in  order  to  examine  the 
neck.  But  the  examination  was  very  unsatisfactory,  for  the  layers  of  muscles  and  fat 
were  so  thick  that  the  spinous  processes  could  not  be  distinctly  perceived,  and  a 
positive  diagnosis  could  not  be  arrived  at.  It  was  clear,  however,  that  there  was  an 
abnormal  gap  or  depression  between  the  spinous  processes  of  the  fourth  and  fifth,  or  the 
iifth  and  sixth,  cervical  vertebrae  ;  that  pressure  on  this  depression  gave  slight  pain  ; 
that  crepitus  was  absent ;  and,  that  the  movements  of  the  head  upon  the  atlas,  and  of 
the  atlas  upon  the  axis,  were  such  as  to  prove  that  these  articulations  were  not  involved. 


1  Bryant,  Practice  of  Surgery,  Am.  ed.,  1879,  pp.  201,  202. 


DISLOCATIONS  OF  THE  VERTEBRA. 


315 


The  respiratory  movements  indicated  tliat  the  lesion  of  tlie  spinal  cord  was  below  the 
origin  of  the  phrenic  nerves,  and  the  total  paralysis  of  the  upper  extremities  that  it 
was  situated  above  the  origin  6f  the  brachial  plexus.    The  patient,  thenceforth,  was 
left  undisturbed.    He  lay  perfectly  supine,  breathing  by  the 
diaphragm  alone,  suffered  no  pain,  and  was  able  to  swallow  Pig^  859 

small  quantities  of  fluids.  His  pulse  which  immediately  after 
the  accident  was  78,  in  two  hours  fell  to  72.  About  three 
ounces  of  turbid  urine  were  withdrawn  by  catheter  in  the 
evening.  He  sank,  gradually,  and  died  forty-four  hours  after 
the  accident. 

Autopsy^  five  hours  after  death.  Rigor  mortis  imperfectly 
established  ;  sugillation  general  over  posterior  portion  of 
body  ;  ulceration  over  the  sacrum  had  already  commenced. 
The  lower  and  back  part  of  the  neck  exhibited  slight  tume- 
faction, yet  sufficient  to  obliterate  the  depression  which  had 
been  felt  during  life.  The  whole  cervical  portion  of  the  spi- 
nal column  was  exposed  by  dissection,  which  revealed  a  dis- 
location forward  of  the  fourth  cervical  vertebra  upon  the  fifth. 
(The  accompanying  wood-cut,  Fig.  859,  clearly  sliows  that 
the  fourth  cervical  vertebra  was  dislocated  from  the  fifth, 
and  not  the  latter  from  the  former,  as  stated  in  the  report  of      ^     ^.    .       ,        .  ^. 

.  '  •     1         rr^i  Luxation  forward  of  the  fourth 

the  case.)    The  luxation  was  "  symmetrical.      lliere  was  cervical  vertebra  upon  the  fifth, 

a  wide  interval  of  one  and  a  half  inches  between  the  spinous  Spec  549,  Sect,  i.,  a.  m.  m. 

processes  of  the  fourth  and  fifth  vertebrae,  which  caused  The  :our  upper  cervical  verte- 

the  depression  perceived  at  the  first  examination  of  i)atient.  ^''^  '"'^  displaced  far  forward, 

mi  /•  r»  -1       1     1  1-1  1       •  c     and  the  axis  of  Uie  vertebral 

There  was  no  fracture  of  the  body,  pedicles,  or  laminae  of  ^^^^^^  ^^^^  ^^^^ 
the  displaced  bone,  but  a  part  of  the  anterior  tubercle  of  the  in  the  same  direction  at  the 
right  transverse  process  of  the  fifth  vertebra  had  been  snapped  place  of  luxation, 
off.  The  ligamenta  subflava  and  capsular  ligaments  connect- 
ing the  fourth  and  fiftli  vertebrae  had  been  ruptured,  as  well  as  the  attachment  of  the 
ligamentum  nuchae  to  these  bones.  The  anterior  and  posterior  common  ligaments  were 
not  broken.  There  -svas  a  slight  extravasation  of  blood  external  to  the  theca  verte- 
bralis,  and  a  considerable  quantity  between  the  theca  and  the  spinal  cord.  At  the 
point  of  luxation,  the  cord  was  bent  at  an  abrupt  angle,  and  its  antero-posterior  di- 
ameter reduced  more  than  one-half  by  compression  from  the  laminae  of  tl)e  displaced 
fourth  vertebra  against  the  body  of  the  fifth,  and  by  tilting  forward  of  the  upper 
four  vertebr£e.  The  meninges  of  the  cord  were  not  torn,  nor  was  the  cord  itself  lace- 
rated, which  may  perhaps  be  accounted  for  by  the  fact  that  the  wide  separation  of  the 
laminae  posteriorly  allowed  it  to  bulge  out  in  that  direction,  and  thus  escape  rupture. 
The  lungs  were  generally  congested,  the  left  more  than  the  right.  The  posterior  por- 
tions were  especially  engorged  ;  but  crepitation  was  nowhere  entirely  absent.  The  heart 
was  slightly  hypertrophied  and  all  its  cavities  empty.  The  osteal  specimen  was  removed 
and  sent  to  the  Army  Medical  Museum.    It  is  represented  in  Fig.  859.^ 

The  symptoms  in  this  case  clearly  indicated  that  there  was  dislocation  for- 
ward of  a  vertebra,  with  much  displacement,  somewhat  below  the  middle  of 
the  cervical  region,  without  much  fracture.  The  completeness  with  which 
the  skin  and  all  the  muscles  below  the  neck,  excepting  the  diaphragm,  were 
paralyzed,  denotes  that  the  spinal  cord  was  either  severed  or  strongly  com- 
pressed by  the  displaced  bone.  The  autopsy  showed  that  the  antero-posterior 
diameter  of  the  cord  was  lessened  more  than  one-half  by  displacement  for- 
ward of  the  fourth  vertebra,  and  that  the  compression  of  the  cord  thus 
caused  was  supplemented  by  the  extravasation  of  considerable  blood  between 
the  theca  and  the  cord.  It  is  not  improbable  that  the  extravasation  of  blood, 
if  it  did  not  directly  occasion,  hastened  by  at  least  some  hours  the  occurrence 
of  deatii,  by  compressing  the  spinal  cord  at  and  above  the  origin  of  the 
phrenic  nerves.    It  should  here  be  stated  that,  in  vertebral  dislocations  and 


'  Circular  No.  3,  S.  G.  0.,  August  17,  1871. 


316 


INJURIES  OF  THE  BACK. 


fractures,  blood  is  often  extra vasated  in  large  quantity  between  the  theca  and 
the  cord,  and  that  such  extravasation  proves  to  be  the  proximate  cause  of  death 
by  compressing  the  cord. 

A  case  with  many  points  of  resemblance  to  the  foregoing  was  treated  some 
years  ago  by  myself: — 

A  robust  man,  aged  about  30,  while  driving  a  peddler's  wagon  having  a  very  high 
seat,  into  a  carriage-house  having  a  rather  low  door,  struck  the  back  of  his  head  with 
great  force  against  a  beam  at  the  top  of  the  doorway,  which  crushed  him  down  into  the 
seat.  He  instantly  became  helpless  and  was  carried  into  the  house.  Two  hours  after- 
ward I  saw  him  ;  he  then  lay  in  bed  on  his  back,  with  his  neck  bent  forward  and  stiff, 
and  he  seemed  to  dread  lest  an  attempt  to  raise  his  head  should  be  made ;  he  could,  how- 
ever, roll  his  head  freely  from  side  to  side.  His  lower  extremities,  body,  and  upper 
extremities  were  completely  paralyzed,  both  as  to  sensation  and  motion.  His  mind  was 
clear,  and  he  said  he  was  free  from  suffering.  He  was  breathing  by  the  diaphragm 
alone,  for  all  the  other  respiratory  muscles  were  paralyzed.  By  turning  his  body  on 
to  the  left  side  I  was  enabled  to  examine  the  back  of  his  neck,  which  was  thick,  mus- 
cular, and  somewhat  swollen.  The  spinous  processes  of  the  fifth  and  sixth,  or  sixth  and 
seventh  cervical  vertebrae  (I  w^as  not  quite  sure  which)  were  widely  separated  from 
each  other,  and  the  vertebrae  above  the  point  of  separation  were  thrown  forward.  The 
abrupt  bending  of  his  neck  forward,  above  mentioned,  resulted  from  the  wide  separa- 
tion of  the  spinous  processes  and  laminae  behind,  and  the  thrusting  forward  of  the  body 
of  the  dislocated  vertebra  and  those  above  it.  I  took  it  for  granted  that  some  fracture 
was  also  present,  but  it  seemed  to  be  the  dislocation  alone  which  caused  the  deformity, 
the  displacement  of  bone,  and  the  compression  of  the  spinal  cord.  I  catheterized  him, 
and  then  noticed  that  he  had  partial  erection  of  the  penis,  or  priapism.  He  was  placed 
in  a  soft  bed  and  a  milk-diet  allowed.  The  attendants  were  cautioned  against  injuring 
his  neck  while  giving  him  food  or  drink.    The  accident  happened  in  the  afternoon. 

The  next  morning  it  was  observed  that  sensibility  had  partially  returned  to  his  arms, 
but  the  paralysis  as  to  motion  was  still  complete  ;  in  other  respects  his  condition  was 
unchanged.    The  urine  was  now  drawn  off  with  a  catheter,  and  again  in  the  evening. 

The  following  day  did  not  bring  any  signs  of  improvement.  The  urine  had  a  strong 
ammoniacal  odor.  The  bowels  had  not  moved.  The  abdomen  was  swollen  by  gases  in 
the  intestines.  A  terebinthinate  enema  was  administered.  Catheterization  twice  a 
day  was  continued. 

On  the  third  morning  he  was  much  w^orse.  His  respiration  was  difficult,  the  move- 
ments being  much  increased  in  frequency,  and  accompanied  by  moist  rales.  His  lips 
were  becoming  blue;  he  was  tympanitic;  he  sank  rapidly,  and  died  asphyxiated, 
seventy  hours  after  the  accident.    An  autopsy  could  not  be  obtained. 

Another  case,  almost  the  exact  counterpart  of  the  last,  I  once  saw  in  con- 
sultation with  the  late  Dr.  Jenks  S.  Sprague,  formerly  president  of  the  I^ew 
York  State  Medical  Society : — 

A  healthy,  middle-aged  farmer  fell  backward  from  the  top  of  a  loaded  hay-wagon, 
and  struck  the  ground  with  the  back  of  his  head  and  neck,  the  whole  weight  of  his 
body  being  superimposed.  He  was  instantly  deprived  of  the  use  of  all  his  limbs.  He 
was  picked  up,  in  a  helpless  state,  and  carried  to  his  home,  where  the  writer  saw  him 
as  consultant,  as  stated  above,  a  few  hours  afterward.  He  was  completely  paralyzed 
both  as  to  sensation  and  voluntary  motion,  up  to  the  root  of  the  neck.  The  head  and 
neck  were  considerably  inclined  forward,  the  latter  being  stiff.  The  spinous  processes 
and  laminae  of  the  last  two  cervical  vertebrae  were  widely  separated  from  each  other, 
and  the  sixth  vertebra  was  dislocated  forward,  so  far  that  its  laminae  strongly  com- 
pressed the  spinal  cord  against  the  body  of  the  seventh.  The  presence  of  fracture  was 
suspected,  although  no  crepitus  nor  movable  fragments  of  bone  could  be  detected.  The 
head  rotated  well  at  the  atlo-axoid  articulation.  He  lay  on  his  back  and  breathed  by 
means  of  the  diaphragm  alone.  Catheterization  was  necessary.  There  was  priapism. 
His  intellect  was  not  disturbed,  and  he  said  that  he  was  free  from  pain. 

The  symptoms  and  progress  of  this  case  bore  so  close  a  resemblance  to  those  attend- 


DISLOCATIONS  OF  THE  VERTEBRA. 


317 


ing  the  last,  that  it  is  not  worth  while  to  describe  them.  He  also  died,  asphyxiated,  on 
the  fourth  day  ;  autopsy  not  allowed. 

In  both  of  my  cases,  the  wide  gap  or  interval  which  marked  the  separation 
of  the  spinous  processes  of  the  two  vertebne  particularly  injured,  the  dis- 
placement forward  of  the  upper  one,  and  the  abru^jt  bend  in  the  axis  of  the 
spinal  column,  forward,  at  the  point  of  separation  between  these  two  vertebrae, 
with  the  stiffness  of  the  neck,  denoted  that  the  first  bone  above  that  point, 
togetlier  with  all  the  cervical  vertebrse  resting  upon  it,  was  dislocated  forward, 
while  the  rest  of  the  spinal  column  remained  fixed  or  unmoved.  Although 
no  crepitus  nor  fragments  of  broken  bone  could  be  detected,  it  still  was  sup- 
posed that  some  degree  of  fracture,  perhaps  but  slight,  was  also  present, 
inasmuch  as  dislocations  of  the  cervical  vertebrae  are  complicated  by  fracture 
in  a  large  majority  of  instances.  N^evertheless,  it  is  quite  possible  that  both 
dislocations  were  uncomplicated  or  pure.  However  this  may  be,  it  is  quite 
clear  that,  in  each  instance,  the  compression  of  the  spinal  cord  was  caused  by 
the  displacement  forward  of  the  dislocated  vertebra  ;  and  that  the  indication 
for  treatment,  if  the  cases  had  not  been  regarded  as  almost  hopeless,  would 
have  been  to  free  the  cord  from  compression  by  putting  the  dislocated  bone 
back  into  its  natural  place.  In  reflecting  upon  these  cases,  I  have  often  regretted 
that  I  did  not  make  trial  of  reducing  the  dislocation,  under  anaesthesia,  at 
least  in  the  case  of  the  peddler,  the  improvement  iri  whose  symptoms  on  the 
second  day  indicated  that  the  cord  was  not  irreparably  injured.  On  the  next 
day,  however,  his  symptoms  were  all  worse,  and  the  prognosis  hopeless.  Had 
I  this  case  now  to  treat,  I  should,  as  soon  as  it  became  clear  that  the  man 
would  not  recover  under  an  expectant  plan  of  treatment,  that  is,  on  the  second 
morning  after  the  accident,  relax  his  muscles  completely  by  administering  an 
anaesthetic,  and  then,  by  carefully  made  extension  and  rotation,  etc.,  proceed 
to  restore  the  dislocated  bone  to  its  normal  position.  In  pursuing  such  a 
course,  I  would  be  guided  by  the  following  considerations :  (1)  The  almost 
absolute  certainty  of  a  fatal  termination  in  tliis  class  of  cases,  within  two  or 
three  days,  if  an  expectant  plan  of  treatment  be  followed.  Of  36  perfectly 
analogous  cases  treated  at  Guy's  Hospital,  all  died  within  seventy-two  hours. 
(2)  The  fact  that  some  strictly  analogous  cases  have  undoubtedly  been  saved 
by  reducing  the  dislocation.  Three  examples  of  recovery,  by  means  of  reduc- 
tion, from  symmetrical  dislocations  occurring  among  the  last  five  cervical 
vertebrae,  that  were  apparently  hopeless,  are  mentioned'in  Professor  Ashhurst's 
tables.  It  is  stated  that,  in  one  of  them,  the  patient,  a  woman,  was  already 
miconscious,  and  her  heart  had  nearly  stopped;  and,  that  in  another,  where 
reduction  was  effected  forty  hours  after  the  accident,  by  extension,  the  patient 
had  been  unconscious  for  half  an  hour,  that  there  was  dyspnoea,  and  tha' 
death  was  imminent ;  the  success  of  the  manoeuvre  was  indicated  by  an  audible 
"  snap."  (3)  The  eftbrt  to  reduce  the  dislocation  should  be  made  as  aftbrding 
the^  sole,  and,  at  the  same  time,  a  not  unreasonable  prospect  of  saving  the 
patient's  life.  I  therefore  would  delay  the  attempt  at  reduction ^  in  such 
extreme  cases,  until  the  symptoms  denoted  that  the  patient  was  rapidly  goino- 
from  bad  to  worse,  as  intimated  above. 

Dislocation  of  some  one  of  the  last  five  cervical  vertebrae  may  be  caused 
^hile  bathing,  by  striking  the  back  of  the  head  upon  the  ground  in  diving, 
as  happened  in  the  following  instances  :— 

A  soldier,  aged  25,^  struck  his  head  in  this  manner  while  bathing.  Paralysis,  etc., 
appeared,  and  dislocation  of  a  cervical  vertebra  was  diagnosticated.  Death  ensued  in 
twenty-three  days.     The  posterior  ligament  between  the  third  and  fourth  cervical 

1  Am.  Medical  Times,  vol.  vii. 


318 


INJURIES  OF  THE  BACK. 


vertebrae  was  found  to  be  ruptured.  (Ashhurst.)  A  similar  accident  happened  to  a 
?ailor,  whose  case  is  reported  by  J.  Roux.  He  plunged  head-foremost  into  the  sea  for 
*  the  purpose  of  bathing,  and  w^as  injured  by  striking  against  a  sail  which  had  been  sunk 
to  prevent  the  attack  of  sharks  ;  on  the  fourth  day  he  died.  Tn  both  of  these  cases  the 
dislocation  was  doubtless  caused  by  forcibly  bending  the  head  and  neck  forward  upon 
the  chest.  This  summer  (1882),  while  I  write,  several  instances  of  cervical  dislocation, 
caused  by  diving  in  shallow  water  and  striking  the  head  against  the  ground,  have  been 
reported  at  Coney  Island,  where,  this  season,  multitudes  greater  than  ever  are  said  to 
bathe. 

Etiology. — The  examples  presented  above,  as  well  as  many  cases  on  record 
which  have  not  been  presented,  show  that  symmetrical  dislocations  of  the 
vertebrae,  at  the  middle  and  lower  part  of  the  cervical  region,  are  generally 
caused  by  powerful  flexion  of  the  neck  upon  the  chest,  from  falling  upon  or 
striking  against  the  back  of  the  head  with  great  force,  "  though  traction  and 
rotation  conjoined  have  occasioned  them."  There  is  also  one  case  on  record 
in  which  the  mode  of  injury  is  said  to  have  been  a  blow,  struck  upon  the 
neck  of  a  drunken  man,  aged  30,  which  caused  him  to  fall.  Reduction  was 
effected  by  extension,  under  chloroform,  on  the  tenth  day,  by  Dr.  Ayres,  of 
Brooklyn,  1^.  Y.,  and  the  patient  recovered.  Dupuytren,  too,  reports  a  fatal 
case,  in  which  dislocation  forward  of  the  fifth  cervical  vertebra,  with  fracture 
of  the  sixth,  was  produced  directly  by  a  plank  striking  on  the  neck. 

A  mong  the  jjredisposing  causes  of  dislocation  in  the  cervical  region  are : 
(1)  the  remarkable  mobility  of  the  cervical  vertebrae  upon  each  other;  (2)  the 
obliquely  horizontal  position  of  their  articular  processes ;  and,  (3)  the  nearly 
horizontal  direction  of  their  spinous  processes.  Moreover,  these  anatomical 
peculiarities  likewise  strongly  favor  the  occurrence  of  dislocation,  without 
fracture,  in  the  cervical  region. 

Fracture  of  the  sternum  is  not  unfrequently  associated  with  the  injuries  of 
the  spinal  column  which  are  caused  by  the  forcible  bending  forward  of  the 
head.  Mr.  Bryant  says  that  it  was  found  in  four  instances  among  the  fifty- 
six  fatal  cases  of  spinal  dislocation  and  fracture  which  were  observed  at  Guy's 
Hospital. 

Diagnosis. — The  symptoms  and  course  of  symmetrical  or  bilateral  disloca- 
tions  of  the  vertebrae,  when  they  occur  at  the  middle  or  lower  part  of  the 
neck,  are  clearly  set  forth  by  the  examples  that  have  just  been  presented. 

1.  Whenever  the  bones  which  enter  into  the  formation  of  the  vertebral 
joints  are  dislocated,  deformity  ensues,  for  the  same  reason  that  it  does  when 
other  bones  are  dislocated,  for  instance,  those  of  the  extremities  ;  and  although 
the  cervical  vertebrae  are  covered  by  thick  layers  of  muscular  tissue,  etc.,  the 
deformity  which  results  from  a  bilateral  dislocation  of  these  bones  can  always 
be  perceived,  if  the  examination  be  conducted  with  sufficient  care  and  skill. 
Of  course,  the  deformity  will  vary  according  to  the  direction  and  extent  of 
the  displacement  of  bone.  But,  generally,  the  displaced  bone,  together  with 
.  all  the  vertebrae  surmounting  it,  is  thrown  forward  in  such  cases.  Oftentimes 
the  spinous  process  of  the  dislocated  vertebra  is  separated  from  the  spinous 
process  of  the  next  vertebra  below  it,  or  that  from  which  it  is  dislocated,  by 
a  distance  of  one  and  a  half  or  even  two  inches ;  and,  in  consequence  of  this 
separation,  a  wide  gap,  with  a  corresponding  depression  of  the  soft  parts,  may 
be  felt  between  them.  In  such  cases,  the  head  is  usually  thrust  forward,  and 
the  axis  of  the  spinal  column  also  bends  abruptly  forward  at  the  place  of 
injury.  At  the  same  time,  the  mobility  of  the  vertebral  joints  that  are  in- 
volved is  more  or  less  completely  destroyed,  and  all  attempts  to  produce 
motion  in  them  cause  corresponding  pains.  Not  unfrequently,  in  cases  where 
the  cervical  vertebrae  are  injured,  it  is  concluded  that  certain  joints  belonging 
thereto  are  not  luxated,  from  the  fact  that  their  mobility  is  not  impaired ;  for 


DISLOCATIONS  OF  THE  VERTEBRAE. 


319 


instance,  it  is  shown  by  nodding  and  rotating  the  patient's  head  that  the  hixa- 
tion  (if  any)  is  not  at  the  atlo-axoid  articulation,  but  somewhere  below  it. 
Oftentimes,  too,  the  body  of  the  disjointed  vertebra  can  be  felt  bulging  for- 
ward into  the  pharynx,  and  this  point  in  the  examination  is  an  important 
one  to  look  after..  As  a  rule,  in  these  cases,  the  abnormal  position  of  the 
salient  points  of  the  dislocated  bone,  as  well  as  the  rigidity  and  painfulness 
of  the  injured  articulations,  can  readily  be  detected  by  a  manual  examination. 
But  if  there  be  preternatural  mobility,  and  especially  if  there  be  crepitus  felt 
in  connection  with  the  displaced  bone,  it  will  be  sti-ong  evidence  that  fracture 
is  present  as  well  as  luxation. 

2.  If,  in  cases  of  cervical  dislocation,  the  spinal  cord  be  not  compressed  by 
the  displaced  bone,  nor  otherwise  injured,  there  will  at  first  be  no  paralysis, 
and  no  subjective  symptoms  whatever,  excepting  the  immobility,  soreness, 
and  painfulness  of  the  disjointed  articulations.  In  such  cases,  however,  spinal 
paralysis  may  subsequently  appear,  and  death  ensue.  Several  instances  of 
this  sort  are  on  record.    For  example : — 

Causse^  gives  the  case  of  a  man  who  injured  his  neck  by  falling  from  a  chariot  on  to 
the  wheel.  There  was  at  first  no  paralysis ;  only  stiffness  of  neck  and  pain  on  bending 
it.  On  the  third  day,  however,  in  turning  liis  head  he  felt  a  crack,  and  became  para- 
lyzed. Death  ensued,  and  complete  forward  dislocation  of  the  fifth  cervical  vertebra 
was  found.  (Ashhurst.)  It  is  not  improbable  that,  in  this  case,  the  luxation  was  in- 
complete at  first,  but  became  complete  on  the  third  day,  in  consequence  of  the  accident 
sustained  in  turning  his  head. 

Dupuytren  likewise  reports  the  case  of  a  mason,  aged  49,  who  fell  backward  down 
stairs,  striking  his  head  on  a  step ;  a  bag  of  plaster  came  upon  his  breast.  In  conse- 
quence, his  head  was  thrown  forward  and  to  the  right,  his  neck  was  stiff,  and  the  spinous 
processes  of  the  fourth  and  fifth  cervical  vertebrae  could  not  be  felt,  while  their  trans- 
verse processes  were  abnormally  prominent.  At  first  there  was  no  paralysis,  but  after- 
wards it  came  on,  and  in  ten  hours  death  ensued.  The  fifth  cervical  vertebra  was  found 
displaced  forward  with  fracture  of  its  processes,  and  the  spinal  cord  was  divided.  It  is 
not  improbable  that  in  this  case,  too,  the  luxation  at  first  was  incomplete,  and  the  spinal 
cord  being  not  compressed  there  was  no  paralysis  ;  but,  in  a  few  hours,  it  became  com- 
plete, because  the  cord  was  divided,  perhaps  from  injudicious  attempts  to  examine  or  to 
remove  the  patient,  and  then  paralysis  immediately  appeared.  The  paralysis  must  have 
increased  rapidly,  for  death  soon  ensued. 

In  analogous  cases,  when  spinal  paralysis  does  not  appear,  recovery  may  take  place. 
For  example  :  Greenhow^  reports  the  case  of  a  female,  aged  25,  who  fell  thirty  feet, 
striking  the  head.  She  sustained  dislocation  of  three  or  four  upper  cervical  vertebrae, 
and  was  insensible  for  three  days,  but  had  no  paralysis.  There  was  a  scalp  wound  and 
fractured  clavicle.  She  was  under  observation  fourteen  days,  and  recovered,  but  the 
deformity  remained. 

Again,  Professor  Hamilton^  mentions  the  case  of  a  man,  aged  40,  who  was  thrown 
from  a  wagon,  striking  the  back  of  his  neck.  He  was  stunned  for  several  hours ;  then 
paralysis  came  on.  However,  he  did  not  die  ;  but,  after  nine  months,  the  spinous  pro- 
cess of  the  seventh  cervical  vertebra  was  still  displaced  to  the  left  side.  His  head  also 
was  bent  forward  and  his  neck  was  stiff ;  he  could  walk  a  few  steps,  but  with  fatigue ; 
he  likewise  had  pain  in  the  legs,  etc.  (Ashhurst.) 

But  if,  in  cases  of  cervical  dislocation,  the  spinal  cord  be  slightly  com- 
pressed, or  slightly  bruised,  or  slightly  torn,  there  will  from  the  outset  be 
paralysis  of  the  parts  to  which  the  injured  nerve-filaments  are  distributed. 
Several  cases  belonging  to  this  category,  whose  issue  was  fatal,  are  on  record. 
It  is  not  necessary  to  reproduce  them. 

Finally,  if  the  spinal  cord  be  crushed  or  strongly  compressed  at  the  middle 


^  M^moire  Medico-legale,  etc. 


2  Lancet,  1851. 


3  Op.  cit. 


320 


INJURIES  OF  THE  BACK. 


or  lower  part  of  tlie  cervical  region  by  a  dislocated  or  a  fractured  vertebra, 
there  will  be  paralysis  embracing  the  whole  of  the  body  excepting  the  head 
and  neck,  priapism,  retention  of  uj-ine  and  feces,  flushed  face,  calor  mordicans, 
diaphrao-matic  breathing,  dyspnoea,  and  in  a  short  time  death  from  asphyxia. 
Several  cases  in  point  have  already  been  presented.  For  diagnosticating  the 
lesion  itself,  however,  the  paralysis  in  these  cases  is  of  no  practical  value, 
inasmucli  as  it  may  result  from  concussion  of  the  spinal  cord,  and  from  the 
effusion  of  blood,  or  of  the  products  of  inflammatory  action  upon  the  cord, 
as  well  as  from  the  displacements  of  bone  Avhich  attend  vertebral  dislocations. 
But,  fov  jfi-ognostic  purposes  the  paralysis  in  such  cases  is  of  great  value. 

The  signs,  then,  by  which  a  bilateral  dislocation  of  a  cervical  vertebra  in 
the  middle  or  lower  part  of  the  neck  may  be  recognized,  consist  of  the 
physical  evidences  of  the  displacement  itself,  the  absence  of  the  symptoms 
which  characterize  fractures,  such  as  crepitus  and  unnatural  mobility  of  the 
vertebra  in  question,  or  of  some  part  thereof.  But,  inasmuch  as  vertebral 
fracture  may  occur  without  being  attended  by  crepitus  or  suspicious  mobility, 
especially  if  the  fracture  be  but'slight,  we  never  can  positively  assert  of  any 
case  of  cervical  dislocation,  during  life,  that  it  is  entirely  uncomplicated  by 
fracture.  Thus,  it  appears,  that  while  the  diagnosis  of  vertebral  dislocation 
(bilateral)  at  the  middle  or  lower  part  of  the  neck  is,  in  general,  not  very  difli- 
cult,  the  diagnosis  of  slight  fracture  simultaneously  involving  the  same  bones, 
is  often  impossible  during  life.  This,  however,  is  not  a  matter  of  much  practical 
importance,  since  the  perils  of  the  case  depend  upon  the  injury  of  the  spinal 
cord,  which  results  mainly  from  the  displacement  of  bone  that  is  due  to  the 
dislocation  ;  and  to  this  point  the  attention  should  first  be  directed  in  treating 
the  case. 

Prognosis. — Luxations  of  the  vertebrae  are  more  dangerous  to  life  than  the 
luxations  of  other  bones,  on  account  of  the  great  risk  there  is  that  the  spinal 
cord  and  spinal  nerves  will  be  directly  or  indirectly  injured  thereby,  and  that 
spinal  paralysis  will  ensue.  Luxations  of  the  cervical  vertebrae  are  more 
dangerous  than  luxations  of  the  dorsal  and  lumbar  vertebrae,  on  account  of 
the  great  risk  there  is  that  the  chief  respiratory  muscles,  the  serratus  posticus 
superior  and  inferior,  the  serratus  magnus  anticus,  the  diaphragm,  etc.,  will 
be  paralyzed  thereby,  and  that  death  from  asphyxia  will  immediately  ensue. 

When  the  spinal  cord  is  crushed  or  strongly  compressed  above  the  third 
cervical  vertebra,  in  cases  of  spinal  dislocation  or  fracture,  life  is  instantly 
destroyed,  because  the  chief  respiratory  nerves,  to  wit,  the  two  phrenic,  the 
four  thoracic,  and  the  respiratory  branches  of  the  intercostal  nerves,  from 
having  their  several  origins  in  the  cord  below  that  point,  instantly  cease  to 
act  (as  do  all  the  spinaf  nerves  that  originate  in  or  pass  off'  from  the  cord 
below  the  same  point),  and  therefore  the  muscles  to  which  they  are  distri- 
buted instantly  cease  to  perform  the  respiratory  movements. 

When  the  spinal  cord  is  crushed  or  strongly  compressed  below  the  origin  of 
the  phrenic  and  lono;  thoracic  nerves,  in  cases  of  cervical  dislocation  or  frac- 
ture, death  will  generally  be  deferred  for  some  little  time,  although  the  whole 
body,  excepting  the  head  and  neck,  will  be  paralyzed  in  respect  to  sensation 
and'  voluntary  motion.  In  such  cases,  the  respiratory  function  is  maintained 
by  the  action  of  the  serratus  magnus  anticus  and  the  diaphragm  alone. 

In  cases  of  dislocation  or  fracture  of  the  spinal  column  above  the  third 
cervical  vertebra,  experience  has  shown  that  life  is  often  instantaneously  de- 
stroyed. In  cases  of  dislocation  or  fracture  below  the  third  cervical  vertebra 
and  above  the  first  dorsal,  where  the  cord  is  so  much  injured  that  there  is 
motor  and  sensory  paralysis  of  nearly  the  whole  body  excepting^  the  head  and 
neck,  and  the  respiratory  process  is  maintained  solely  by  the  diaphragm  and 
Berratus  magnus,  life  is  seldom  prolonged  more  than  72  hours,  and,  as  a  rule, 


DISLOCATIONS  OF  THE  VERTEBR.?].  321 

not  above  48  hours.  In  one  of  Dupuytren's  cases,  that  has  just  been  men- 
tioned, death  ensued  in  10  hours;  and  Professor  Hamilton  refers  to  an  instance 
of  complete  dislocation  of  the  fifth  cervical  vertebra,  without  fracture,  in 
which  death  occurred  in  2  hours.  But,  on  the  other  hand,  Mr.  Bryant  men- 
tions the  case  of  a  gentleman,  aged  29,  with  complete  paralysis  below  the 
fifth  cervical  vertebra,  caused  by  a  fall  upon  the  neck,  who  was  still  alive 
over  six  years  afterward,  and  breathing  by  tlie  diaphragm  alone.  Mr.  Hilton, 
likewise,  has  recorded  the  case  of  a  man  who  lived  for  fourteen  years  com- 
pletely paralyzed  from  the  neck  downward,  after  sustaining  a  fracture  of  the 
fifth  and  sixth  cervical  vertebrae.  Such  exceptions  to  the  rule,  however,  are 
very  rare. 

The  prognosis  in  cases  of  dislocation  or  fracture  of  the  cervical  vertebrae 
must  be  mainly  determined  by  the  seat  of  the  lesion,  and  the  amount  of  dam- 
age which  the  spinal  cord  has  received.  Usually,  the  nearer  the  seat  of  the 
injury  is  to  the  respiratory  centre,  the  greater  is  the  dangler  to  life.  When, 
however,  no  paralysis  appears  in  the  case,  it  will  generally  end  in  recovery, 
for  luxations  of  the  vertebrae  unattended  by  lesions  of  the  spinal  cord  do  not 
seem  to  be  any  more  hazardous  to  life  than  luxations  of  other  bones  of  a  cor- 
responding size.  It  should  not  be  forgotten,  however,  that  where  there  is  no 
paralysis  at  first,  it  may  supervene  in  a  few  hours  in  consequence  of  the  dis- 
placement of  bone  becoming  increased,  or  from  the  extravasation  of  blood 
between  the  theca  and  the  cord,  or  from  the  occurrence  of  traumatic  inflam- 
mation of  the  cord  or  its  membranes.  Several  illustrative  cases  have  already 
been  mentioned.  In  the  following  instance,  paralysis  and  death  resulted  from 
traumatic  meningo-myelitis : — 

Simon  ^  relates  the  case  of  a  woman,  aged  18,  who  fell  eleven  or  twelve  feet  and  was 
stunned.  She  walked  home,  three  or  four  miles,  and  resumed  work  for  eleven  days. 
Then  pain,  fever,  etc.,  appeared;  and,  on  the  sixteenth  day,  paralysis.  Delirium* 
"jumping  of  legs,"  etc.,  followed,  and,  in  eighteen  days,  death  ensued.  Fracture  of  the 
seventh  cervical  vertebra  was  found,  and  the  spinal  canal  filled  with  pus.  (Ashhurst.) 

^  Certain  symptoms  are  considered  of  peculiarly  evil  omen  in  cases  of  spinal 
injury.  They  are  a  steady  increase  in  the  extent  or  degree  of  the  par- 
alysis, dysphagia,  dyspnoea,  flushed  face,  and  alteration  of  the  vital  tem- 
perature. These  symptoms,  however,  and  their  import,  will  be  discussed 
further  on  m  this  article.  Here,  I  will  only  mention  a  single  case  reported 
by  Brodie,2  wherein  the  cervical  portion  of  the  spine  was  injured,  and  there 
was  paraplegia  with  diaphragmatic  breathing.  A  thermometer  placed 
between  the  thighs  showed  the  body-heat  to  be  111°  Fahr.  Death  ensued 
m  twenty-two  hours.  Displacement  of  the  fifth  from  the  sixth  cervical  ver- 
tebra was  found,  and  laceration  of  the  cord  with  eftusion  of  blood  in  the 
spinal  canal. 

The  jyroximate  cause  of  death  in  dislocations  and  fractures  of  the  lower  cer- 
vical vertebrae  generally  consists  in  a  creepino;  upward  of  certain  morbid 
processes  which  have  been  set  up  in  the  spinal  membranes,  or  in  the  substance 
of^  the  spinal  cord,  opposite  the  vertebral  lesion,  from  the  place  of  primary 
injury  to  the  roots  of  the  phrenic  nerves  (above  the  third  cervical  vertebra) 
whereupon  these  nerves  cease  to  act,  the  diaphragm  ceases  to  contract,  and 
death  from  asphyxia  ensues.  In  some  cases  the  morbid  process  consists  in 
extravasation  of  blood  between  the  theca  vertebralis  and  the  cord,  which 
spreads  upward  until  it  compresses  the  cord  at  and  above  the  third  cervical 
vertebra,  as  happened  in  the  case  of  a  soldier  mentioned  above,  who  dislo- 
cated his  neck  in  vainly  attempting  to  turn  a  somersault.   In  other  cases,  the 

'  Proc.  Lond.  Path.  Soc,  vol.  vi.  2  Med.-Chir.  Trans.,  vol.  xx. 

VOL.  IV. — 21 


322 


INJURIES  OF  THE  BACK. 


morbid  process  consists  of  an  ascending  spinal  meningitis.  In  still  others,  it 
consists  of  an  ascending  traumatic  myelitis,  and  this  class  is  probably  a 
numerous  one.  People  who  are  fatally  injured  in  the  cervical  part  of  the 
spine,  as  a  rule,  do  not  live  long  enough  to  get  sacral  and  gluteal  eschars,  or 
bed-sores,  nor  for  vesical  and  renal  disease  to  occur  in  consequence  of  the 
rachidian  lesions. 

Treatment  of  Cervical  Dislocations.— Rere,  it  may  be  well  to  state  again, 
that  in  all  pure  dislocations  of  the  cervical  vertebrae,  certainly  in  all  that  are 
bilateral  or  symmetrical,  the  intervertebral  substance  is  torn  through,  and 
the  upper  vertebra  is  displaced  forward  from  the  lower ;  that  in  dislocations 
and  fractures  combined,  of  the  last  five  or  six  cervical  vertebrae,  the  interver- 
tebral substance  is  also  torn  through,  and  the  upper  vertebra  displaced  for- 
ward from  the  lower ;  and  that,  in  such  cases,  the  fracture  is  generally  found 
in  the  spinous  process,  the  laminae,  or  the  pedicles  of  the  dislocated  vertebra, 
but  not  in  its  body.  Thus,  it  is  seen  that  the  displacement  is  strictly  analo- 
gous, in  cases  of  dislocation  combined  with  fracture,  to  what  it  is  in  pure 
dislocation,  and  that  the  treatment  of  the  former  should  be  substantially 
the  same  as  the  treatment  of  the  latter. 

Moreover,  in  dislocations  and  fractures  of  the  spinal  column,  it  is  not  the 
lesions  of  the  vertebrae,  per  se,  which  disable  and  kill,  as  much  as  it  is  the 
displacement  of  bone,  and  the  extravasation  of  blood  between  the  theca  and 
the  cord,  or  into  the  cord  itself,  and  the  consecutive  inflammation  of  cord  and 
membranes,  that  may  attend  these  lesions ;  for,  by  the  above-named  conse- 
quences of  spinal  injury,  the  substance  of  the  spinal  cord  is  directly  torn,  or 
bruised,  or  compressed,  or  disorganized,  so  that  the  spinal  nervous  functions 
in  the  segment  of  the  cord  below  the  place  of  injury  may  cease  entirely  to  be 
performed,  and  the  parts  dependent  thereon  for  innervation  become  com- 
pletely paralyzed.  It  is,  then,  the  displacements  of  bone,  the  intra-spmal 
extravasations  of  blood,  and  the  inflammations  of  the  cord  and  its  membranes 
that  attend  these  lesions,  which  the  surgeon  must  chiefly  consider  m  conduct- 
ing the  treatment  of  these  cases. 

When  a  person  receives,  in  any  way,  a  dislocation  or  a  fracture  of  the  neck, 
or  of  any  other  part  of  the  spinal  column,  the  first  thing  of  importance  to  do 
is  to  eflect  the  person's  removal  to  hospital  or  home  without  producing 
additional  injury.  To  this  end,  the  patient  should  be  placed  m  an  extended 
position,  on  the  flat  of  the  back,  upon  a  board,  settee,  or  stretcher,  and  in  that 
way  carried  in  as  nearly  a  fixed  or  immovable  position  as  possible.  If  the 
lesion  be  situated  above  the  third  cervical  vertebra,  a  small,  firmly  rolled 
wad  of  clothing  should  generally  be  placed  under  the  neck  m  order  to  keep 
it  raised  up,  and  thus  prevent  the  head  from  falling  forward  and  dragging 
with  it  the  spinal  cord  against  the  odontoid  process  of  the  axis.  In  such 
cases,  too,  the  head  should  be  kept  steady,  and  prevented  from  rolling  from 
side  to  side.  it 

At  the  first  examination,  the  surgeon  should  make  the  diagnosis  as  com- 
plete and  accurate  as  possible,  particularly  in  regard  to  the  distortion  or 
deformity  of  the  injured  parts  and  the  displacement  of  the  injured  bones,^  so 
that  future  examinations  on  these  points  may  be  avoided.  Should  the  lesion 
prove  to  be  a  dislocation,  whether  it  be  pure  or  attended  by  fracture,  the 
question  will  immediately  arise  whether  it  ought  to  be  reduced  or  not;  that 
is,  whether  the  principal  indication  in  the  treatment  of  dislocations  m  general 
ought  to  be  fulfilled  in  treating  vertebral  dislocations,  or  not.  On  this 
point,  which  is  nearly  the  main  point  in  the  treatment  of  such  cases,  the 
opinions  of  surgeons  have  been  unhappily  divided.  Mr.  Erichsen  says, 
Reduction  has  been  cftected  [witli  success]  in  a  sufiicient  number  of  cases 


DISLOCATIONS  OF  THE  VERTEBRAE. 


323 


of  this  kind  to  justify  the  proceeding  ])eing  adopted  when  the  danger  is 
imminent."^  Dupuytren,  on  the  other  hand,  affirmed  that  such  attempts 
were  very  dangerous,  and  that  he  had  often  known  patients  to  perish  while 
the  extension  w^as  being  made  (Ilamilton) ;  from  which  the  legitimate  infer- 
ence would  follow  that  reduction  was,  in  such  cases,  a  i)roceeding  too  hazard- 
ous to  be  admissibk\  I  have,  however,  serious  doubts  as  to  Dupuytren's 
assertion  being  well-founded,  for  I  do  not  find  any  case  whatever  reported 
in  detail,  which  Dupuytren  couW  personally  have  known,  wherein  the 
patient  perished  while  extension  was  being  made,  i^o  instance  of  the  sort 
is  mentioned  among  the  394  eases  which  are  embraced  in  Professor  Ash- 
hurst's  tables,  nor  elsewhere,  as  far  as  I  am  informed.  Moreover,  an  inspec- 
tion of  Professor  Ashhurst's  tables  cleai-ly  shows  that  "  in  the  treatment  of 
dislocations  in  the  cervical  region,  the  mortality  has  been  nearly  four  times 
greater  when  constitutional  or  general  treatment  has  been  relied  on  exclu- 
sively, than  when  attempts  have  been  made  to  reduce  the  dislocation  by  ex- 
tension, rotation,  etc."^  An  inspection  of  the  same  tables  also  shows  that  in 
the  treatment  of  dislocations,  in  the  whole  spinal  column,  "  the  proportion  of 
deaths  has  been  almost  three  times  as  large  when  general  treatment  has  been 
exclusively  used  as  when  extension  has  been  employed.  The  results  of  those 
cases  which  have  survived  have  also  been,  as  a  rule,  more  satisfactory  after 
extension  than  without  it."^  I  have  already  mentioned  several  instances  in 
which  reduction  was  successfully  employed  in  the  treatment  of  cervical  dis- 
locations, in  some  of  which  recovery  w^ould  otherwise  have  been  utterly 
hopeless. 

It  seems  to  me  that  the  inference  is  fairly  warranted,  from  the  foregoing 
considerations,  that  extension  (combined,  of  course,  with  rotation  or  pressure 
as  required)  should  be  employed  in  every  case  of  spinal  dislocation,  or  of  spinal 
fracture  with  dislocation,  where  the  spinal  functions  are  disturbed.  AVhen 
the  diagnosis  is  not  clear,  it  will  be  better  to  adopt  this  mode  of  treatment 
than  to  reject  it,  and  I  should  be  disposed  to  try  it  in  every  case  wdiere  either 
shortening  or  marked  angular  displacement  was  found.  (Ashhurst.)  It  seems  to 
me,  also,  that  in  recent  years  the  current  of  surgical  opinion  has,  with  justice, 
strongly  set  in  favor  of  treating  spinal  dislocations,  those  with  as  well  as  those 
without  fracture,  by  reducing  them.  Professor  Porta,  after  carefully  analyzing 
twenty-seven  cases  in  point,  comes  to  the  conclusion  that  the  first  indication 
in  the  treatment  of  vertebral  dislocations  as  in  that  of  other  dislocations,  is 
to  reduce  them.  Mr.  Bryant  (1878)  says :  "  I  have  seen  several  cases  in  which 
marked  relief  was  afforded  by  this  course,  and  the  records  of  surgery  contain 
many  more.  Practised  with  discretion,  extension  of  the  spine  is  doubtless  a 
valuable  means  of  treatment."'*  Whenever  it  is  applicable,  the  best  plan  of 
eftecting  reduction  consists  in  making  extension  and  counter-extension  by  the 
gradual  traction  of  assistants,  whilst  the  surgeon  endeavors  to  effect  manual 
replacement.  Generally  the  patient's  muscles  should  be  kept  relaxed  by 
anaesthetics  during  the  operation.  In  all  cervical  cases  where  the  dislocation 
is  disposed  to  return,  extension  should  be  continued  for  some  days  after  the 
operation,  by  means  of  a  weight  of  al)out  three  pounds  attached  to  the  patient's 
head  with  strips  of  plaster,  and  a  band  to  suspend  it  from  the  head  of  the  bed. 
By  so  doing  recovery  might  have  been  effected  in  a  case  mentioned  by  Mal- 
gaigne : — 

A  man  was  injured  by  a  weight  falling  eight  or  ten  feet,  upon  his  neck.  There  was 
no  paralysis,  but  the  injured  part  of  the  neck  was  stiff,  and  moving  it  caused  great  pain. 
Delirium  appeared  on  the  third  day  ;  and,  in  five  days  after  the  accident,  the  man  died. 


*  Science  and  Art  of  Surgery,  p.  293,  Am.  ed.  1854. 
3  Ibid.,  p.  66. 


2  Op.  cit.,  p.  64. 
4  Op.  cit.,  p.  204. 


324 


INJURIES  OF  THE  BACK. 


Incomplete  luxation  with  fracture  of  a  cervical  vertebra  was  found.    It  had  been  re- 
duced, but  the  displacement  had  been  reproduced,  as  the  autopsy  showed. 

Mention  should  not  be  omitted  of  a  recent  case,  reported  by  Dr.  Landon 
Carter  Grray,  of  Brooklyn,  Y.,  in  which  a  dislocated  third  cervical  vertebra 
was  successfully  reduced,  after  four  months'  malposition : — 

A  boy,  aged  15,^  injured  his  neck  by  falling  on  his  head  in  a  vain  attempt  to  turn  a 
somersault.  For  thirteen  weeks  after  the  dislocation,  there  was  only  a  difficulty  in 
deo-lutition.  Then,  the  phenomena  came  fast  and  many.  First,  a  vesical  paresis  ; 
next,  a  numbness  of  the  upper  extremity  ;  then,  a  numbness  of  the  right  leg;  then,  a 
motor  paralysis  of  both  upper  and  lower  extremities  ;  and  finally,  when  he  came  under 
treatment,  there  was  found,  though  the  relative  dates  of  the  appearance  could  not  be 
ascertained,  a  paresis  of  the  left  face,  tactile  antesthesia  of  the  left  upper  and  lower 
extremities,  an  occasional  tremor,  exaggerated  tendon-reflex  (although  there  had  been 
no  hasty  micturition),  and  contractures  of  certain  muscles  of  the  neck  and  shoulders. 

On  the  back  of  the  neck,  over  the  third  vertebra,  a  projection  about  as  large  as  a 
pigeon's  egg  was  found.  Pressure  upon  it  caused  some  pain  around  the  point  of  pressure, 
but  none  was  felt  at  the  front  or  side  of  the  neck.  The  spinous  process  of  the  third 
vertebra  deviated  markedly  to  the  right.  By  inserting  a  finger  into  the  mouth,  hori- 
zontally backward  on  a  level  with  the  upper  surface  of  the  tongue,  a  distinct  depression 
could  be  felt  in  the  posterior  pharyngeal  wall,  corresponding  to  the  third  cervical  verte- 
bra. In  order  to  effect  reduction,  the  boy  was  laid  flat  on  his  back  on  the  table, 
and  etherized  until  all  his  muscles  were  well  relaxed.  Grasping  the  head  by  one  hand 
placed  upon  the  occiput  and  the  other  on  the  brow,  both  hands  being  covered  by  those 
of  an  assistant,  and  counter-extension  being  firmly  maintained,  extension  was  steadily 
made  upward  to  what  was  deemed  a  proper  degree,  and  then  the  head  was  slowly  and 
cautiously  rotated  from  left  to  right.  It  was  necessary  to  make  this  rotation  three 
several  times  before  the  bone  went  into  place,  each  rotation,  however,  effecting  evident 
improvement,  although  no  tendinous  snap  was  heard  at  any  time.  But  go  into  place  it 
did,  and  without  the  manifestation  of  any  dangerous  symptom. 

All  the  morbid  phenomena  immediately  disappeared ;  and  although  they  returned 
somewhat  after  a  reluxation  following  violent  emotion,  a  second  reduction  caused  a 
permanent  cure.  - 

The  formidable  nature  of  the  spinal  lesion,  and  the  happy  issue  of  the  oper- 
ative treatment,  render  this  case  a  very  instructive  one  to  the  surgical  student; 
and  the  clearness  and  brevity  with  which  the  symptoms  and  the  operative 
procedures  are  ^et  forth,  must  prove  equally  attractive.  Moreover,  this  case 
shows  that  dislocations  of  the  cervical  vertebrBe,  even  when  the  displacement 
of  bone  is  not  sufficient  to  seriously  compress  the  spinal  cord,  are  always  acci- 
dents of  considerable  importance,  because  of  the  deformity  and  debility  of 
the  injured  part  which  always  result ;  but,  more  especially,  because  of  the 
morbid  action,  not  unfrequently  inflammatory,  in  the  spinal  meninges  and  m 
the  spinal  cord  itself,  which  may  ensue.  An  ascending  myelitis  sometimes, 
perhaps  often,  has  this  origin. 

Several  additional  cases  of  symmetrical  luxation  of  the  cervical  vertebrje,  more  or 
less  complete,  which  have  been  successfully  treated  by  reduction,  also  require  brief 
mention  in  this  place  :  (1)  The  late  Dr.  James  R.  Wood,  of  New  York,=^  had  a  case  of 
partial  dislocation  of  a  cervical  vertebra,  occurring  in  a  child  ;  reduction  was  effected, 
and  recovery  followed.  (Ashhurst.)  (2)  A  sailor,  aged  46,^  fell  forward  on  the  right 
side  of  his  head,  and  sustained  a  dislocation  of  the  fifth  and  sixth  cervical  vertebrae 
[with  fracture?].  There  was  pain,  crepitus,  and  partial  paralysis.  The  luxation  was 
reduced  by  extension  and  rotation,  and  the  paralysis  instantly  disappeared.  (Ashhurst.) 

1  Annals  of  Anat.  and  Surg.,  February,  1882;  Am.  Journ.  Med.  Sciences,  April,  1882,  pp. 

590,  591.  ,  ...      ^      .    ,  ^ 

2  Gross's  System  of  Surgery,  vol.  ii.         .         ,  .  '  l^^ve.  Surgical  Cases. 


DISLOCATIONS  OF  THE  VERTEBRAE. 


325 


(3)  A  soldier^  fell  from  a  horse  ;  he  was  stunned,  and  had  a  cervical  vertebra  dislo- 
cated ;  mobility  of  head  was  noted.  Reduction  was  effected  by  extension  and  manipu- 
lation.   He  could  walk  again  in  three  days,  and  recovered  in  eiglit  days.  (Ashhurst.) 

(4)  A  male  child,  aged  3i  years,^  was  injured  by  another  child  jumping  on  his  back. 
He  fell  and  had  the  third  or  fourth  cervical  vertebra  dislocated,  but  no  paralysis.  The 
luxation  was  reduced  by  extension,  and  recovery  ensued.  (Ashhurst.)  (5)  Dr.  J. 
FlogeP  reports  a  case  in  which  a  subluxation  of  the  cervical  vertebrae  was  successfully 
reduced. 

But,  perhaps,  the  most  suggestive  example  of  recovery,  by  means  of  reduction,  from 
an  apparently  hopeless  dislocation  of  a  cervical  vertebra,  is  one  to  which  I  have  barely 
alluded  ;  it  certainly  deserves  further  mention.  Hickerman,  of  Ohio,  found  in  the  case 
of  a  girl  one  of  the  vertebrae  dislocated,  causing  a  prominence  in  the  back  part  of  the 
pharynx,  opposite  the  fourth  and  fifth  cervical  vertebrae,  and  almost  completely  suspend- 
ing respiration  and  the  action  of  the  heart.  He  seized  the  head  of  the  patient  under 
his  left  arm  and  thus  made  extension,  while  with  the  index  finger  of  his  right  hand  he 
made  pressure  upon  the  projection  in  the  pharynx.  In  about  one  minute  the  bone 
receded  under  the  pressure,  and  immediately  the  respiration  became  natural.  Re- 
covery was  complete.*    As  already  stated,  there  are  several  similar  cases  on  record. 

In  striking  contrast  with  these  excellent  results  achieved  by  reduction,  is 
the  fact  that  among  the  394  cases  contained  in  Professor  Ashhurst's  tables, 
no  mention  is  made  of  even  one  case  of  bilateral  or  symmetrical  dislocation 
of  a  cervical  vertebra,  attended  with  paraplegia  from  compression  of  the  spinal 
cord  by  the  displaced  bone,  in  which  recovery  took  place  under  the  expectant 
treatment,  and  but  few  in  which  death  was  long  deferred. 

But  the  restoration  of  a  cervical  vertebra,  when  luxated,  to  its  normal  posi- 
tion, is  seldom  easy,  generally  difficult,  and  sometimes  almost  impossible  to 
accomplish,  as  the  following  examples  will  help  to  show : — 

GaitskilP  is  the  authority  for  a  case  of  complete  bilateral  dislocation  of  the  seventh 
cervical  vertebra,  attended  by  paralysis,  which  in  the  upper  extremities  was  only  par- 
tial. The  efforts  at  reduction  failed  and  the  patient  died.  Mention  has  also  been  made 
on  one  of  the  preceding  pages  of  a  case  of  luxation  of  the  second  cervical  vertebra  from 
the  third,  reported  by  Spencer,^  in  which  the  attempt  at  reduction  likewise  failed,  and 
in  which,  after  forty-eight  hours,  the  man  died.  (Ashhurst.) 

These  two  cases  show  that  the  surgeon  who  attempts  to  reduce  luxations 
of  the  cervical  vertebrae,  must  expect  to  encounter  great  difficulties  at  times, 
and  should  be  prepared  to  overcome  them ;  this  he  can  generally  do  by  per- 
severing sufficiently  in  appropriate  and  well-directed  efforts  at  reduction, 
while  the  muscles  of  the  patient  are  completely  relaxed  by  the  inhalation  of 
chloroform  or  ether. 

Having  reduced  the  dislocation,  and  taken  adequate  measures  (above  men- 
tioned) to  prevent  its  recurrence,  as  well  as  to  provide  against  the  falling  for- 
ward of  the  patient's  head  in  such  a  way  as  to  drag  the  spinal  cord  against  the 
odontoid  process  of  the  axis,  by  placing  a  small,  firm  pillow  under  the  neck, 
while  the  patient  lies  flat  on  his  back  and  extended  in  bed,  the  fulfilment  of 
the  second  indication  for  treatment  must  next  be  attended  to,  w^hich  consists 
in  moderating  the  inflammatory  reaction  at  the  injured  joints,  and  preventing 
its  spread  to  the  spinal  membranes  and  the  spinal  cord  itself.  Two  examples 
have  already  been  presented  on  the  authority  of  Mr.  Simon  and  M.  Mal- 
gaigne,  which  go  far  to  show  that  the  spread,  in  such  cases,  of  traumatic 
inflammation  from  the  injured  joints  to  the  spinal  meninges  and  the  spinal 

*  Journal  de  Desaiilt,  t.  iii.  ^  Jouru.  der  Chlrurgie,  1822,  Bd.  ill. 
3  Wien.  med.  Halle,  1864,  S.  147  ;  New  Syd.  Soc.  Year-Book,  1864,  p.  280. 

*  Hamilton,  Princ.  and  Pract.  of  Surgery,  p.  315. 
5  London  Repository,  vol.  xv. 

s  Boston  Medical  and  Surgical  Journal,  vol.  x. 


326 


INJURIES  OF  THE  BACK. 


marrow,  is  do  idle  dream.  Among  the  best  means  to  fulfil  the  second  indica- 
tion, is  to  keep  the  injured  joints  as  nearly  immovable  as  possible,  by  apply- 
ing a  bag  half-filled  with  sand  close  to  each  side  of  the  head  and  neck, 
continuously  day  and  night,  so  as  to  entirely  prevent  any  lateral  or  rotatory 
motion  of  the  parts.  The  patient  should  be  supplied  with  food  and  drink 
while  in  the  supine  position,  and  without  raising  his  head.  'Not  unfrequently 
the  application  of  leeches  and  cold  lotions  may  be  advisable.  This  plan  of 
treatment  should  be  continued  until  the  cure  is  complete.  Potassium  iodide 
may  oftentimes  be  administered  with  advantage  in  order  to  promote  the  ab- 
sorption of  inflammatory  efiusions  and  of  blood  from  the  spinal  canal.  The 
diet  should  be  nourishing  and  easy  to  assimilate.  Pain  should  be  subdued 
and  sleep  secured  by  administering  opium  or  morphia. 

The  condition  of  the  back  must  be  daily  examined  in  order  to  forestall 
the  occurrence  of  bed-sores.  The  parts  must  be  kept  dry  and  clean.  Pressure 
must  be  removed  from  the  salient  points  as  far  as  possible,  w^hich  can  best  be 
done  by  placing  the  patient  on  a  water-bed.  The  condition  of  the  bladder 
should  be  cared  for  from  the  outset.  Eetention  of  urine  is  almost  certain  to 
exist,  for  a  time,  and  over-distension  of  the  viscus  is  very  detrimental.  Cathe- 
terization should  be  performed  with  extreme  care  at  least  twice  a  day.  If 
the  urine  become  offensive,  the  bladder  should  be  washed  out  daily  with  a 
"weak  solution  of  borax  or  boracic  acid.  The  bowels  should  be  moved  by 
enemata  rather  than  by  purgatives.  When  incontinence  of  urine,  or  of  feces, 
or  of  both,  exists,  the  greatest  attention  must  constantly  be  paid  in  order  to 
keep  the  parts  clean  and  dry.  The  frequent  application  of  a  spirit  lotion, 
containing  two  per  cent,  of  carbolic  acid,  to  the  parts,  often  proves  useful. 

In  cases  where  the  paralysis  begins  in  the  lower  extremities,  some  hours 
after  the  accident,  and  steadily  rises  higher  and  higher,  should  the  surgeon 
conclude  the  cause  thereof  to  be  the  extravasation  of  blood  (hemorrhage) 
occurring  within  the  theca  vertebralis,  he  might  be  justified  in  exhibiting 
the  fluid  extract  of  ergot,  in  full  doses,  and  the  acetate  of  lead  and  opium,  as 
haemostatics. 

Unilateral  Dislocations  of  the  Cervical  Vertebrce. — Hitherto,  the  symmetrical 
or  bilateral  luxations  of  the  cervical  vertebrae  only  have  claimed  our  atten- 
tion ;  but,  now,  the  unilateral  ones  must  be  considered.  They  essentially 
consist  in  the  displacement  of  the  inferior  articular  process  on  one  side  of  a 
cervical  vertebra,  from  the  corresponding  superior  articular  process  of  the 
vertebra  which  lies  next  below  ;  and  they  cause  the  victim's  face  to  be  turned 
toward  the  side  opposite  to  that  on  which  the  luxation  is  situated.  Many 
examples  of  this  lesion  have  occurred,  and  a  considerable  number  have  been 
recorded.  Twenty-nine  cases  are  mentioned  in  Professor  Ashhurst's  tables. 
Desault  related,  in  his  lectures,  the  case  of  a  lawyer,  who  produced  this  luxa- 
tion, while  sitting  in  his  ofiice  with  his  back  to  the  door,  by  turning  his  head 
suddenly  round  to  see  who  was  coming  in.  Chopart  showed  a  young  man, 
aged  24,  who  sustained  a  similar  lesion  from  turning  his  head  too  far  round ; 
his  face  was  turned  to  the  left,  and  his  chin  ever  afterward  rested  upon  the 
left  shoulder.  (Boyer.)  The  following  is  an  excellent  example  in  which  the 
deformity  was  removed  with  success  by  reducing  the  luxation : — 

Maxson,  of  Geneva,  N.  Y.,  relates  the  case  of  a  young  girl,  aged  about  9  years, 
who  had  a  dislocation  of  the  right  oblique  process  of  the  fifth  or  sixth  cervical  vertebra, 
caused  by  turning  her  head  suddenly  round  while  at  play.  At  first,  she  complained 
only  of  inability  to  straighten  the  neck,  and  she  became  faint  whenever  she  was  moved. 
About  forty -eight  hours  after  the  accident,  her  mother  attempted  to  turn  her  head 
slightly,  and  a  severe  convulsion  ensued.  Soon  after  that,  Dr.  Maxson  saw  her,  and 
could  distinctly  feel  the  displacement  of  the  transverse  process.    He  grasped  her 


DISLOCATIONS  OF  THE  VERTEBRiE. 


327 


head  with  both  hands,  and  turned  it  gently  in  the  same  direction  as  that  to  which  it 
was  already  inclined,  namely,  toward  the  left  shoulder,  in  order  it'  possible  to  disengage 
the  process  ;  then  lifting  or  extending  the  head,  he  carefully  rotated  it  in  the  opposite 
direction,  that  is,  toward  the  right  side,  and  the  reduction  was  accpmplished.  Her 
recovery  was  speedy  and  complete.^ 

Etiology. — In  23  of  the  29  examples  of  this  lesion  that  are  mentioned  in 
Professor  Ashhurst's  tables,  the  mode  of  injury  was  as  follows:  Turning 
the  head  quickly  round,  6  instances;  falling  on  to  the  head,  9;  a  fall  striking 
on  the  neck,  2 ;  a  bundle  slipped  on  the  shoulder,  2 ;  a  fall  in  running,  1 ; 
direct  violence,  1 ;  being  thrown  against  a  wall,  1 ;  tumbling  heels  over  head 
on  a  bed,  by  a  boy  8  or"9  years  old,  1.  In  6  cases  the  mode  of  injury  is  not 
stated.  Thus,  it  appears  that  unilateral  luxation  of  the  cervical  vertebrae 
is  often  caused,  directly,  by  voluntary  action  of  the  muscles  in  turning  the 
head  suddenly  to  one  side,  as  w^ell  as  by  blows  and  falls  ui)on  the  neck  itself; 
and  that  it  also  is  often  caused,  indirectly,  by  falling  upon  the  head,  and  by 
other  forms  of  external  violence,  especially  if  they  produce  both  rotation  of 
the  head  and  inclination  of  it  to  one  side,  as  well  as  flexion. 

Symptoms  mid  Course. — The  phenomena  and  consequences  of  this  lesion 
may  be  best  described  by  briefly  presenting  another  example  :— 

M.  Parisot"  was  called  to  a  woman,  aged  59,  who  had  fallen  from  a  load  of  hay,  and 
found  her  condition  as  follows,  thirty-six  hours  after  the  accident :  The  face  was  inclined 
to  the  right,  and  her  chin  rested  a  little  external  to  the  sterno-clavicular  articulation  of 
that  side.  The  cervical  region  was  concave  on  the  right  side,  the  heads  of  the  sterno- 
cleido-mastoid  muscle  being  relaxed ;  on  the  left  side  it  was  convex,  and  the  lateral 
muscles  were  tense.  The  spinous  processes  could  be  felt,  but  without  any  projection. 
The  head  and  neck  were  fixed  immovably,  and  any  attempt  at  motion  caused  great 
pain.  The  patient  could  not  raise  her  head  at  all.  Her  face  was  congested,  and  the 
jugular  veins  were  turgid  ;  there  was  slight  exophthalmos,  and  her  respiration  was 
becoming  difficult.  The  right  arm  was  paralyzed  as  to  motion,  and  its  sensibility  was 
obtuse  ;  there  were  also  "  pins  and  needles,"  and  cold  sensations  at  the  ends  of  the 
fingers.  The  left  arm  was  freely  moved,  but  "  pins  and  needles"  were  likewise  felt 
therein.  All  the  symptoms  were  aggravated  by  any  attempt  to  raise  the  head.  The 
position  of  the  head  had  been  unchanged  since  the  accident ;  but  the  subjective  symp- 
toms had  come  on  gradually,  and  were  increasing.  There  was  no  loss  of  innervation 
in  the  lower  part  of  the  body.  The  diagnosis  was  unilateral  dislocation  of  the  fifth 
from  the  sixth  cervical  vertebra,  on  the  right  side. 

The  patient  was  placed  sitting  on  the  floor  ;  the  shoulders  and  legs  fixed ;  the  ope- 
rator, standing  behind,  seized  the  lower  jaw  with  both  hands,  the  thumbs  abutting  on 
the  mastoid  processes,  and  raised  the  head  gradually,  then  turned  it  briskly  inward. 
A  crack  was  heard ;  the  patient  immediately  experienced  great  relief,  and  tried  to  turn 
her  head  around,  but  the  paralysis  had  not  disappeared.  She  was  placed  in  bed,  with 
her  head  extended  by  means  of  a  weight  of  two  kilogrammes  [about  4^  lbs.]  suspended 
from  a  band  fastened  around  the  jaw  ;  leeches  and  cold  lotions  were  also  applied.  Next 
day,  the  paralysis  of  the  arm  had  disappeared  ;  in  seventeen  days,  the  pricking  sensa- 
tions were  gone,  and  the  patient  recovered. 

This  case,  take  it  all  in  all,  is  a  not  unfair  representative  of  a  rather  nume- 
rous class  of  cases,  in  which  unilateral  dislocations  of  the  cervical  vertebrae 
have  occurred.  The  stiffness,  soreness,  pain,  and  immobility  of  the  neck, 
with  the  face  turned  away  from  the  dislocated  side,  the  peculiar  distortion 
exhibited  by  the  neck  itself,  the  paralysis  of  one  upper  extremity,  attended 
with  other  symptoms  of  nervous  disorder,  more  dangerous  in  character  and 
constantly  increasing  in  severity,  all  of  which  were  promptly  relieved  by 
restoring  the  luxated  vertebra  to  its  normal  position,  are  phenomena  that  have 

1  Hamilton,  op.  cit.,  p.  315. 

«  Gaz.  Hebd.,  24  Nov.  1865  ;  New  Syd.  Soc.  Bienn.  Retrospect,  18^5-66,  p.  283. 


328 


INJURIES  OF  THE  BACK. 


been  observed  in  many  other  instances  of  this  lesion  that  have  been  recorded. 
In  several  cases,  too,  dysphagia  has  been  present ;  and,  in  one  instance,  the  dis- 
located vertebra  was  found  to  cause  a  projection  into  the  phar}- nx.  In  another 
case,  paralysis  of  the  upper  extremities,  convulsions,  and  hiccough  were  pre- 
sent, but  they  disappeared  on  reducing  the  dislocation,  and  recovery  ensued. 
In  but  one  instance  is  it  stated  that  there  was  no  weakness  of  the  limbs. 
More  or  less  paralysis,  however,  was  noted  in  almost  all  the  examples  of  this 
lesion  which  are  mentioned  in  Professor  Ashhurst's  tables.  While,  in  some 
of  them,  the  paralysis  was  but  slight,  or  quite  limited  in  extent,  and  did  not 
appear  until  some  hours  after  the  accident,  in  others,  it  was  extensive, 
appeared  instantly,  and  increased  rsipidly,  so  that  death  ensued  in  a  few 
hours  if  reduction  was  not  effected ;  in  one  case,  wdiere  paralysis  with  dys- 
phagia instantly  appeared,  death  ensued  in  six  hours,  and,  on  dissection, 
incomplete  unilateral  dislocation  of  a  cervical  vertebra  was  found;  in  another 
case,  where  the  accident  instantly  caused  paralysis,  death  ensued  in  thirty-six 
hours  under  expectant  treatment,  and,  on  autopsy,  unilateral  dislocation  of  a 
cervical  vertebra  was  found;  in  still  another  case,  where  death  ensued  in 
thirty-six  hours,  beside  the  dislocation,  serous  effusion  on  the  arachnoid  was 
found.  In  a  case  where  paralysis,  with  congestion  of  the  neck  and  face,  was 
noted,  death  ensued  in  fifty-seven  hours,  and  unilateral  dislocation  of  the  fifth 
from  the  sixth  cervical  vertebra  was  found,  with  rupture  of  the  interverte- 
bral cartilage,  and  compression  of  the  spinal  cord  by  the  displaced  bone. 

Diagnosis. — The  recognition  of  unilateral  luxations  of  the  cervical  verte- 
brae, when  complete,  is  generally  not  difiicult ;  certainly  it  is  much  less  dif- 
ficult than  that  of  bilateral  or  symmetrical  dislocations  of  these  bones.  The 
symptoms  which  characterize  this  lesion  are  the  twisting  of  the  neck,  and 
the  fixed  position  of  the  face  turned  more  or  less  completely  round  toward 
the  opposite  shoulder,  perceptible  immediately  after  the  accident ;  the  immo- 
bility, with  the  abnormal  lateral  curvature,  of  the  neck  itself;  the  abnormal 
position  of  the  transverse  process  belonging  to  the  luxated  side  of  the  mis- 
placed vertebra ;  and  the  tenseness  of  the  muscles  on  one  side  of  the  neck 
combined  with  relaxation  of  those  on  its  other  side.  Besides,  the  functions 
of  the  spinal  cord  or  spinal  nerves  are,  in  general,  more  or  less  disturbed  by 
the  displaced  bone,  and,  consequently,  there  is  oftentimes  observed  in  such 
cases  paralysis  of  one  or  both  of  the  upper  extremities,  with  dysphagia,  and 
sometimes  also  paralysis  of  the  lower  extremities,  or  paraplegia. 

Prognosis. — The  probability  of  a  favorable  issue  is  usually  much  greater  in 
a  case  of  unilateral  dislocation  of  a  cervical  vertebra  than  it  is  in  a  case  of 
bilateral  dislocation  of  the  same  vertebra ;  for,  in  the  former  instance,  the 
spinal  cord  usually  sustains  much  less  injury  than  in  the  latter.  Moreover, 
unilateral  dislocation  of  these  bones  is  complicated  with  fracture  much  less 
frequently  than  bilateral  or  symmetrical  dislocation.  At  all  events,  the 
statistics  show  that  the  prognosis  is  much  more  favorable  if  only  one  of  the 
articular  processes  of  a  cervical  vertebra  be  luxated,  than  it  is  w^hen  both  are 
displaced.  For  example,  among  the  twenty-nine  cases  of  unilateral  disloca- 
tion which  are  mentioned  in  Professor  Ashhurst's  tables,  there  were  twenty- 
one  recoveries  and  only  eight  deaths.  Furthermore,  it  is  very  instructive  to 
note  that,  of  the  twenty-one  recoveries,  fifteen  appear  to  have  been  achieved  by 
reducing  the  dislocation,  and  four  without  attempting  to  reduce  it,  while  in 
two  instances  the  treatment  is  not  stated ;  and  that,  among  the  eight  deaths, 
there  was  only  one  case  in  which  reduction  was  employed,  and  that  in  this 
case  the  autopsy  showed  that  the  dislocation  had  been  reproduced. 

The  symptoms  of  peculiarly  evil  import  are,  a  steady  increase  of  the  area 
in  which  paralysis  is  noted,  dysphagia,  the  advent  of  difiicult  breathing,  with 
turgescence  of  the  veins  of  the  neck  and  face,  and  the  appearance  of  exoph- 


DISLOCATIONS  OF  THE  VERTEBRA. 


329 


thalmos  from  impending  suffocation.  In  such  cases,  if  tlie  spinal  cord  be  not 
promptly  relieved  from  pressure  by  reducing  the  dislocation — that  is,  if  the 
cause  of  the  morbid  phenomena  be  not  promptly  removed — death  will 
speedily  ensue.  In  some  cases,' however,  death  does  not  occur  until  the  lapse 
of  many  days.  In  at  least  one  instance  on  record,  the  paralysis  came  on 
gradually,  and  death  ensued  in  twelve  days.  In  another  instance,  the  para- 
lysis did  not  begin  until  several  hours  after  the  accident,  but  it  gradually 
increased,  and  death  ensued  in  forty  days. 

Treatment — The  lirst  indication  in  the  treatment  of  unilateral  luxations 
of  the  cervical  vertebrae,  no  doubt,  is  to  reduce  the  luxation.  In  no  case  can 
the  deformity  resulting  from  the  luxation  be  removed,  unless  this  indication 
be  first  fulfilled  ;  and,  in  most  cases,  recovery  from  this  accident  cannot  take 
place,  unless  the  dislocated  bone  be  seasonably  restored  to  its  normal  position. 
As  already  intimated,  reduction  was  employed  in  sixteen  of  the  twenty-nine 
cases  of  this  lesion,  mentioned  in  Professor  Ashhurst's  tables,  and  it  proved 
successful  in  all  but  one  of  the  sixteen ;  in  the  solitary  instance  of  failure, 
an  autopsy  showed  that  the  dislocation  had  been  reproduced.  In  no  one  of 
the  eight  t'atal  cases  was  a  reduction  of  the  dislociition  permanently  efiected. 

Moreover,  the  paral}- sis  was  instantly  removed  by  reduction  in  many  of  the 
successful  cases.  The  motions  of  the  head  and  neck,  too,  Avere  instantly 
restored  by  reduction  in  several  of  them.  Likewise,  the  accomplishment  of 
reduction  w^as  attended  by  an  audible  sound  in  several  instances. 

Concerning  the  method  by  which  extension  and  rotation  are  to  be  applied 
in  order  to  reduce  the  dislocation,  Mr.  Erichsen  says :  "  In  these  cases  I  have 
known  reduction  effected  by  the  surgeon  placing  his  knees  against  the  pa- 
tient's shoulders,  drawing  on  the  head,  and  then  turning  it  into  position,  the 
return  being  attended  by  a  distinct  snap."^  For  other  methods  of  apply- 
ing extension,  etc.,  in  these  cases,  the  reader  is  referred  to  the  examples  of  the 
accident,  already  presented. 

To  prevent  a  recurrence  of  the  dislocation,  it  may  be  advisable  to  apply  a 
collar  of  stiff"  pasteboard  to  the  neck,  for  eight  or  ten  days,  as  practised  by 
Malgaigne  and  others  ;  or  to  make  permanent  extension  by  means  of  a  weight 
of  two  or  three  pounds  attached  to  the  head  by  means  of  a  band  and  strips  of 
adhesive  plaster,  as  practised  by  M.  Parisot. 

To  avert  inflammation  of  the  injured  vertebral  joints,  spinal  membranes, 
and  spinal  cord,  rest  upon  the  back  in  bed,  with  a  small  firm  pillow  placed 
under  the  neck,  and  a  half-filled  bag  of  sand  fitted  to  each  side  of  the  head 
and  neck  to  prevent  any  lateral  movement  thereof,  are  always  necessary. 
Not  unfrequently,  leeches  and  cold  compresses  should  also  be  applied  to  the 
injured  part.  The  risks  arising  from  consecutive  inflammation  are  well  illus- 
trated by  Dr.  Reyburn's  case  of  unilateral  dislocation  of  the  fifth  cervical 
vertebra,  in  which,  though  reduction  Avas  effected,  death,  caused  by  abscess 
of  the  spinal  cord,  followed  fourteen  days  subsequently.^  Pain  should  be 
moved  and  sleep  procured  by  giving  morphia  or  opium. 

Boyer  rejected  all  efforts  to  reduce  the  dislocation  in  these  cases,  and  quoted 
Petit-Radel's  celebrated  case  to  illustrate  the  danger  of  such  efforts.  But,  as 
Malgaigne  has  shown,  the  case  of  Petit-Radel  was  not  at  all  such  as  repre- 
sented by  Boyer ;  and  the  fact  that  in  his  case  the  efforts  at  reduction  caused 
sudden  death,  proved  nothing  but  that  the  efforts  were  unskilfully  made  by 
an  incompetent  person.  (Ashhurst.)  In  that  case  the  transverse  ligament  of 
the  atlas  was  ruptured  by  the  efforts  at  reduction,  and  the  spinal  cord  was 
pressed  forward  against  the  odontoid  process  of  the  axis,  with  an  instantly 
fatal  result. 


'  Op.  cit.,  p.  293. 


2  Am.  Jonni.  of  the  Med.  Sciences,  July,  1871,  p.  110. 


330 


INJURIES  OF  THE  BACK. 


The  various  kinds  of  cervical  dislocation  enumerated  above  are  of  great 
importance :  (1)  Because  they  constitute  the  sole  lesions  in  about  one-half  of 
all  the  cases  of  vertebral  injury  which  occur  in  civil  life ;  (2)  Because  they 
are  very  deadly  and  often  end  very  quickly  ;  and  (3)  Because  there  is  ground 
for  hope  that  with  improved  methods  of  treatment  their  fatality  may  be 
considerably  diminished. 

Dislocations  in  the  Dorsal  and  Lumbar  Eegions. — Dislocations  of  the 
vertebrae  unattended  by  fracture  are  comparatively  rare  in  the  dorsal  and 
lumbar  regions.  To  illustrate  this  point,  I  will  again  state  that,  in  394  cases 
of  spinal  Injury  collected  by  Professor  Ashhurst,  only  17  examples  of  pure 
dislocation  are  reported  as  having  occurred  in  the  dorsal  region,  and  but  3  in 
the  lumbar  region,  while  104  cases  of  uncomplicated  dislocation  are  credited 
to  the  cervical  region.  Again,  of  56  fatal  cases  of  spinal  fracture  and  dis- 
location observed  at  Guy's  Hospital,  in  which  there  were  autopsies,  36  occurred 
in  the  cervical  region  (11  thereof  being  examples  of  pure  dislocation,  and  the 
remaining  25  being  instances  of  dislocation  combined  with  fracture),  18 
occurred  in  the  dorsal  region,  and  2  in  the  lumbar  (Bryant) ;  but  only  two  or 
three  of  the  dorsal  and  lumbar  cases,  at  the  utmost,  were  examples  of  pure 
dislocation.  The  comparatively  great  infrequency  of  pure  dislocations  in 
the  dorsal  and  lumbar  regions  is  explicable :  (1)  by  the  fact  that  in  traumatic 
spinal  lesions  of  all  sorts  the  cervical  region  is  affected  much  oftener  than 
both  the  other  regions  combined ;  and  (2)  by  the  way  in  which  the  articular 
processes  of  the  dorsal  and  lumbar  vertebrae  are  locked  together,  and  b}-  the 
extreme  obliquity  of  the  dorsal  spinous  processes,  the  consequence  whereof 
is,  as  a  rule,  that  at  least  some  one  or  more  of  them  is  broken  when  a 
dislocation  occurs  in  these  regions.  Luxations  unattended  by  fracture  are, 
therefore,  quite  exceptional  in  the  dorsal  and  lumbar  spine. 

Etiology. — Dislocations  of  the  dorsal  and  lumbar  vertebrae  are  always  due, 
direct!}'  or  indirectly,  to  the  application  of  external  force ;  muscular  action 
is  never  their  chief  cause.  They  are  often  produced  by  heavy  falls  from  high 
places  upon  the  back,  shoulders,  or  buttocks  ;  and,  in  such  cases,  the  disloca- 
tion is,  in  the  first-mentioned  instance,  directly,  and,  in  the  last  two  instances, 
indirectly  occasioned,  as  a  rule.  Dorsal  and  lumbar  dislocations,  too,  are  not 
unfrequently  caused,  directlj^,  by  heavy  blows  upon  the  back  and  loins.  For 
example,  in  20  cases  of  ' dorsal  or  lumbar  dislocation  collected  by  myself, 
the  lesion  was  caused  by  falling  from  high  places,  e.g.,  from  trees,  from  the 
windows  and  upper  floors  of  houses,  etc.,  in  8  instances;  by  falling  down 
fourteen  or  fifteen  steps  in  1  instance;  and,  by  falling  upon  the  buttocks  in  1 
instance.  Also,  the  lesion  was  caused  by  a  blow  on  the  back  from  a  ton- 
weight,  in  1  instance ;  by  being  struck  on  the  back  by  a  falling  door,  in  1 
instance  ;  by  the  fall  of  a  scaftbld-pole,  in  1  instance  ;  by  being  struck  by  fall- 
ing timber  on  the  shoulders,  in  1  instance,  and  on  the  loins,  in  1  instance ; 
by  the  running  of  a  carriage-wheel  against  the  back,  in  1  instance ;  by  being 
struck  on  the  back  by  a  falling  wall,  in  1  instance ;  by  the  fall  of  a  mass  of 
chalk,  in  1  instance ;  and,  by  striking  the  back  against  a  beam  in  driving 
through  an  archway,  in  2  instances.  In  each  of  the  10  cases,  first  mentioned, 
the  luxation  was  caused  by  a  heavy  fall ;  and,  in  each  of  the  remaining  10 
cases,  it  was  produced  by  a  heavy  blow  on  the  back. 

To  illustrate  dorsal  luxation,  the  following  case  is  in  point : — 

A  man,^  from  falling  down  through  five  hatchways,  received  a  dislocation  of  the  sixth 
from  the  seventh  dorsal  vertebra,  and  was  brought  to  the  Brooklyn  City  Hospital. 
No  other  injury  was  sustained.    He  presents  all  the  symptoms  of  this  lamentable 


»  Medical  Record,  p.  145,  vol.  ix.  1874. 


DISLOCATIONS  OF  THE  VERTEBRAE. 


831 


accident,  but  has  now  been  lying  upon  a  water-bed  for  ninety  days,  and,  to  all  appear- 
ances, is  in  a  far  better  condition  than  he  was  one  month  ago.  The  patient  is  kejpt 
partly  under  the  influence  of  morphia." 

The  following  example,  from  being  more  fully  reported,  is  much  more  instructive: 
A  man,  aged  21,^  fell  from  a  chestnut  tree,  October  4,  1871,  a  distance  of  some  twenty- 
five  or  thirty  feet,  striking  the  ground  with  his  shoulders  and  back.  When  picked  up 
he  was  insensible.  On  recovering  consciousness,  he  complained  of  severe  pain  in  the 
back,  shooting  round  into  the  hypogastrium  and  left  groin.  About  two  hours  after  the 
accident,  Dr.  Simpson  found  him  lying  partially  on  his  right  side,  with  knees  drawn  up 
and  almost  immovable.  His  back  was  slightly  bruised  and  scratched,  and  presented  a 
deformity  indicating  apparently  a  displacement  forward  of  the  vertebrae  at  the  lumbo-dorsal 
junction  ;  sensation  in  lower  extremities  diminished,  but  not  obliterated  ;  intense  pain  in 
back  and  in  abdomen.  Cold  applications  to  the  patient's  back  were  ordered,  and  that 
he  should  be  kept  as  quiet  as  possible  ;  forty  drops  of  liq.  opii  comp.  every  two  hours, 
during  the  night.  Next  morning,  Br.  Hasbrouck  saw  the  patient  in  consultation.  He 
recognized  the  partial  dislocation  of  the  last  dorsal  vertebra,  but  doubted  the  propriety 
of  attempting  to  reduce  it.  He  suggested,  however,  that  potassium  iodide,  grs.  v, 
repeated  every  four  hours,  should  be  added  to  the  treatment. 

Urine  was  passed  by  the  patient  without  assistance  on  the  night  succeeding  the  injury. 
After  that,  catheterization  had  to  be  practised  twice  daily,  for  the  next  ten  days,  when 
voluntary  micturition,  with  some  straining,  was  re-established.  There  was  constipa- 
tion, which  was  not  relieved  by  enemata,  nor  by  purgatives  per  orem,  until  a  hardened 
mass  of  feces  in  the  rectum  had  been  broken  down  by  a  finger  introduced  for  the  purpose. 
After  twelve  days,  the  bowels  became  regular.  All  the  symptoms  now  began  to  improve 
regularly,  excepting  the  deformity  of  the  back,  which  increased  much  in  extent.  In 
about  three  weeks  after  the  accident,  the  patient  began  to  sit  up  in  bed ;  and,  four  or 
five  weeks  later,  to  walk  around  the  house,  with  the  aid  of  a  cane.  During  the  fall  and 
early  winter,  his  back  continued  quite  weak.  In  January,  1872,  he  had  a  brace  fitted 
for  the  support  of  his  back.  March  26,  1872,  he  commenced  work  again  at  his  trade, 
that  of  a  mason.  With  the  artificial  support  furnished  by  the  brace,  he  feels  as  well, 
he  says,  as  he  did  before  the  accident. 

These  two  cases  illustrate  very  well,  not  only  the  etiology  and  symptoma- 
tology of  dorsal  luxations,  but  likewise  some  important  points  in  the  treat- 
ment of  these  lesions.  The  patient  first  mentioned,  derived  much  benefit 
from  the  water-bed  upon  which  he  had  been  lying  for  three  months,  when 
his  case  was  reported,  and  from  the  prolonged  use  of  enough  morphia  to 
keep  him  free  from  all  pain,  and  to  procure  for  him  sufiiicient  sleep.  Opium 
administered  in  this  w^ay,  to  such  patients,  generally  exerts  a  happy  infiuence 
in  preventing  the  occurrence  of  inflammatory  complications  in  the  spinal  mem- 
branes and  spinal  cord,  as  well  as  in  sustaining  the  patient's  strength. 

In  the  case  last  mentioned,  the  lesion,  that  is,  the  luxation  forward  of  the 
twelfth  dorsal  upon  the  first  lumbar  vertebra,  was  caused,  indirectly,  by  fall- 
ing from  a  great  height  upon  the  shoulders  and  back.  There  was,  for  a  time, 
insensibility  from  cerebral  concussion.  The  forward  displacement  of  the 
twelfth  dorsal  vertebra  was  cognizable  by  inspection  and  by  manual  exami- 
nation ;  and  there  was  incomplete  paralysis  of  the  parts  below  the  spinal 
lesion.  The  symptoms  and  consequences  of  a  vertebral  dislocation  were 
therefore  clearly  present ;  but  great  pain  in  the  injured  portion  of  the  spinal 
column,  and  in  the  parts  of  the  abdomen  to  which  the  spinal  nerves  involved  in 
the  lesion  were  distributed,  was  also  observed.  It  was  subdued  by  administer- 
ing the  opium  solution  in  large  doses  and  at  short  intervals  (gtt.  xl  every 
two  hours).  Opium  or  morphia,  when  exhibited  in  full  doses,  is  one  of  the 
most  efiicient  agents  we  possess  for  allaying  inflammatory  excitement,  espe- 
cially in  fibrous  and  serous  membranes.    Cold  applications  to  the  injured 


1  American  Journal  of  the  Medical  Sciences,  April,  1873,  pp.  502,  503. 


332 


INJURIES  OF  THE  BACK. 


parts  of  the  back  were  made,  and  absolute  quietude  was  enjoined.  Besides 
the  opium,  potassium  iodide,  5  grains  every  four  hours,  was  given  internally. 
Thus,  it  will  be  perceived,  that  strong  measures  were  adopted  from  the  out- 
set to  allay  any  inflammation  of  the  spinal  membranes  or  the  spinal  cord 
which  might  threaten  to  follow  the  injury.  To  these  antiphlogistic  measures 
I  attribute  most  of  the  success  which  was  obtained  in  the  treatment  of  this 
case.  The  non-employment  of  extension  and  counter-extension  was  evidently 
a  mistake ;  for,  had  they  been  continuously  applied  for  two  or  three  weeks, 
the  displacement  of  bone  would  not  have  increased,  as  actually  happened,  and 
the  bladder  would  not  have  become  paralyzed  on  the  day  after  the  accident. 
The  excellent  results  which  were  obtained,  in  this  case,  by  obviating  the  ten- 
dency to  inflammation  in  the  bruised  and  strained  spinal  membranes  and  spi- 
nal cord,  by  employing  appropriate  treatment  internally  as  well  as  externally, 
should  teach  us  to  do  likewise  in  all  similar  cases.  That  there  is  a  real  need 
for  so  doing,  in  such  cases,- the  following  observations  will  prove: — 

A  man,  aged  40,  was  admitted  to  the  Saint  Andre  Hospital,  at  Bordeaux,^  with 
severe  injury  of  the  back.  Mobility  of  the  eleventh  dorsal  spinous  process  was  detected. 
Temporary  loss  of  consciousness  from  shock  occurred.  Then  severe  pain  in  the  seat 
of  the  injury,  which  was  near  the  origin  of  the  eleventh  dorsal  nerves,  was  complained 
of.  The  parts  supplied  by  the  sacral  and  lumbar  plexuses  of  nerves  were  paralyzed,  and 
voluntary  motion  of  the  lower  extremities  was  abolished.  Anaesthesia  of  the  lower 
extremities,  and  of  the  abdominal  wall  as  high  as  the  umbilicus,  existed,  with  exagge- 
rated reflex  motility  in  the  lower  extremities.  There  was  priapism,  with  retention  of 
urine  and  feces,  and  tympanites,  from  vesical  and  intestinal  paralysis.  The  pulse  rose 
to  112;  the  breathing  became  diaphragmatic  and  difficult;  and,  on  the  eleventh  day, 
death  occurred.  Dissection  revealed  fracture  of  the  laminae  of  the  eleventh  dorsal  ver- 
tebra, with  dislocation  of  its  body  in  front  of  the  twelfth,  contusion  of  the  cord,  and 
ascending  myelitis.  Here,  then,  a  contusion  of  the  spinal  cord  arising  from  a  disloca- 
tion with  fracture  of  the  spinal  column,  eventuated  in  a  traumatic  inflammation  of  the 
spinal  cord,  which  caused  death  by  spreading  upward  until  it  involved  the  roots  of  the 
phrenic  nerves,  and  thus  suppressed  the  respiratory  movements ;  and  the  fatal  issue  of 
this  case  could  have  been  prevented,  only  by  averting  the  consecutive  inflammation  of 
the  spinal  cord. 

Bryant^  reports  the  case  of  a  laborer,  aged  33,  injured  by  timber  falling  on  his 
shoulders.  At  first,  there  was  loss  of  sensation,  but  not  of  motion  ;  afterward,  loss  of 
motion,  but  return  of  sensation  ;  finally,  loss  of  both.  In  ten  days  death  ensued.  Dis- 
location forward  of  the  eleventh  dorsal  vertebra,  with  fracture  of  the  twelfth,  was 
found  ;  and  the  spinal  cord  was  disorganized.  (Ash hurst.)  In  cases  such  as  this,  the 
disorganization  of  the  spinal  cord  which  directly  precedes,  and  is  the  proximate  cause 
of  death,  is  always  due  to  inflammatory  action  ;  and  well  directed  efforts  to  subdue  it 
should  always  be  made,  by  appropriate  treatment,  both  general  and  local. 

Robert^  mentions  the  case  of  a  laborer,  aged  25,  who  was  injured  in  the  back  by  a 
scaffold-pole  falling  on  him.  There  was  paralysis  (paraplegia),  etc.,  noted,  but  no 
deformity.  In  eleven  days,  however,  he  died.  Dislocation  of  the  fifth  from  the  sixth 
dorsal  vertebra  was  found  ;  and  the  spinal  cord  was  difl[luent.  This  case  clearly  belongs 
to  the  same  category, as  the  last  two,  and  in  it  an  ascending  myelitis  of  a  destructive 
character  also  resulted  from  the  injury,  and  caused  death. 

Charles  Bell*  relates  the  case  of  a  coal-wagoner,  thrown  from  his  cart  while  drunk, 
striking  upon  his  neck  and  shoulders.  He  complained  of  a  stiff  neck,  could  not  stand 
alone,  and  dragged  his  legs  when  supported  ;  but  when  lying  in  bed,  no  paralysis  ap- 
peared. Between  the  shoulders,  at  the  root  of  the  neck,  there  was  swelling  and  ecchy- 
mosis  ;  and  in  the  loins  acute  pain.    Leeches  were  applied  to  the  swelling.    On  the 

1  Pousson  et  Lalesqiie,  Revue  Mensuelle,  Juillet,  1880  ;  Lond.  Med.  Record,  Jan.  15,  1881. 

2  Guy's  Hospital  Rej)orts,  3d  S.,  vol.  v. 

3  Half- Yearly  Abstract  of  Med.  Science,  1854. 
Surg.  Ol>servatioiis,  Part  ii.,  p.  145. 


DISLOCATIONS  OF  THE  VERTEBRiE. 


383 


eWhth  day  convulsions  occurred,  and  were  followed  by  mania.  On  the  eleventh  day 
pa'J-alysis  appeared,  which  afterward  began  to  pass  away.  On  the  twentieth  day  death 
ensued.  Dissection  revealed  diastasis  of  the  seventh  cervical  from  the  first  dorsal  ver- 
tebra;  the  intervertebral  cartilage  had  disappeared  from  suppurative  infiammation, 
and  purulent  matter  had  dropped  to  the  bottom  of  the  spinal  sheatli  (theca  vertebralis). 
Outside  of  the  injured  vertebra  a  large  abscess  was  found.  In  this  case  the  vertebral 
lesion  had  given  rise  to  a  destructive  inflammation  of  the  intervertebral  cartilage  and 
the  formation  of  much  pus,  together  with  a  suppurative  inflammation  of  the  spinal 
meninges ;  the  latter  condition,  unless  arrested  by  timely  treatment,  necessarily  proves 
fatal. 

Charles  BelP  reports  the  case  of  a  plasterer,  aged  25,  who  fell  forty  feet,  striking  his 
back  against  a  stone  step.  Depression  between  the  spinous  processes  of  the  lower 
dorsal  vertebrae  was  observed,  but  no  paralysis.  He  had  acute  pain  in  the  back.  On 
the  third  day  he  was  delirious,  threw  himself  out  of  bed,  etc.  On  the  fifth  day  he  had 
to  be  tied  in  bed,  and,  on  the  same  day,  he  died.  Dissection  showed  fracture  of  the 
body  and  spinous  process  of  the  eleventh  dorsal  vertebra  ;  the  spinal  cord  was  not  com- 
pressed by  the  fracture  ;  but  greenish  pus  was  found  between  the  cord  and  the  theca 
vertebralis,  and  there  was  effusion  on  the  brain.  (Ashhurst.)  From  the  vertebral  frac- 
ture there  evidently  arose  in  this  case  traumatic  cerebro-spinal  meningitis,  of  a  suppu- 
rative character,  which  caused  death.  It  is  not  probable  that  this  inflammation  could 
have  been  successfully  combated  without  the  aid  of  local  blood-letting  by  leeches  or 
cups,  and  the  continuous  application  of  an  ice-bag  or  an  iced  poultice,  with  opium  and 
morphia  in  large  doses,  and  potassium  iodide,  as  well  as  absolute  quietude  of  the  injured 
and  inflamed  parts. 

Dupuytren^  mentions  a  case  which,  during  life,  was  supposed  to  be  concussion  of  the 
spinal  cord  only  ;  there  was  partial  paralysis  and  sloughing  ;  but,  in  the  end,  death 
ensued.  Dissection  revealed  fracture  of  the  tenth  dorsal  vertebra;  blood-clots  and 
meningitis  opposite  the  ninth,  tenth,  and  eleventh  dorsal  vertebras.  (Ashhurst.)  Besides 
the  spinal  fracture  and  the  spinal  meningitis,  the  autopsy  in  this  case  revealed  an 
eff'usion  of  blood  between  the  cord  and  theca  vertebralis.  Such  hemorrhages  are  fre- 
quent concomitants  of  the  vertebral  fractures  and  dislocations  that  occur  in  the  dorsal 
and  lumbar  regions,  as  well  as  in  those  that  occur  in  the  cervical  region. 

Dr.  C.  A.  Lee»  reports  the  case  of  a  man,  aged  48,  injured  by  falling  from  a  building 
across  a  plank.  At  first,  he  was  stunned  ;  and,  afterward,  very  restless.  On  the  next 
day  paralysis  appeared  ;  and  a  projection  in  the  middle  of  the  back  was  noted.  In  five 
weeks  death  ensued.  Dissection  showed  fracture  of  two  dorsal  vertebrae  ;  the  spinal 
cord  was  softened  ;  and  purulent  matter  was  found  in  the  vertebral  canal.  Here,  too, 
spinal  meningitis  arose  from  fracture  of  the  dorsal  vertebrjE,  and  was  attended  by  the 
formation  of°pus.  Obviously,  such  cases  cannot  be  conducted  to  a  successful  issue, 
unless  the  occurrence  of  traumatic  spinal  meningitis  in  them  be  seasonably  recognized, 
and  the  disorder  itself  combated  by  appropriate  treatment. 

Many  additional  examples  of  spinal  meningitis  and  myelitis  arising  from 
spinal  dislocations  and  fractures  might  be  cited  from  the  records.  But, 
enouo;h  of  them  already  have  been  presented  to  clearly  show  that,  m  every 
case  of  vertebral  dislocation  or  fracture,  where  life  continues,  there  exists  a 
strong  tendency  for  consecutive  inflammation  of  the  spinal  membranes  and 
cord  to  ensue ;  that,  not  unfrequently,  traumatic  meningitis  or  myelitis  is  the 
proximate  cause  of  death,  in  such  cases;  and  that  the  surgeon  should,  m  all 
such  cases,  employ  remedial  measures  of  known  efficacy,  from  the  outset,  m 
order  to  prevent  the  traumatic  irritation  of  the  spinal  membranes  and  cord 
from  rising  to  the  grade  of  inflammatory  action. 

Symptoms  and  Prognosis. — When  dislocation  of  the  joints  of  a  vertebra 
occurs  in  the  dorsal  or  lumbar  region,  it  is  always  attended  by  functional 

«  Ibid.,  p.  138.  ^^^^ 
2  Diseases  and  Injuries  of  Bones.  London,  Sydenham  Society,  1847. 
a  American  Journ.  Med.  Sciences,  0.  S.  vol.  xvii. 


INJURIES  OF  THE  BACK. 


disturbance  and  displacement  of  the  bones  which  form  the  compound  articu- 
lation ;  and,  generally,  by  ecch^miosis.  Inasmuch  as  the  vertebral  joints  are 
more  superficial  in  the  dorsal  and  lumbar  regions  than  they  are  in  the  cer- 
vical, the  displacement  of  bone  is  more  easily  recognized  by  sight  and  touch 
in  the  former  regions  than  it  is  in  the  latter.  The  sj^mptoms  by  which  luxa- 
tions of  the  dorsal  and  lumbar  vertebrae  may  be  known,  are  the  deformity  and 
the  disturbances  of  function  which  arise  from  the  displacement  of  the  luxated 
bones,  and  the  ecchymosis.  The  displacement  is  often  denoted  by  a  projec- 
tion backward  of  the  lower  vertebra.  Sometimes  a  distinct  gap  can  be  felt 
between  the  dislocated  vertebra  and  the  bone  next  below  it.  Frequently 
their  spinous  processes  are  found  to  be  separated  by  a  considerable  interval. 
Occasionally  they  are  so  widely  separated  that  three  fingers  can  be  laid  be- 
tAveen  them.  Oftentimes  the  patient  has  severe  pain  in  the  injured  part  of  , 
the  back,  l^ot  unfrequently  the  patient  has  also  severe  pain  in  parts  far 
removed  from  the  back,  that  is,  in  the  parts  where  the  spinal  nerves  that 
pass  through  the  inter-vertebral  notches  at  the  place  of  injury,  are  distributed 
or  have  their  terminal  extremities.  Should  the  spinal  cord  be  much  injured, 
there  will  be  paralysis  both  sensory  and  motor  (paraplegia)  of  all  the  parts 
supplied  by  spinal  nerves  that  issue  from  the  segment  of  the  cord  which  lies 
below  the  lesion.  Paralysis  of  the  bladder  will  be  denoted  by  retention  or 
by  incontinence  of  urine ;  paralysis  of  the  intestines  by  retention  or  by  in- 
continence of  feces,  and  by  tympanites.  The  area  of  lost  sensibility  usually 
corresponds  very  closely  to  that  of  the  motor  paralysis,  because  the  anterior 
and  posterior  roots  of  the  spinal  nerves  emerge  from  the  cord  on  the  same 
level.  The  following  example  will  serve  to  show  how  profound  and  durable 
the  sensory  paralysis,  as  well  as  the  motor,  may  be : — 

Dr.  W.  D.  Purple^  reports  the  case  of  a  man,  aged  22,  injured  from  being  struck  by 
the  limb  of  a  tree.  There  was  dislocation  of  the  fifth  and  sixth  dorsal  vertebrse  with 
permanent  as  well  as  complete  paralysis,  both  sensory  and  motor,  of  the  lower  part  of 
the  body,  or  paraplegia.  Six  years  afterward  he  had  both  thighs  amputated  high  up, 
because  the  paralyzed  limbs  were  useless  appendages.  He  felt  nothing  whatever  dur- 
ing the  operation,  although  no  anaesthetic  was  employed.  Seven  years  after  the  injury 
he  died  from  other  causes  ;  no  autopsy. 

But,  in  many  cases  of  vertebral  dislocation  or  fracture  with  injury  of  the 
cord,  marked  hypercBSthesia  with  intense  pain  is  noted  just  above  the  paralyzed 
region. 2  The  last-named  symptoms,  however,  will  be  discussed  in  connection 
wUh  the  subject  of  Traumatic  Myelitis,  as  it  is  the  disorder  from  which  they 
arise. 

Should  the  ganglionic  nerves  which  lie  along  the  spinal  column,  on  each 
side  thereof,  and  in  close  relation  thereto,  be  much  injured,  especially  in  the 
cervical  region,  there  may  arise  therefrom,  as  well  as  from  injuries  of  the 
spinal  cord,  vaso-motor  disturbances,  denoted  b}^  alterations  of  the  pulse,  by 
flushing  of  the  face,  and  by  a  considerable  increase  or  diminution  of  the 
body-heat.  Paralysis  of  the  vaso-motor  nerves,  thus  induced,  lessens  the  blood- 
pressure  in  the  arteries,  and  modifies  the  character  of  the  pulse  accordingly. 
With  each  blood-wave,  the  condition  of  feeble  pressure  passes  suddenly  into 
a  condition  of  forcible  pressure  at  tl^e  moment  of  the  ventricular  systole,  and 
suddenly  reverts  to  the  former  condition,  for  the  blood  flows  too  readily 
through  the  paralyzed  capillaries  from  the  arterial  into  the  venous  system. 
MM.  Pousson  and  Lalesque  found  this  forcible  impulse  or  peculiar  sensation 
of  a  strong  pulse  to  be  most  marked  in  large  arteries,  e.  g.,  the  femoral  and 
the  abdominal  aorta.     The  sphygmographic  tracing  presents,  with  pulse- 

1  New  York  Journal  of  Med.,  1853. 

2  Med.  News  and  Abstract,  March,  1881,  pp.  179,  180. 


DISLOCATIONS  OF  THE  VERTEBR.^. 


385 


modifications  of  this  kind,  a  very  liigli  and  vertically  ascending  line,  and  a 
concave  and  prolonged  descending  line.^  .    ,  .  .  . 

In  regard  to  changes  of  the  body-heat  in  consequence  of  spinal  nijuries,  1 
will  briefiy  mention'a  few  examples : — 

Dr.  T.  G.  Mcrton^  found  in  a  case  wliere  tlie  fifth,  sixth,  and  seventh  cervical  ver- 
tebrse  were  fractured,  with  paralysis,  etc.,  that  tlie  temperature  two  hours  after  tlie  acci- 
dent was  102°  Fahr;  in  eleven  days  the  patient  died.  Professor  William  Pepper^ 
relates  a  case  in  which  there  were  fractures  of  the  first  and  fourth  cervical  vertebrae, 
with  anterior  luxation  of  the  latter,  as  well  as  compression  of  the  si)inal  cord,  death 
ensuing  24^  hours  after  the  injury ;  the  whole  cutaneous  surface  was  much  warmer  than 
normaf,  and  a  thermometer  in  the  axilla  registered  108.5°  Fahr.  at  the  moment  of 
death  ;  the  cheeks  were  brightly  flushed,  and  very  hot ;  but  the  pupils  were  about 
normal.  Mr.  Shaw*  relates  the  case  of  a  drayman,  aged  35,  injured  by  a  bag  of  hops 
falling  upon  his  head  and  shoulders,  in  which  there  were  fracture  of  the  fourth  dorsal 
vertebra,  paralysis,  priapism,  and  a  temperature  of  103-100°  Fahr.  (Ashhurst.)  Bro- 
die's  case  of  spinal  injury,  in  which  the  mercury  rose  to  111°  Fahr.,  has  already  been 
mentioned.  A  number  of  cases  are  on  record  in  which  "  calor  mordicans"  was  noted. 
On  the  other  hand.  Dr.  A.  Nieden^  reports  the  case  of  a  man,  aged  60,  injured  by 
falling  down  fourteen  or  fifteen  steps,  in  which  there  were  temporary  loss  of  conscious- 
ness, complete  paralysis  of  lower  extremities,  bladder,  and  greater  part  of  trunk,  pro- 
gressive lowering  of  the  temperature,  and  pulse  of  a  remarkable  character.  He  died 
on  the  eleventh  day  after  the  accident,  with  a  temperature  of  80.6°  Fahr.  He  remained 
conscious  until  his  temperature  was  81°  Fahr.  and  his  pulse  30.  T\\Q,autopsy  showed 
luxation  without  fracture  of  the  first  dorsal  vertebra,  with  compression  of  the  spinal 
cord.  A  somewhat  similar  case  was  under  the  care  of  Mr.  Hutchinson,  at  the  London 
Hospital.  There  was  complete  paralysis  as  high  as  an  inch  above  the  nipples,  with 
marked  priapism  ;  temperature  98°.  The  next  day  the  pulse  was  noted  at  36  and 
small ;  in  the  evening,  the  temperature  in  the  rectum  was  only  95.8°,  in  the  distended 
penis  93°.  The  patient's  cheeks  and  lips  were  of  very  good  color,  remarkably  so  ;  while 
to  the  touch  they  seemed  as  cold  as  those  of  a  corpse.  But  he  did  not  complain  of  feeling 
cold.  The  temperature  sank  to  95°,  and,  on  the  sixth  day,  he  died.  The  temperature 
did  not  rise  after  death.  The  autopsy  showed  fracture  of  the  fifth  cervical  vertebra, 
and  severe  injury  of  the  cord.«  Something  like  a  "flushed  face"  appears  to  have  been 
noted  in  this  case,  although  the  temperature  was  much  below  the  normal. 

1^0  clear  explanation  of  cases  such  as  this  has  yet  been  made.  But  par- 
alysis of  the  vaso-motor  nerves  may  arise  from  lesions  of  the  spinal  cord,  as 
well  as  from  injuries  of  the  ganglionic  chain  of  nerves,  or  the  great  sympa- 
thetic. "  Flushing  of  the  face,"  in  cases  of  spinal  injury,  is  usually  attended 
by  lachrymation  and  contracted  pupils,  and  is  clearly  due  to  vaso-motor 
paralysis. 

Mr.  Erichsen  says  that  he  has  seen  unequivocal  instances  of  continued  low 
temperature  of  the  body,  taken  in  the  mouth  and  axilla,  in  cases  of  spinal 
concussion— as  low  as  92°  or  93°  F.,  and  continuing  for  many  months  from 
2°  to  3°  F.  below  the  normal.^  He  also  refers  to  Dr.  I^ieden's  case  in  which 
the  first  dorsal  vertebra  was  dislocated,  mentioned  above.  "  More  commonly 
the  low  temperature  is  confined  to  the  extremities,  especially  the  feet,  which 
are  sensibly  colder  than  other  parts  of  the  body.  Often  the  feet  are  as  low  as 
80°  to  85°  F.,  and  will  remain  so  for  very  long  periods  of  time."^ 

The  -prognosis  in  cases  where  the  dorsal  or  lumbar  vertebrae  are  injured  is 
usually  much  less  unfavorable  than  it  is  in  cases  where  the  cervical  vertebrae 

»  Ibid.,  p.  181. 

2  Proceedings  of  the  Pathological  Soc.  of  Philadelphia,  vol.  i. 
«  American  Journal  Med.  Sciences,  April,  1867,  pp.  437,  438. 

4  Holmes's  System  of  Surgery,  vol.  ii.  ^  clin.  Soc.  Trans.,  vol.  vi.  1873. 

8  New  Syd.  Soc.  Retrospect,  1873-4,  pp.  351,  352. 

'  On  Concussion  of  the  Spine,  etc.,  1882,  p.  65.  *  Ibid. 


336 


INJURIES  OF  THE  BACK. 


have  sustained  similar  lesions  ;  and,  as  a  rule,  the  further  the  seat  of  injury  is 
removed  from  the  respiratory  centres,  the  more  favorable  is  the  prognosis.  In 
dorsal  and  lumbar  dislocations  and  fractures,  without  intra-spinal  hemorrhage, 
the  chief  sources  of  danger  to  life  are  the  occurrence  of  spinal  meningitis,  of 
ascending  myelitis,  of  trophic  lesions  such  as  sacral  and  gluteal  eschars  or 
bed-sores,  and  of  vesical  or  renal  inflammation.  The  appearance  of  either  of 
these  complications  greatly  increases  the  gravity  of  every  case.  There  are 
some  symptoms,  however,  which  are  especially  bad  prognostics.  Among 
them  may  be  mentioned  persistent  elevation  or  depression  of  the  body-tem- 
perature, flushing  of  the  face,  great  frequency  or  infrequency  of  the  pulse, 
early  appearing  and  rapidly  spreading  sacral  or  gluteal  eschars  or  acute  bed- 
sores, incontinence  of  urine  and  feces  succeeding  retention,  enlargement  of 
the  paralyzed  area  in  an  upward  direction  and  increase  of  the  paralytic 
symptoms,  especially  when  they  are  progressive,  diaphragmatic  breathing, 
and"  dyspnoea.  Incontinence  of  feces  and  urine  succeeds  retention  in  these 
cases,  because  the  sphincter  muscles  have  become  paralyzed ;  and  this  circum- 
stance denotes  that  the  nerve  centres  upon  which  their  action  depends  have 
become  aftected.  Progressive,  upward  extension  and  deepening  of  the  para- 
lysis, generally  indicate  progressive,  upw^ard  disorganization  of  the  cord. 
Diaphragmatic  breathing  coming  on  some  days  after  the  accident,  is  a  most 
unfavorable  symptom,  and  generally  denotes  that  the  compression  or  disor- 
ganization of  the  spinal  cord  has  attained  so  high  a  point  that  the  diaphragm 
alone  of  all  the  respiratory  muscles  remains  unparalyzed.  Dyspnoea  occurring 
in  this  connection  usually  indicates  that  the  aeration  of  the  blood  is  quite 
imperfect,  and  that  the  induction  of  fatal  coma  in  consequence  thereof  may 
be  at  hand.  Priapism  is  generally  a  dangerous  symptom,  but  not  necessarily 
a  fatal  one ;  for  there  are  cases  on  record  of  recovery  from  spinal  injury  where 
this  symptom  had  existed. 

The  progressive  diminution  of  paralysis,  in  these  cases,  is  a  most  favorable 
symptom.  The  return  of  motor  powxr  is  not  unfrequently  attended  by  in- 
voluntary contractions  and  twitchings  of  the  muscles ;  these  symptoms, 
however,  are  not  to  be  considered  unfavorable  at  this  stage,  although  they 
are  supposed  by  Brodie,  and  probably  with  justice,  to  indicate  compression 
or  mechanical  irritation  of  the  spinal  cord  when  they  attend  an  earlier  stage. 

Treatment — In  no  case  of  dislocation  of  the  dorsal  or  lumbar  vertebrfe, 
however  clear  the  symptoms  of  the  dislocation  may  be,  can  it  be  asserted  with 
absolute  certainty  during  life  that  no  fracture  is  present.  While  pure  dislo- 
cations of  these  vertebrse  are  quite  rare,  dislocations  combined  with  fracture 
are  quite  common  in  the  dorsal  and  lumbar  regions ;  but  the  treatment  of 
both  forms  of  injury  should  be  conducted  on  substantially  the  same  plan. 
The  want  of  a  strictly  exact  diagnosis  in  this  regard  is,  therefore,  not  as  essen- 
tial to  the  therapeusis  of  dorsal  and  lumbar  dislocations  as  it  is  in  those  of  the 
cervical  region. 

The  condition  of  the  injured  parts  in  dorsal  and  lumbar  dislocations,  as 
w^ell  as  in  cervical,  is  usually  as  follows:  The  muscular  and  connective  tissue 
around  the  displacement  is  extensively  lacerated  and  infiltrated  w^ith  blood ; 
the  intervertebral  disk  or  ligament  is  torn  through  at  the  seat  of  displacement, 
so  as  to  allow  the  body  of  the  upper  vertebra  to  be  thrown  forward  from  that 
of  the  lower ;  the  anterior  and  posterior  common  ligaments  are  much  stretched 
and  extensively  detached ;  the  ligamenta  subflava  and  the  capsular  ligaments 
are  lacerated ;  the  laminae,  or  certain  of  the  vertebral  processes,  are  fractured ; 
the  theca  vertebralis  is  stained  with  blood,  bruised,  stretched,  and  perhaps 
somewhat  torn;  the  spinal  canal  contains  more  or  less  blood;  while  the  spinal 
cord  is  ecchymosed  and  abruptly  bent,  and  sometimes  presents  a  compressed 


DISLOCATIONS  OF  THE  VEKTEBR.?:. 


337 


appearance,  or  is  even  divided  completely,  at  a  point  corresponding  to  the 
displacement  of  the  vertebrae. 

The  victim  of  this  accident  should  be  taken  up  from  the  place  where  he 
has  fallen,  and  removed  to  hospital  or  home  with  great  care  to  avoid  in- 
creasing the  displacement  of  the  luxated  bone  and  the  injury  of  the  S})inal 
cord,  as  already  described  for  cases  of  cervical  dislocation.  The  patient 
should  be  placed  in  bed ;  and  then,  for  reasons  ah-eady  stated  under  the  head 
of  treatment  of  cervical  dislocations,  which,  however,  are  equally  applicable 
in  cases  of  dorsal  or  lumbar  dislocation,  the  replacement  of  the  luxated  bone 
into  its  normal  position  should  be  attempted.  But  before  proceeding  furtlier 
with  the  discussion,  I  will  briefly  describe  the  various  methods  which  have 
been  successfully  employed,  in  practice,  for  accomplishing  this  result  in  the 
dorsal  and  lumbar  regions ;  and,  probably,  I  cannot  do  it  in  a  better  way 
than  by  presenting  abstracts  of  the  cases  themselves. 

Malgaigne^  mentions  a  case  of  Melcliiori's,  in  which  a  carter  was  injured  in  tlie  dor- 
sal region  by  a  wheel  running  against  him.  There  was  backward  dislocation  of  the 
eighth  dorsal  vertebra,  and  paralysis.  Reduction  was  effected  by  position  in  bed. 
Recovery  ensued  in  six  months.  Slight  deformity,  however,  remained.  (Ashhurst.) 
When  it  is  found  that,  by  placing  the  patient  upon  his  back  in  bed,  the  displaced 
vertebra  is  restored  to  its  normal  position,  with  the  aid,  perliaps,  of  moderate  exten- 
sion and  some  pressure  laterally  applied,  a  good  hair  mattress  or  a  water-bed  (the  latter 
is  much  preferable)  should  be  arranged  for  his  reception,  and  he  must  be  kept  lying 
upon  it,  as  nearly  immovable  as  possible,  until  firm  union  has  taken  place. 

Rudiger'  is  credited  with  the  case  of  a  musketeer,  who  was  struck  on  the  back  by  a 
falling  wall,  and  sustained  dislocation  backward  and  to  the  right  side  of  the  twelfth 
dorsal  vertebra.  Reduction  was  effected  by  position  (on  the  belly)  in  bed  ;  extension 
and  pressure  were  continued  for  fifteen  days.  In  six  weeks  recovery  ensued.  (Ash- 
hurst.) This  case  shows  that  the  surgeon,  by  consulting  his  ingenuity,  may  some- 
times, perhaps  not  unfrequently,  make  the  patient's  posture  in  bed  materially  assist  in 
reducing  a  vertebral  dislocation  of  the  back  or  loins,  when  the  dorsal  decubitus  utterly 
fails  to  do  it.  Moreover,  while  the  patient  lies  with  the  back  uppermost,  a  free  oppor- 
tunity is  afforded  for  the  efficient  application  of  local  treatment,  to  prevent  the  develop- 
ment of  consecutive  spinal  meningitis  and  myelitis. 

Parker*  mentions  the  case  of  a  man  who  was  struck  on  the  back  by  a  falling  door, 
and  sustained  dislocation  of  the  last  dorsal  on  the  first  lumbar  vertebra,  with  slio-ht 
fracture.  There  were  paralysis,  priapism,  etc.  Reduction  was  accomplished,  with  an 
audible  sound,  by  making  extension  and  counter-extension,  under  chloroform.  After 
several  months  the  patient  recovered,  and,  when  discharged,  could  walk  with  a  cane. 
(Ashhurst.)  It  is  important  to  note  that,  notwithstanding  there  was  priapism  in 
this  case,  recovery  ensued.  The  dislocation  was  reduced  by  making  extension  and 
counter-extension,  under  chloroform.  I  think  the  best  plan  for  the  surgeon  to  pursue, 
on  failing  to  reduce  such  a  dislocation  by  the  patient's  position  in  bed,  would  generally 
be  to  relax  the  muscles  completely  by  anjesthesia,  and,  then,  to  effect  the  reduction  by 
means  of  extension  and  counter-extension  steadily  made  by  his  assistants,  with  lateral 
pressure  locally  applied  by  himself. 

Brodie*  refers  to  the  case  of  a  man,  injured  by  a  mass  of  chalk  falling  upon  him. 
The  first  lumbar  vertebra  projected  backward  over  the  last  dorsal.  The  dislocation  was 
reduced  with  some  difficulty  by  Mr.  Hardwicke.  The  reduction  was  attended  by  a 
*' jerk  or  snap."  The  patient  was  relieved  ;  but,  after  two  or  three  years,  partial  paral- 
ysis still  remained.  (Ashhurst.)  No  doubt,  in  this  case  likew'ise,  the  reduction  was 
accomplished  by  making  extension  and  counter-extension. 

Smith^  mentions  a  case  of  Schmucker's,  in  which  a  soldier  was  injured  by  a  wall 
falling  on  his  back.    He  w^as  stunned  ;  there  was  displacement  backward  of  the  last 

*  Traite  des  Fract.  et  des  Luxat.,  t.  ii.  2  Desault,  Jouni.  de  Chir.,  t.  iii. 

'  New  York  Journal  of  Med.,  1852.  *  Med. -Chir.  Trans.,  vol.  x^c.  p.  157. 

6  New  York  Journal  of  Med.,  1852. 

VOL.  IV. — 22 


338  INJURIES  OF  THE  BACK. 

dorsal  and  first  lumbar  vertebrae,  and  dyspnoea.  The  displacement  was  reduced  by 
extension  and  pressure.    In  six  weeks  the  man  recovered.  (Ashhurst.) 

Crowfoot  reports^  the  case  of  a  coachman,  aged  42,  who  in  driving  under  an  arch 
struck  the  back  of  his  neck  against  a  beam.  There  was  displacement  forward  of  the 
ninth  dorsal  vertebra,  and  of  the  tenth,  backward,  with  paralysis.  He  was  treated  by 
continuous  extension  with  success,  and  resumed  his  occupation  in  one  year;  slight 
deformity,  however,  remained.  (Ashhurst.) 

After  reduction,  should  the  displacement  reappear,  and  particularly  if  the 
dislocated  bone  should  manifest  a  disposition  to  slip  out  of  place  again,  it 
will  be  advisable  to  make  the  extension  continuous,  which  may  be  done  in 
several  different  w^ays ;  but,  probably,  with  the  least  amount  of  trouble,  by 
raising  the  head  of  the  bedstead  upon  blocks  so  as  to  make  of  the  bed  itself 
an  inclined  plane  sloping  downward  to  the  foot,  when,  by  attaching  with  a 
suitable  band  the  upper  part  of  the  patient's  body  to  the  head  of  the  bedstead, 
the  desired  result  would-be  obtained.  Continuous  extension  might  also  be 
advantageously  employed  in  cases  where  attempts  at  immediate  reduction 
had  failed,  with  a  reasonable  hope  that,  under  its  influence  aided  by  the 
patient's  posture  in  bed,  the  luxated  bone  would  be  induced  to  slip  into  place 

again.  -,     n  i 

To  sum  up  this  branch  of  the  treatment— the  surgeon  should  seek  to  restore 
the  displaced  vertebra  to  its  normal  position  by  some  one  of,  or,  should  the 
occasion  require,  by  all  the  means  of  effecting  reduction  which  have  just  been 
pointed  out,  that  is,  by  arrano;ing  the  patient's  posture  in  bed,  upon  the  back 
or  upon  the  belly,  according  to  the  case ;  by  making  extension  and  counter- 
extension,  under  anaesthetics,  with  the  help  of  skilled  assistants ;  or  by 
making  continuous  extension,  which  the  surgeon  can  generally  accomplish 
without  skilled  help. 

Having  fulfilled  the  first  therapeutical  indication,  the  surgeon  must  at  once 
take  care  that  the  paralyzed  bladder  does  not  become  over-filled  with  urine ; 
for,  should  this  occur,  much  harm  would  ensue.  To  this  end,  catheterization 
must  be  cautiously  practised  at  least  twice  a  day,  with  a  soft  instrument ; 
and,  at  each  time,  the  surgeon  should  cautiously  compress  the  paralyzed  blad- 
der with  his  own  hand,  applied  to  the  abdominal  walls  of  the  patient,  m  order 
to  secure  a  complete  evacuation  of  the  viscus ;  for  any  urine  that  might  be 
allowed  to  remain  in  it  would,  by  undergoing  decomposition,  cause  unneces- 
sary mischief.  Vesical  and  even  renal  inflammation  may  readily  ensue  in 
these  cases.  But  this  subject  will  be  found  to  be  more  fully  discussed  under 
the  head  of  Disorders  of  the  Urinary  Organs  arising  from  Lesions  of  the 
Spinal  Cord.  . 

The  surgeon  must  also  take  care  that  the  patient  is  provided  with  such  a 
bed  as  will  least  favor  the  occurrence  of  bed-sores  ;  the  best  is  a  water-bed,  the 
next  best  a  good  hair  mattress.  The  surgeon  must  at  every  visit  examine 
the  private  parts  and  buttocks  of  the  patient,  in  order  to  see,  for  himself,  that 
they  are  kept  dry  and  clean,  and  are  not  inflamed,  and  that  no  gangrenous 
bleb  nor  eschar  is  forming.  Motions  of  the  bowels,  when  needed,  should  be 
procured  by  enemata  rather  than  by  purgatives.  Immediately  after  a  motion, 
the  parts  should  be  completely  freed  from  feces  by  carefully  wiping  them,  and 
then  they  should  be  cleansed  by  applying  a  spirit-lotion  containing  two  per 
cent,  of  carbolic  acid.  This  topic,  however,  will  be  more  fully  discussed 
under  the  head  of  Sacral  Eschars  and  Acute  Bed-Sores  arising  from  Lesions 
of  the  Spinal  Cord.  i     i,  • 

The  occurrence  of  consecutive  meningitis  and  myelitis  must  also  be  obvi- 
ated aft  much  as  possible.    I  have  already  shown  by  a  brief  mention  of  seven 


1  Trans.  Prov.  Med.  and  Surg.  Assoc.,  1853. 


DISLOCATIONS  OF  THE  VERTEBRA. 


339 


examples,  and  by  a  reference  to  many  others,  that  there  exists,  in  every  case 
of  spinal  dislocation  or  fracture,  a  more  or  less  strong  tendency  for  consecutive 
inflammation  of  the  spinal  membranes  or  spinal  cord  to  ensue,  and  that  in 
such  cases  the  consecutive  inflammation  of  the  spinal  membranes  or  spinal 
cord,  by  itself,  not  unfrequently  causes  death.  Moreover,  I  shall  presently 
show  that  consecutive  inflammations  of  the  spinal  membranes  and  spinal 
cord,  of  this  sort,  always  much  increase  the  severity  of  the  urinary  symp- 
toms and  of  the  bed-sores  which  are  met  with  in  cases  of  vertebral  dislocation 
and  vertebral  fracture,  and  that  the  prevention  of  these  inflammations  must 
be  ranked  among  the  most  efiicient  means  at  our  disposal  for  controlling  these 
mihappy  complications  of  spinal  injury.  Thus,  one  is  enabled  to  perceive 
how  important  the  fulfilment  of  the  last-mentioned  therapeutical  indication 
really  is. 

Xow,  this  indication  is  to  be  accomplished,  that  is,  inflammation  of  the 
bruised  and  torn  spinal  meninges  and  spinal  cord  is  to  be  obviated  or  con- 
trolled :^  (1)  by  reducing  the  vertebral  displacement,  as  already  directed  ;  (2) 
by  keeping  the  spinal  column  in  a  state  of  perfect  rest,  or  as  nearly  immovable 
as  possible,  after  the  reduction  has  been  efi:ected  ;  (3)  should  the  patient's  pos- 
ture in  bed  permit,  by  drawing  blood  from  the  injured  part  by  leeches  or  cups, 
and  by  applying  dry  cold,  by  means  of  an  ice-bag,  with  compresses  interposed, 
and,  subsequently,  by  the  employment  of  counter-irritants.  But,  whatever 
the  patient's  posture  in  bed,  opium  or  morphia  should  be  administered  with 
suflicient  freedom  to  allay  pain  and  procure  sleep,  as  already  stated ;  and  by 
keeping  the  patient  somewhat  under  the  influence  of  this  drug  until  nature 
has  repaired  the  breaches,  much  good  can  be  done  in  the  way  of  controlling 
any  inflammatory  action  which  may  arise  in  the  injured  meninges;  and, 
probably,  in  the  spinal  cord  also.  Potassium  iodide,  in  doses  of  five  grains 
every  four  hours,  belladonna  in  full  doses,  and  fluid  extract  of  ergot,  half  a 
fluidrachm  three  times  a  day,  will  often  prove  to  be  very  useful  remedies  for . 
traumatic  myelitis,  as  well  as  for  traumatic  spinal  meningitis. 

But,  in  attempting  to  reduce  dislocations  of  the  dorsal  and  lumbar  verte- 
br8e,  is  there  not  considerable  danger  that  the  spinal  cord  may  be  injured  by 
the  eflibrts  of  the  surgeon  himself?  Many  a  person,  doubtless,  will  be  inclined 
to  answer  this  question  aflirmatively,  without  much  reason  or  reflection. 
Experience,  however,  has  shown  that  this  danger  is  more  hypothetical  than 
real.  For  example,  reduction  was  effected  in  fourteen  cases  of  displacement 
from  injury  of  the  dorsal  or  lumbar  vertebrae,  Avhich  are  mentioned  in  Dr. 
Ashhurst's  tables.  In  eleven  instances  the  displacement  occurred  in  the  dorsal 
region ;  in  three  in  the  lumbar.  Seven  patients  recovered,  two  were  relieved, 
and  five  died.  Of  the  cases  in  which  the  issue  was  successful  I  will  not  fur- 
ther speak ;  but  the  fatal  ones  I  will  briefly  relate : — 

(1)  Higginson^  is  credited  with  the  case  of  a  man,  aged  34,  injured  in  the  spine  so 
that  there  was  projection  of  the  lumbar  vertebrae  one  inch  beyond  the  dorsaL  Reduc- 
tion was  accomplished  by  making  extension,  under  chloroform,  with  relief  to  the  symp- 
toms. In  four  weeks,  however,  he  died  ;  no  account  is  given  of  the  autopsy.  (Ash- 
hurst.)  (2)  Bryant^  mentions  the  case  of  a  laborer  under  Mr.  Ccck's  care,  aged  34, 
who  fell  from  a  scaffold  across  a  wall.  There  were  pain,  paralysis,  priapism,  and  delbrmity 
in  the  lower  part  of  the  spine.  The  last  was  removed  by  making  extension  and  pres- 
sure. At  the  end  of  eight  months  deatli  occurred.  The  autopsy  showed  dislocation  for- 
ward of  the  eleventh  dorsal  vertebra  and  fracture  of  the  twelfth;  the  cause  of  death  is 
not  stated.  (Ashhurst.)  (3)  Holmes^  relates  the  case  of  a  young  man,  aged  19, 
struck  on  the  loins  by  faUing  timber.  The  last  dorsal  vertebra  was  dfslocated.  °It  was 
reduced  by  extension,  and  the  reduction  was  attended  by  an  audible  sound.    No  relief 


J  British  Medical  Journal,  1862. 
^  Ibid.,  vol.  2. 


2  Proc.  Path.  Soc.  London,  vol.  viii. 


340 


INJURIES  OF  THE  BACK. 


ensued.  Death  occurred  twenty-three  days  after  the  accident.  The  autopsy  showed  dis- 
location witli  slight  fracture  of  the  twelfth  dorsal  vertebra,  fracture  of  the  first  lumbar 
vertebra,  and  secondary  deposits  in  both  knee-joints.  (Ashhurst.)  (4)  Luke^  refers  to 
the  case  of  a  man  having  fracture  of  the  seventh  dorsal  vertebra,  with  displacement, 
which  was  reduced  by  extension,  the  reduction  being  accompanied  by  an  audible 
sound.  Death  from  erysipelas  occurred  seven  days  after  the  injury.  The  spinal  cord 
was  found  to  be  softened  and  disorganized  ;  there  was  purulent  matter.  (Ashhurst.) 
(5)  Birkett^  relates  the  case  of  a  man,  aged  31,  who  fell  into  the  hold  of  a  ship, 
striking  his  back,  and  dislocating  the  lower  part  of  the  spinal  column.  The  fascia  was 
torn  off  from  several  dorsal  spines,  and  there  was  paralysis,  etc.  Extension  under  chlo- 
roform gave  no  relief;  it  was  followed  by  great  pain.  At  the  end  of  four  and  a  half 
months  death  ensued.  The  autopsy  showed  displacement  of  the  eleventh  from  the  twelfth 
dorsal  vertebra,  with  fracture  of  the  articular  processes ;  spinal  cord  disorganized  ;  sup- 
puration of  the  kidneys.  (Ashhurst.) 

In  but  one  of  these  five,  cases  can  it  be  asserted  with  any  plausibility  that 
the  efforts  at  reduction  were  themselves  attended  by  any  misadventure  what- 
ever. In  the  last  case,  the  employment  of  extension  did  not  relieve  the  symp- 
toms, and  was  followed  by  severe  pain.  Still  death  did  not  occur  until  four 
and  a  half  months  afterward;  and,  whether  the  advent  of  the  pain  was 
merely  a  coincidence,  or  not,  it  is  certain  that  the  use  of  extension  was  not, 
per  se,  attended  by  any  destructive  lesion.  In  the  other  four  examples,  death 
was  caused  by  erysipelas,  by  septicaemia,  and,  probably,  by  myelitis. 

Moreover,  three  cases  of  vertebral  fracture  with  considerable  displacement 
are  related  by  Professor  Konig,  of  Gottingen,  in  the  Centralblatt  fiir  Chirur- 
gie,  No.  7, 1880,  in  each  of  which  the  deformity  was  corrected  by  suspending 
the  patient,  without  any  bad  effect ;  and,  in  No.  46  of  the  same  journal,  we 
find  a  paper  by  Dr.  W.  Wagner  that  tells  of  two  similar  cases.  All  five 
patients  recovered.^  .     .     ,  . 

Thus,  we  perceive,  that  the  experience  recorded  on  this  point  is  already 
rather  voluminous,  and  that  it  decidedly  favors  the  employment  of  judicious 
and  intelligently  directed  efforts  to  reduce  the  displacements  in  cases  of  dorsal 
and  lumbar  dislocations  and  fractures,  as  well  as  in  those  of  the  cervical  region. 


Fractures  of  the  Vertebra. 

Men  suffer  from  traumatic  lesions  of  the  vertebrae,  from  fractures  as  well 
as  from  dislocations  of  these  bones,  much  more  frequently  than  women,  because 
the  former,  by  their  occupations,  are  much  more  exposed  to  the  various  acci- 
dents in  life  which  cause  these  lesions,  than  the  latter. 

Fractures  of  the  vertebra  may  be,  (1)  simple,  (2)  compound,  (3)  comminuted, 
and  (4)  complicated.  By  a  pure  fracture  is  meant  a  simple  fracture,  which  is 
not  complicated  with  a  dislocation.  Compound  fractures  of  the  vertebrae  are 
chiefly  caused  by  the  impact  of  gunshot  missiles.  Gunshot  fractures  ot  the 
vertebrae  are  of  frequent  occurrence.  They  constitute  a  special  class  of  inju- 
ries, and  will  be  separately  considered.  All  forms  of  spinal  fracture  are 
frequently,  but  not  necessarily,  complicated  with  injury  of  the  spinal  cord, 
as  well  as  with  dislocation.  i  .  i 

An  inspection  of  the  recorded  cases  of  spinal  injury  involving  the  vertebrae 
and  not  caused  by  gunshot  missiles,  that  is,  of  the  recorded  cases  which 
occur  in  civil  life,  shows  that  the  lesions  consist  of  pure  fractures  in  about 
one-fifth  of  the  instances,  of  pure  dislocations  in  another  one-fifth,  and  of 
dislocations  combined  with  fractures  in  the  remaining  three-fifths. 


1  Lancet,  1850.  ^  British  Medical  Journal,  1859. 

3  Medical  News  and  Abstract,  1881,  p.  105. 


FRACTURES  OF  THE  VERTEBRA. 


341 


Pure  fractures  of  the  vertebrEe  are  of  rather  infrequent  occurrence  in  the 
cervical  region.  Of  36  cases  observed  at  Guy's  Hospital,  and  mentioned  by 
Mr.  Bryant,  in  which  the  cervical  vertebrae  were  injured,  there  ^^'as  no  ex- 
ample of  pure  fracture,  while  there  were  11  examples  of  pure  dislocation, 
and  25  examples  of  fracture  combined  with  dislocation.  Still,  pure  frac- 
tures of  the  cervical  vertebrje  are  sometimes  met  with.  '  I  have  already 
presented  one  instance,  and  shall  mention  several  others.  But  it  is  in  the 
dorsal  and  lumbar  regions  that  most  cases  of  pure  fracture  of  the  vertebrae 
are  found,  the  very  regions  in  which  pure  dislocations  of  the  vertebrae 
least  frequently  occur.  However,  pure  fractures  fall  much  short  of  the  ma- 
jority in  even  these  regions ;  for,  of  18  cases  in  which  the  dorsal,  and  2  cases 
in  which  the  lumbar  vertebrae  were  injured,  that  were  observed  at  Guy's 
Hospital,  and  are  mentioned  by  Mr.  Bryant,  nearly  tw^o-thirds  appear  to  have 
been  examples  of  fracture  and  dislocation  combined. 

In  the  25  cases  of  cervical  fracture  combined  with  dislocation  that  were 
noted  at  Guy's  Hospital,  the  lesion  was  below  the  third  cervical  vertebra  in 
all  but  three  examples.  In  one  of  these,  it  involved  the  second,  third,  and 
fourth  cervical  vertebrae ;  in  another,  the  arch  of  the  atlas  and  the  spinous 
processes  of  the  second  and  third  vertebrae ;  and,  in  the  third  case,  the  bodies 
and  laminae  of  the  third,  fourth,  and  lifth  cervical  vertebrae. 

In  the  18  dorsal  cases,  of  all  sorts,  seven  were  in  the  upper  and  eleven  in 
the  lower  half  of  the  dorsal  region.  Thus,  it  seems  clear  that  the  lower  parts 
of  both  the  cervical  and  the  dorsal  regions  are  much  more  liable  to  fracture 
and  dislocation  than  the  upper  parts. 

The  following  case  w^ill  serve  to  illustrate  the  most  common  form  of  frac- 
ture combined  w^ith  dislocation,  which  is  met  with  in  the  cervical  region: — 

On  the  morning  of  November  10,  1852,  an  unknown  man,  but  poorly  clad,  was 
found  lying  dead  on  the  cellar-bottom  of  an  unfinished  house  at  the  corner  of  Franklin 
Street  and  Broadway,  where  it  seems  that  he  had  fallen  from  the  street,  some  time 
during  the  previous  night.  Autopsy,  by  the  writer,  at  the  Sixth  Ward  Station  House, 
at  11  A.  M.,  for  the  coroner. — Rigor  mortis  strong.  Head  and  neck  bent  far  forward. 
Spinous  processes  of  the  sixth  and  seventh  cervical  vertebrae  movable.  On  exposing 
them  by  a  free  incision,  the  muscular  and  connective  tissue  around  the  sixth  and 
fieveuth  cervical  vertebrae  was  found  extensively  infiltrated  with  blood.  The  spinous 
process  of  the  seventh  cervical  (vertebra  prominens)  was  broken  short  off.  The 
laminae  of  the  sixth  cervical  vertebra  w^ere  fractured  at  a  little  distance  from  the 
spinous  process  of  that  vertebra,  which  accounts  for  the  mobility  of  this  s[)inous  process 
also.  The  body  of  the  sixth  cervical  vertebra  was  luxated  forward  from  that  of  the 
seventh.  The  intervertebral  substance,  the  anterior  and  posterior  common  ligaments, 
the  capsular  ligaments,  and  the  ligamenta  subflava  were  all  torn  tlu'ough.  The  spinal 
cord  was  crushed  by  the  displacement,  and  the  theca  vertebralis  contained  much  blood. 
Externally,  the  tlieca  was  coated  with  blood. 

The  fractures  of  the  laminae  of  the  sixth,  and  of  the  spinous  process  of  the  seventh  ver- 
tebra, were  doubtless  caused  by  striking  the  back  part  of  the  neck,  at  its  root,  upon  the 
hard  cellar-bottom  ;  the  laceration  of  the  ligaments,  and  tlie  displacement  forward  of 
the  body  of  the  sixth  vertebra  from  that  of  the  seventh,  doubtless  resulted  from  the 
extreme  degree  of  flexion  to  wiiich  the  spinal  column  was  simultaneously  subjected  at 
the  root  of  the  neck. 

Death  quickly  ensued,  because  of  the  cerebral  concussion  which  attended  the  fall, 
and  because  of  the  shock  which  arose  from  the  crushing  of  the  spinal  cord;  but  prin- 
cipally because  of  the  extravasation  of  blood  within  the  theca  vertebralis,  which  speedily 
paralyzed  the  cord,  by  compressing  it,  as  high  as  the  roots  of  the  phrenic  nerves  above 
the  third  vertebra,  and  thus  completely  arrested  the  respiratory  movements. 

This  case  is  offered  as  an  illustration,  because,  in  most  cases  of  fracture 
combined  with  dislocation  that  are  observed  in  the  cervical  region,  the 
laminae,  or  the  spinous  or  transverse  processes,  are  fractured,  the  ligamenta 


342 


INJURIES  OF  THE  BACK. 


subflava,  the  capsular  ligaments,  and  the  intervertebral  disk  are  lacerated 
(more  or  less),  and  the  body  of  the  upper  vertebra  is  thrown  forward  from 
that  of  the  lower. 

In  the  following  example  death  suddenly  resulted  from  falling  upon  the 
back  in  such  a  way  as  to  crush  three  dorsal  vertebrae,  together  with  the  spinal 
cord : — 

Peter  Riley,  a  laborer,  fell  from  the  walls  of  Trinity  Chapel,  then  being  built,  on 
Saturday,  November  27,  1852.  He  went  down  perpendicularly  a  distance  of  about 
fifty  feet,  and  struck  his  back  squarely  across  a  beam.  When  picked  up  by  his  com- 
rades immediately  afterward,  he  spoke  tenderly  of  his  mother  and  sisters,  and  said 
"  my  back  is  broke."  He  died  in  about  twenty  minutes.  At  the  autopsy  I  found  the 
fourth,  fifth,  and  sixth  dorsal  vertebrae  much  comminuted,  that  is,  broken  into  many 
fragments.  The  muscles  covering  them  were  badly  bruised  and  torn,  and  contained 
much  extravasated  blood.  The  skin,  however,  was  not  broken.  An  incision  through 
the  skin  having  been  made,  the  soft  parts  investing  these  vertebrae  were  found  so  much 
disintegrated  that,  after  picking  out  some  fragments  of  broken  bone,  I  thrust  my  fingers 
with  ease  directly  through  the  spinal  column  into  the  right  pleural  cavity.  The  theca 
vertebralis  and  the  spinal  cord  must  also  have  been  torn  asunder. 

The  speediness  with  which  death  followed  the  injury  in  this  case  was  due 
to  shock,  caused  by  the  extent  and  severity  of  the  spinal  lesion  itself,  and 
to  internal  hemorrhage  from  the  intercostal  arteries  that  were  torn,  and,  per- 
haps, from  other  sources.  Professor  Ashhurst^  mentions  a  case  taken  from 
the  Pennsylvania  Hospital  Eecords,  which  is  somewhat  similar  to  the  last : — 

A  laborer  fell  from  the  sixth  story,  and  thereby  sustained  a  comminuted  fracture  of 
the  lumbar  vertebras,  fracture  of  the  coccyx,  and  fractures  of  both  legs.  Death  ensued 
in  one  day  from  exhaustion  and  internal  (post-peritoneal)  hemorrhage. 

But  comminuted  fractures  of  the  dorsal  or  lumbar  vertebrae  may  be  attended 
by  rupture  of  the  aorta,  and  death  from  internal  hemorrhage  may  follow  in 
the  course  of  a  few^  minutes.    Several  examples  of  this  sort  are  on  record : — 

(1)  Forster^  mentions  a  case  of  Roper's,  in  which  a  man,  aged  55,  was  knocked  down 
and  driven  against  by  an  omnibus.  He  was  stunned,  and  in  five  minutes  he  died. 
Fracture  of  the  fourth  lumbar  vertebra  and  laceration  of  the  aorta  were  found.  (2) 
Curling^  mentions  the  case  of  a  rigger,  aged  54,  who  fell  from  masthead  to  deck,  and 
died  in  fifteen  minutes.  The  autopsy  showed  fractures  at  the  first,  second,  and  third 
lumbar  vertebrse,  with  rupture  of  the  aorta.  (3)  Curling*  also  reports  the  case  of  a 
wagoner,  aged  46,  supposed  to  have  been  run  over  by  a  wagon.  He  died  in  a  few 
minutes.  The  autopsy  showed  fractures  of  the  eighth,  ninth,  and  tenth  dorsal  vertebrae ; 
the  aorta  was  ruptured.  In  such  instances,  however,  the  nature  of  the  accident  can 
often  be  correctly  surmised  from  the  seat  of  the  fracture  and  the  grating  of  the  frag- 
ments, together  with  the  sudden  appearance  of  the  signs  of  internal  hemorrhage,  such 
as  a  wax-tike  pallor  of  the  countenance;  lips  bloodless,  or  dark-purple  at  their  margins; 
cold  sweats  ;  weak,  frequent,  small,  fluttering  pulse  ;  syncope,  etc.,  ending  quickly  in 
death  ;  but  without  any  external  flow  of  the  extravasated  blood. 

Comminuted  fractures  of  the  dorsal  or  lumbar  vertebrae  are  sometimes 
found  to  be  compound,  in  consequence  of  the  integuments  and  muscles  being 
lacerated  by  the  same  exhibition  of  force  which  has  caused  the  fractures  them- 
selves. Such  fractures,  probably,  result  most  frequently  from  being  crushed 
in  railway  collisions.  "  Brief  mention  is  made  in  the  reports  of  some 
instances  of  compound  fracture  of  the  spine  from  railway  accidents."^  ^o 
details,  however,  of  these  instances  are  published ;  but,  such  cases  must 

1  Op.  cit.,  pp.  116,  117.  2  proc.  Path.  Soc.  London,  vol.  viii. 

3  London  Hosp.  Reports,  vol.  i.  ^  Ibid. 

6  Circular  No.  3,  S.  G.  0.,  Aug.  17,  1871,  p.  129. 


FRACTURES  OF  THE  VERTEBRiE. 


343 


almost  inevitably  prove  fatal,  and  all  that  the  surgeon  can  do  for  them  is  to 
mitigate  suffering  by  administerining  opiates  and  stimulants. 

The  following  example  will  serve  to  illustrate  one  dangerous  sequel  which 
sometimes,  perhaps  often,  presents  itself  in  cases  of  simple  vertebral  fracture, 
namely,  traumatic  myelitis : — 

Private  John  Hackey,  Co.  E,  6th  Cavalry,  aged  30,  received,  at  Fort  Waco,  Texas, 
March  5,  1870,  by  falling  from  the  second  floor  of  a  building  occupied  as  barracks,  a 
fracture  of  the  fourth  cervical  vertebra.  Complete  paralysis,  both  sensory  and  motor, 
of  the  lower  extremities,  and  of  most  of  the  trunk  and  upper  extremities,  immediately 
ensued.  He  was  admitted  to  hospital  without  delay.  But,  on  the  morning  of  the  7th, 
he  died  of  acute  myehtis,  about  forty-eight  hours  after  the  accident.  His  intelligence 
remained  unimpaired  throughout.    The  treatment  was  sedative  and  stimulant.^ 

The  paraplegia  which  immediately  ensued,  in  this  case,  appears  to  have 
been  due  to  concussion  of  the  spinal  cord,  for  no  mention  is  made  of  com- 
pression of  the  cord  from  displacement  of  bone  nor  from  any  other  cause. 
The  symptoms  of  concussion  ran  quickly  into  the  symptoms  of  acute  inflam- 
mation of  the  spinal  cord,  and  death  soon  ensued. 

In  the  following  instructive  case,  there  occurred  simple  fracture  of  the  fifth 
cervical  vertebra,"without  displacement  of  the  fragments,  and  compression  of 
the  spinal  cord  from  extravasation  of  blood  at  and  around  the  seat  of  frac- 
ture : — 

Private  Emmet  J.,  Co.  A,  5th  Infantry,  aojed  19,  in  diving  from  the  bank  of  the 
Arkansas  River,  near  Fort  Lyon,  Colorado,  July  3,  1868,  for  the  purpose  of  bathing, 
struck  his  head  against  the  bottom,  and  immediately  became 
powerless  in  the  legs  and  arms.    He  would  have  drowned  had  Fig.  860. 

no  help  been  given.  He  was  carried  on  a  stretcher  to  the  hos- 
pital, lying  on  his  abdomen.  Upon  admission,  at  1  P.  M., 
the  pulse,  respiration,  and  temperature  (although  not  counted) 
seemed  normal;  the  pupils  were  unaffected;  there  was  priap- 
ism. Power  soon  returned  to  his  arms,  although  it  was  feeble. 
His  extremities  remained  warm  ;  and,  when  touched,  sensa- 
tion was  found  more  acute,  that  is,  less  blunted,  in  the  left  than 
in  the  right  leg.  He  complained  of  feeling  dead  below  the 
neck.  ^  No  irregularity  or  distortion  of  the  spine  was  revealed 
by  a  careful  examination  ;  but,  there  was  tenderness  over  the 
fifth  cervical  vertebra.  A  sinapism  was  applied  to  the  nape 
of  his  neck  ;  and,  in  an  hour,  he  asked  to  be  turned  over,  that 
is,  on  to  the  back.  At  5  P.  M.  the  pulse  was  104  ;  respiration 
18;  temperature  105°.    Ice  was  applied  to  the  upper  part  of 

the  spine,  a  saline  aperient  was  prescribed,  and  small  pieces  of  g^owin^  fracture,  ^vithout 
ice  given  to  be  held  in  the  mouth.  At  9  P.  M.  the  pulse  was  100  ;  displacement,  of  the  body  of 
respiration  24  ;  temperature  102'^  ;  he  was  catheterized,  and  the  fifth  cervical  vertebra, 
placed  on  a  water-bed.  On  the  morning  of  the  4tli,  the  pulse,  (Spec.  5724,  Sect,  i,  a.  m.  m.) 
respiration,  and  temperature  were  all  lessened.  Cold  applica- 
tions to  the  spine  were  continued  in  the  form  of  iced  water,  and  the  catheter  was  used 
twice  during  the  day.  At  5  P.  M.  the  bowels  were  moved  involuntarily.  On  the  5th, 
the  temperature  sank  considerably  below  the  normal  (Fig.  861);  sensation  in  the  lower 
extremities  was  abolished  ;  and  the  respiration  was  abdominal,  that  is,  diaphragmatic. 
Dry  rubbings  were  prescribed,  with  tonics,  and  nutritious  food.  On  the  6th,  sensation 
had  partly  returned  to  the  left  leg,  and  the  breathing  was  better,  there  being  more 
movement  of  the  chest.  By  the  11th,  the  patient  was  able  to  pass  his  urine  without  a 
catheter,  but  sensibility  did  not  return  to  the  right  leg.  On  the  morning  of  the  13th, 
he  had  a  chill,  which  recurred  on  the  morning  of  the  14th,  and  again  in  the  afternoon. 
After  this,  his  countenance  became  dusky,  and  the  temperature  rose  during  the  next 

1  Circular  No.  3,  S.  G.  0.,  Aug.  17,  18"1,  p.  129. 


344 


INJURIES  OF  THE  BACK. 


three  or  four  days.  He  had  not  perspired  since  the  injury.  On  the  morning  of  the 
18th,  the  urine  became  turbid,  the  stomach  was  irritable,  and  he  complained  of  his 
lungs  feeling  like  stone.  By  the  morning  of  the  20th,  the  pulse  had  become  so  feeble 
that  it  could  not  be  counted,  the  bowels  were  loose,  the  urine  was  ammoniacal  and 


Fig. 


Thermograph  of  a  fatal  case  of  fracture,  without  displacement,  of  the  fifth  cervical  vertebra. 

thick  with  mucus,  and  vomiting  occurred.  Increased  respiration  and  a  very  high 
temperature  (105°)  followed.  On  the  21st,  catheterization  had  again  to  be  employed, 
but  the  instrument  was  used  with  difficulty,  owing  to  the  formation  of  coagula  in  the 
bladder.  He  also  suffered  from  bed-sores.  By  the  24th,  his  stomach  became  so 
irritable  as  to  retain  scarcely  anything.  On  the  25th,  there  was  complete  anorexia. 
On  the  26th,  the  temperature  was  91.8°.  He  died  at  noon  on  the  28th.  Autopsy. 
Brain  normal.  The  body  of  the  fifth  cervical  vertebra  was  found  fractured  (Fig.  860). 
There  was  no  displacement  of  the  vertebra.  It  was  ascertained  that  hemorrhage 
had  compressed  the  spinal  cord  at  and  around  the  seat  of  fracture.  In  the  dorsal 
reo-ion,  the  spinal  canal  showed  no  abnormity,  excepting  the  spinal  fluid  which 
escaped.  It  was  filled  with  transparent,  floating  globules,  and  resembled  volatile-oil 
water.  Lungs  healthy,  excepting  the  posterior  portions,  which  were  hypostatically 
congested  ;  liver  slightly  enlarged.  Splenic  extremity  of  stomach  congested.  The 
kidneys  were  enlarged  and  engorged  with  blood  ;  the  pelvis  of  the  left  was  filled 
with  pus ;  but  no  other  abscess  could  be  found.  Tiie  ureters  were  very  dark  m  color, 
and  one  of  them  contained  a  clot  at  the  entrance  to  the  bladder.  The  walls  of  the 
bladder  were  dark-purple  in  color,  inflamed,  and  thickened  ;  its  mucous  membrane 
was  absent  in  patches.  The  pathological  specimens  were  sent  to  the  Army  Medical 
Museum.^ 

Viewing  the  clinical  history  of  this  case  in  the  light  thrown  upon  it  from 
the  autopsy,  the  paralysis  which  instantly  followed  the  injury  appears  to  have 
been  due  to  concussion  of  the  spinal  cord,  and  it  may  well  be  that  injuries  ot 
a  similar  character,  involving  the  upper  part  of  the  spinal  column,  axe  often 
attended  by  spinal  concussion.    However,  the  paralytic  symptoms  that  were 


I  Circular  No.  3,  S.  G.  0.,  August  17,  1871,  pp.  129-131. 


FRACTURES  OF  THE  VERTEBRi?:.  ^^^^ 


due  to  concussion  soon  began  to  pass  away,  and  on  the  follownig  day  were 
succeeded  by  the  symptoms  of  compression  of  the  spinal  cord,  caused  by 
hemorrhage  into  the  spinal  canal,  which  increased  in  severity  until  sensibdity 
as  well  as  motor  power  was  abolished  in  the  lower  part  of  the  body,  the  res- 
piration becoming  diaphragmatic  from  paralysis  of  the  other  respiratory 
muscles,  and  the  patient's  temperature  sinking  to  95.8°  on  the  mornnig  ot 
the  second  day.  Then,  the  hemorrhage  having  ceased,  the  absorption  ot  the 
extravasated  blood  was  immediately  commenced,  and  it  was  continued  with 
so  much  activity  that  on  the  following  day,  July  6,  sensation  had  ijartly 
returned  to  the  left  leg,  and  the  respiration  was  better,  for  all  of  the  chest- 
muscles  again  participated  in  the  respiratory  movements.  By  the  11th,  he 
was  so  much  improved  that  his  micturition  was  entirely  voluntary.  But  the 
sensibility  did  not  return  to  his  right  leg,  and  this  circumstance  showed  that 
the  conducting  filaments  of  the  spinal  cord  itself  were  considerably  injured, 
probably  by  contusion  and  ecchymosis  of  the  cord-substance.  On  the  13th, 
or  two  days  later,  consecutive  spinal  meningitis  and  myelitis  began  with  a 
chill,  after  which  the  patient's  temperature  rose  considerably  above  the  nor- 
mal,'and  his  countenance  became  dusky  from  vaso-motor  paralysis.  By  the 
20th,  the  inflammatorv  lesion  of  the  spinal  cord  and  membranes  was  attended 
by  trophic  lesions  of  the  urinary  bladder  and  kidneys,  and  of  the  soft  parts 
over  the  sacrum  and  buttocks,  which  will  hereafter  be  described  under  the 
head  of  Acute  Bed-sores,  and  of  Disorders  of  the  Urinary  Organs  from  Le- 
sions of  the  Spinal  Cord.  The  blood  found  in  the  bladder  on  the  21st  had 
probably  flowed  into  that  ora;an  through  the  ureters  from  the  kidneys.  The 
patient's  stomach  soon  gave  out  entirely,  and  in  a  few  days  more  he  sank  ex- 
hausted from  vesical  and  renal  inflammation,  and  from  acute  bed-sores. 

The  thernio2:raph  of  this  case  (Fig.  861)  shows  at  a  glance  three  remarkable 
periods  of  depression  in  the  temperature,  the  first  of  which  corresponded  to 
the  compression  of  the  spinal  cord  by  extravasated  blood  (July  3  and  4) ;  the 
second,  to  the  invasion  of  the  spinal  cord  and  spinal  meninges  by  consecutive 
inflammation  (July  12,  13,  14);  and  the  third,  to  the  occurrence  of  exhaus- 
tion as  the  end  drew  near.  After  the  first  and  second  periods  of  depression, 
the  temperature  rose  considerably.  ^  -i  g  -o 

By  what  symptoms  externally  perceptible  was  this  fracture  attended  i  By 
one  only,  to  wit— by  tenderness  under  pressure  over  the  fifth  cervical  ver- 
tebra. In  the  absence,  however,  of  distortion  or  deformity,  or  other  evidence 
of  luxation,  the  presence  of  fracture  should  be  suspected  in  cases  such  as 
this.  But  the  occurrence  of  spinal  paralysis  under  such  circumstances  should 
not,2jer  se,  cause  a  fracture  of  the  vertebrse  to  be  surmised,  since  the  paralysis 
might  just  as  well  result  from  concussion  or  contusion  of  the  spinal  cord,  as 
it  did  in  fact  at  the  outset  of  this  case.  The  spinal  column  was  suddenly  bent 
until  it  broke  at  the  fifth  cervical  vertebra,  but  the  fragments  instantly  sprang 
back  into  place  again.  At  the  same  moment,  the  spinal  cord  was  bent, 
stretched,  and  bruised  ;  the  spinal  arteries  were  ruptured,  hemorrhage  there- 
from ensued,  and  thus  the  symptoms  of  compression  readily  succeeded  the 
symptoms  of  concussion  of  the  spinal  cord. 

Besides  these  dano:ers,  that  is,  contusion  and  compression  of  the  spinal  cord, 
together  with  spinaf  meningitis  and  myelitis,  fractures  of  the  upper  cervical 
vertebra  are  attended  by  others.  Should  the  cord  be  crushed,  or  even  pierced, 
above  the  roots  of  the  phrenic  nerves  by  a  fragment  of  displaced  bone,  the 
respiratory  movements  would  at  once  cease  entirely,  because  the  respiratory 
muscles  would  all  be  paralyzed,  and  death  from  asphyxia  would  immediately 
ensue.  This  accident  not  unfrequently  happens,  and  the  victims  thereof  but 
seldom,  comparatively,  receive  the  attention  of  surgeons.  Abernethy,  how- 
ever, is  credited  with  mentioning  the  case  of  a  coal-heaver  who  fell  from  a 


346 


INJURIES  OF  THE  BACK. 


wagon  while  drunk.  There  was  no  apparent  injury  ;  still,  he  could  not  rise 
in  bed  ;  and,  in  turning  his  head  to  be  shaved,  he  suddenly  died.  Fracture 
of  a  cervical  vertebra  was  found ;  and  the  cord  was  penetrated  by  a  splinter. 
The  lesion  must  of  course  have  been  not  lower  than  the  third  cervical 
vertebra. 

Professor  William  Pepper^  relates  the  case  of  a  girl,  aged  19,  who  broke  her  neck 
by  falling  from  a  pie-cherry  tree,  and  was  admitted  to  the  Pennsylvania  Hospital  twenty- 
four  hours  afterward.  All  power  to  move  the  extremities  and  muscles  of  the  trunk  was 
gone.  Sensation,  too,  was  entirely  lost  from  a  little  below  the  clavicle  downward. 
There  was  retention  of  feces  and  urine  ;  the  bladder  was  much  distended,  no  urine 
having  been  passed  since  the  accident.  The  respiration  was  entirely  diaphragmatic^ 
and  32.  The  fades  indicated  great  respiratory  oppression.  Pupils  normal;  intellect 
clear ;  voice  feeble,  and  frequently  interrupted  ;  the  tongue  could  be  protruded  at  will, 
and  moved  in  any  direction.  The  cheeks  were  brightly  flushed  and  very  hot.  The 
skin  everywhere  was  much  hotter  than  normal ;  pulse,  small  and  frequent ;  temperature 
in  axilla,  108.5°.  "She  abruptly  asked  to  be  raised  in  bed ;  her  breathing  became 
gulping  and  imperfect,  and  in  less  than  two  minutes  she  fell  back  dead."  Pulsation 
was  still  perceptible  at  the  wrist  almost  one  minute,  and  the  cardiac  sounds  were  yet 

audible  between  three  and  four  minutes,  after  the  last  respiration.    Autopsy  The 

tissues  surrounding  the  cervical  vertebrae  were  ecchymosed,  and  infiltrated  with  bloody 
serum,  but  no  blood  had  escaped  into  the  pharynx.  There  was  a  comminuted  fracture 
of  the  atlas,  the  lateral  masses  being  separated  and  the  arches  broken  in  two  places^ 
The  fourth  vertebra  was  luxated  anteriorly  from  fracture  of  the  articular  processes. 

The  paraplegia  which  attended  the  accident  was  due  to  the  forward  luxa> 
tion  of  the  fourth  cervical  vertebra.  The  flushing  of  the  face,  and  the  great 
elevation  of  the  body-heat  were  due  to  vaso-motor  paralysis  which  resulted 
from  injury  of  the  sympathetic  nerve.  The  sudden  death  was  caused  by  punc- 
turing the  spinal  cord  with  fragments  of  the  broken  atlas,  and  compressing 
it  against  the  odontoid  process  of  the  axis.  E'ot  improbably,  the  girl's  head 
slipped  forward  on  the  summit  of  the  spinal  column,  when  she  was  raised  up 
in  bed.  The  same  accident  occurred  to  this  patient,  on  being  raised  up  in  bed, 
as  befell  one  of  Mr.  Hilton's  patients  and  nearly  happened  to  another  (whose 
cases  have  already  been  mentioned),  where  the  ligaments  belonging  to  the 
articulatio  capitis  had  been  so  extensively  destroyed  by  disease,  as  to  allow 
the  head  to  slip  forward  and  compress  the  spinal  cord,  with  deadly  effect, 
against  the  odontoid  process  of  the  axis.  The  sudden  death  of  the  patient 
w^hose  case  has  just  been  related  shows,  that  the  same  care  is  needed  in  cases 
of  injury  and  in  cases  of  disease  of  the  first  vertebra,  alike,  if  the  spinal  cord 
be  liable  to  sudden  compression  from  the  slipping  or  falling  forward  of  the 
head,  in  consequence  of  the  injury  or  the  disease. 

The  following  example  teaches  the  same  important  lesson : — 

Dr.  H.  F.  Eberman,^  reports  the  case  of  a  man,  aged  about  70,  who,  while  descend- 
ing the  steps  from  a  hay-loft,  slipped  and  fell,  striking  his  occiput  violently  on  the 
ground,  and  forcibly  bending  his  head  forward  on  to  his  chest.  He  lay  insensible,  for 
a  considerable  time.  But,  after  recovering  from  the  stunning,  he  arose,  and  placing 
both  hands  to  his  neck,  walked  to  the  bar-room  of  the  hotel  (half  a  square  from  the 
place  of  accident),  where  he  remarked  that  he  thought  his  neck  was  hurt,  asked  for  a 
glass  of  whisky,  and  drank  it.  Then,  he  returned  to  the  stable,  and  lay  down  on  some 

hay  ;  in  about  half  an  hour  he  expired.    Autopsy  The  transverse  process  on  the  riglit 

side  of  the  atlas  was  found  to  be  broken  off ;  the  third  cervical  vertebra  was  fractured 
transversely  through  its  body,  the  right  arch  was  broken  entirely  through,  and  the 
articulating  processes  on  both  sides  were  fractured  through  the  middle  ;  the  inter-spinous 
and  posterior  vertebral  ligaments  were  ruptured  ;  but  the  spinal  cord  remained  intact. 

A  Am.  Joiirn.  Med.  Sciences,  April,  1867,  pp.  438,  439. 
«  Ibid.,  October,  1879,  p.  590. 


FRACTURES  OF  THE  VERTEBRiE. 


347 


The  sudden  death  of  this  man,  too,  was  due  no  doubt  to  a  compression  of 
the  spinal  cord  against  the  odontoid  process  of  the  axis,  which  w^as  sudde:il 
caused  by  the  elevating  or  thrusting  forward  of  his  head,  and  the  subsidence 
of  his  neck,  that  would  naturally  occur  when  he  turned  over  upon  his  back, 
as  he  lay  flat  on  the  hay,  without  a  pillow  to  keep  the  nape  ot  his  neck 
raised  up  sufficiently  to  avoid  such  a  calamity.  This  displacement  ot  tlie  frag- 
ments of  the  broken  atlas,  etc.,  could  have  been  avoided  by  placing  a  small  firm 
pillow  under  the  patient's  neck,  when  putting  him  to  bed,  and  by  confining 
his  head  and  neck  in  a  fixed  position  by  means  of  heavy  sand-bags  so  placed 
on  either  side  thereof  as  to  prevent  all  motion  in  the  neck,  as  recommended 
by  Mr.  Hilton  in  analogous  cases  of  cervical  disease.  Had  such  a  procecd- 
ino-  been  instituted,  in '  this  case,  and  continued  until  consolidation  of  the 
fractures  had  been  effected,  recovery  no  doubt  would  have  ensued.  Lhe 
following  example  shows  not  only  that  this  view  is  correct,  but  also  that 
spontaneous  recovery  from  similar  fractures  sometimes  occurs : — 

A  man,  aged  32,  fell  from  a  hay-wagon,  striking  his  occiput  on  the  ground,  and  was 
stunned.^  He  walked  half  a  mile  to  visit  a  surgeon  ;  in  three  days  he  resumed  work  ; 
his  neck  was  stiff,  and  there  was  tumefaction  over  the  axis ;  after  several  months,  dys- 
phagia and  tumefaction  in  the  pharynx  appeared.  Nevertheless,  he  recovered  ;  and, 
about  one  year  and  a  half  after  the  accident  he  died  of  pleurisy.  The  autopsy  showed 
fractures  of  the  atlas  and  odontoid  process  of  the  axis.  (Ash hurst.) 

As  a  symptom  of  the  fractures  of  the  atlas  and  third .  cervical  vertebra 
which  had  occurred  in  Dr.  Eberman's  case,  it  may  be  mentioned  that  the  man 
walked  with  a  hand  placed  on  each  side  of  his  neck,  apparently  in  order  to 
support  it.  Sir  Astley  Cooper^  relates  a  case  of  simple  fracture  of  the  atlas, 
that  was  under  the  elder  Cline's  care,  in  which  the  same  symptom  was  pre- 
sent : — 

"  A  girl  received  a  severe  blow  upon  her  neck  ;  after  which  it  was  observed  that, 
whenever  she  wanted  to  look  at  any  object,  either  above  or  below  her,  she  alw^ays  sup- 
ported her  head  with  her  hands,  and  then  gradually  and  carefully  elevated  or  de- 
pressed it,  according  as  she  wished,  towards  the  object.  After  any  sudden  shock  she 
used  to  run  to  a  table,  and  placing  her  hands  under  her  chin,  rest  them  against  the  table, 
until  the  agitation  caused  by  the  concussion  had  subsided.  Twelve  months  after  the 
accident  the  child  died  ;  and  on  examination,  a  transverse  fracture  of  the  atlas  was 
found,  but  no  displacement.  AVhen  the  head  was  depressed  or  elevated,  the  dentiform 
process  of  the  second  vertebra  became  displaced,  carrying  with  it  a  portion  of  the  atlas, 
and  occasioning  pressure  on  the  spinal  marrow,  which  was  also  produced  by  any  violent 
agitation." 

Fractures  of  the  odontoid  process,  as  a  rule,  suddenly  destroy  life ;  the  vic- 
tims being  literally  pithed  by  that  process.  This  accident  often,  but  not 
always,  proves  instantly  fatal. 

For  example,  Melcliiori^  mentions  the  case  of  a  woman,  aged  68,  who  was  killed  by 
falling  from  a  ladder  and  striking  her  forehead  on  the  ground.  Death  was  instanta- 
neous. Dissection  showed  fractures  of  the  atlas  and  odontoid  process  of  the  axis;  and 
the  atlas  was  displaced  backward.  (Ashhurst.) 

When,  how^ever,  it  happens  that  the  fragments  of  the  broken  odontoid 
process  are  not  displaced  sufficiently  to  injure  the  spinal  cord,  the  patient 
may  survive  until  such  a  displacement  is  produced  by  some  accident  or  other, 
as  doubtless  occuii^-ed  in  the  following  instance : — 

Richet*  relates  the  case  of  a  man,  aged  22,  who  attempted  suicide  by  a  pistol-shot  in 
the  neck.    He  survived  the  injury  for  seventeen  days,  during  which  time  he  could 


'  Am.  Journ.  Med.  Sciences,  0.  S.,  vol.  xxiii. 

3  Gaz.  Medica  Stati  Sardi,  1850, 


2  Lectures,  vol.  ii.  p.  8. 
4  These  de  Concours,  1851. 


348 


INJURIES  OF  THE  BACK. 


move  only  by  supporting  his  head  with  his  hands.  Death  suddenly  occurred.  Dissec- 
tion showed  fracture  of  the  odontoid  process.  (Ashhurst.) 

Professor  Willard  Parker,  of  New  York,  some  years  ago,  had  the  case  of  a  milkman, 
aged  40,  who  was  injured  by  being  thrown  from  a  wagon  about  fifteen  feet,  and  striking 
his  head  and  face  on  the  ground.  There  was  pain  in  the  neck  and  a  protuberance  on 
the  left  side  thereof.  He  could  not  turn  his  head,  but  supported  it  with  his  hands.  He 
got  so  well  that  he  resumed  his  milk  business,  and  survived  the  injury  for  five  months. 
He  died  suddenly,  after  a  hard  day's  work,  on  the  fragments  becoming  displaced  by  an 
accident,  his  head  dropping  forward  upon  his  chest,  at  the  table,  to  such  a  degree  as  to 
compress  the  spinal  cord.  Dissection  showed  fracture  of  the  odontoid  process  ;  and  the 
lower  end  turned  back  to  the  spinal  cord. 

This  patient  would  have  recovered  had  he  but  kept  his  head  and  neck  at 
perfect  rest  until  consolidation  of  the  fracture  had  ensued.  In  the  following 
example  recovery  did  take  place,  and  some  time  afterward  the  man  died  of  a 
non-surgical  disorder : — 

Mr.  B.  Phillips^  had  under  his  care  a  laborer,  aged  32,  injured  by  falling  head  fore- 
most from  a  hay-rick.  In  a  little  while  he  was  able  to  arise.  In  two  days  he  went  to 
work  again.  A  month  afterwards,  he  walked  two  miles  to  consult  his  surgeon.  His 
neck  was  stiff,  there  was  a  protuberance  at  the  back  of  the  pharynx,  with  some  difficulty 
in  swallowing,  but  no  paralysis.  One  year  after  the  accident  he  died  from  dropsy.  The 
autopsy  showed  fractures  of  the  atlas  and  odontoid  process,  with  displacement  of  some 
pieces  forward  against  the  pharynx ;  the  occipital  bone  had  settled  down  on  the  axis, 
and  formed  a  new  joint ;  the  spinal  cord  was  unhurt.  The  spinal  foramen  in  the  first 
and  second  vertebras  is  quite  large  ;  and,  therefore,  these  bones  may  be  extensively 
damaged  without  seriously  injuring  the  spinal  cord. 

Mr.  R.  Debenham'^  also  mentions  a  case  in  which  the  odontoid  process  was  fractured, 
and  recovery  followed.  The  subject  was  a  shoemaker,  and  the  lesion  was  verified  by 
dissection  two  years  after  the  accident.  Cases  in  which  the  odontoid  process  w^as  spon- 
taneously fractured,  that  is,  fractured  in  consequence  of  disease,  have  been  reported  by 
Hyrtl,  by  Else,  and  by  Flint ;  and,  in  each  instance,  death  occurred  instantaneously.^ 

Professor  Stephen  Smith,  in  an  article  on  "  Fracture  of  the  Odontoid  Pro- 
cess,"'^ has  collected  tw^entj-two  cases.  Six  occurred  spontaneously,  in  con- 
sequence of  disease,  and  all  ended  fatally  except  one,  in  which  a  portion  of  the 
bone  was  discharged  through  the  throat ;  four  were  gunshot  cases,  all  fatal ; 
seven  were  caused  by  external  violence,  all  likewise  fatal ;  five  were  cases  in 
which  a  portion  of  the  bone  had  been  discharged,  w^ith  four  recoveries  and 
one  death  ;  aggregating  but  five  recoveries  and  seventeen  deaths.  Dr.  Smith 
has  found,  by  experiment,  that,  although  the  odontoid  process  is  not  fractured 
by  being  driven  against  the  transverse  ligament  on  the  anterior  arch  of  the 
atlas,  the  odontoid  ligaments  combined  are  stronger  than  the  odontoid  process, 
and  "  that  the  efficient  agents  in  this  fracture  are  the  odontoid  ligaments."  The 
odontoid  process  has  been  fractured  from  violence  dii-ectly  applied ;  and  from 
external  violence  indirectly  applied,  e.g.^  to  the  forehead,  to  the  side  of  the 
head,  and  to  the  back  part  of  the  neck.  The  s3miptoms  of  this  accident 
are  pain  and  stiffness  in  the  neck,  swelling  in  the  region  of  the  first  and 
second  vertebrse,  and  a  protuberance  in  the  pharynx  at  the  same  region ;  but, 
probably,  the  chief  symptom  is  that  the  patient  carries  the  head  supported 
on  the  two  hands.  This  symptom,  however,  has  been  observed  in  cases  where 
the  occipito-atloid  articulation,  that  is,  the  articulatio  capitis^  has  been  disrupted, 

»  Medico-Chirurgical  Transactions,  vol.  xx.  p.  78. 
2  London  Hosp.  Reports,  vol.  iv.  p.  210. 

*  P.  Bevan  (Dublin  Med.  Press,  February,  1863)  reports  a  case  in  which  there  was  fracture  of 
the  odontoid  process,  perfect  anchylosis  of  its  apex  with  the  occipital  bone,  and  partial  luxation 
forward  of  the  atlas.    (New  Syd.  Soc.  Year-book,  1864,  p.  280.) 

^  American  Journal  of  the  Medical  Sciences,  October,  1871,  pp.  338-58. 


FRACTURES  OF  THE  VERTEBRiE. 


349 


as  well  as  in  cases  where  the  bones  forming  the  atlo-axoicl  articulations  have 
been  broken  ;  and,  generally,  it  denotes  that  either  the  atlas,  or  the  axis,  or 
both  of  these  bones  are  fractured.^ 

"  Latent  Fracture  of  the  Spine,''  as  Mr.  Simon  has  denominated  an  important 
lesion  of  the  spinal  column  which  occasionally  presents  itself  to  surgeons, 
must  also  be  considered  in  connection  with  those  fractures  of  the  vertebrae 
which  are  attended  by  but  little  or  no  displacement  of  the  fragments.  In  the 
examples  of  so-called  latent  fracture  of  the  vertebrje,  the  spinal  cord  is  not  at 
all  affected  by  concussion,  nor  by  contusion,  nor  is  it  compressed  by  displaced 
bone,  nor  by  extravasated  blood.  The  breach,  in  these  cases,  usually  consists 
of  a  linear  fracture  through  the  body  of  a  cervical  or  a  dorsal  vertebra.  On 
the  withdrawal  of  the  force  which  iissures  the  bone,  the  fragments  at  once 
sprino-  back  into  place  again.  The  patient  complains  only  of  pain,  soreness, 
and  stiffness  in  the  injured  part  of  the  spine,  for  some  days ;  and,  perhaps, 
havino-  returned  to  work,  continues  at  the  same  until  the  symptoms  ol  sup- 
purative inflammation  present  themselves  at  the  seat  of  the  fracture,  and 
until  an  abscess  forms  in  the  spinal  canal  between  the  theca  vertebralis  and 
the  bone,  as  well  as  external  to  the  bone,  in  the  same  locality,  ihese  cases 
are  strictly  analogous  to  those  of  circumscribed  abscess  occurring  between 
the  dura  mater  and  the  bone,  in  consequence  of  a  linear  fracture  ol  the  skull, 
which  have  often  been  observed  in  latent  injuries  of  the  head.  As  subcra- 
nial abscesses  not  unfrequently  cause  death,  per  se,  by  compressing  the  bram, 
even  so  these  cases  may  terminate  in  death  by  compression  ot  the  spinal  cord, 
without  the  occurrence  of  that  diffused  traumatic  spmal  meningitis  or  myelitis 
which  often  supervenes,  as  we  have  already  shown,  in  cases  ot  verteoral  trac- 
ture  or  dislocation.  Mr.  Simon^  relates  an  instructive  example  ot  the  spmal 
lesion  in  question : — 

A  crirl,  ao-ed  18,  injured  her  neck  by  faUing,  in  the  dark,  about  twelve  feet  down  an 
embankment.  At  first  she  was  stunned.  Afterward  she  walked  home,  a  distance  ot 
about  three  miles.  She  resumed  work,  and  remained  thereat  for  eleven  days,  bhe 
entered  St.  Thomas's  Hospital  on  the  fifteenth  day  after  the  accident,  on  account  of  severe 
pain  in  her  neck,  with  fever,  etc.  No  displacement  nor  irregularity  of  the  spine  could 
be  detected.  There  was  no  anaesthesia  nor  paralysis.  Her  complaints  of  pain  and 
tenderness  were  vague.  She  chiefly  spoke  of  suffering  between  the  shoulders  ;  turning 
over  into  a  prone  position  in  bed  was  accomplished  slowly,  stifily,  and  with  cries.  i.arly 
on  the  sixteenth  day,  she  complained  of  numbness  and  twitching  in  her  limbs,  particu- 
larly in  the  lower ;  in  the  evening,  voluntary  motion  was  lost  completely  in  the  legs,  and 
nearly  in  the  arms;  sensibility  was  hkewise  very  much  impaired  in  both.  Delirium, 
"  iumpino-  of  the  le^^s,"  and  tympanitic  distension  of  the  abdomen,  as  well  as  high  fever 
now  appeared.  On  the  eighteenth  day  she  died.  Autopsy.  30  hours  after  death—''  A 
horizontal  line  of  fracture  was  found  traversing  the  body  of  the  seventh  cervical  vertebra, 
just  above  its  inferior  surface.  Beyond  a  very  little  gaping  in  front,  which  would  allow 
the  edo-e  of  a  scalpel  to  be  insinuated  flatly  between  the  fragments,  there  was  not  the 
slicrhtelt  displacement ;  and  the  posterior  common  ligament  was  untorn.  Ihe  spinal 
canal  contained  between  the  osseous  walls  and  the  dura  mater  [theca  vertebralis]  a  large 
quantity  of  pus,  which,  from  two  inches  below  the  foramen  magnum,  descended  the 
whole  lena-th  of  the  cord.  At  the  several  intervertebral  holes  it  had  crept  somewhat 
along  the  Issuing  nerve-sheaths,  and,  between  the  first  and  second  dorsal  vertebras  had 

I  But  fracture  of  the  axis  unattended  by  any  notable  displacement  may  prove  quickly  fatal, 
by  causing  hemorrhage  into  the  spinal  canal,  and  compression  of  the  spinal  cord  therefrom,  as 
happened  in  the  following  instance  :  Arnott  (Lancet,  1851)  reported  the  case  of  a  man,  aged 
74,  iniured  in  the  neck  by  falling  down  stairs.  There  was  paralysis  of  the  upper  extremities, 
but  not  of  the  lower.  In  one  hour  death  ensued.  Dissection  showed  fracture  of  the  spnious  pro- 
cess  of  the  axis  ;  the  fragment  was  wedged  in  between  the  axis  and  the  third  vertebra.  There 
was  effusion  of  blood  in  the  vertebral  canal.  (Ashhurst.) 

«  Transactions  of  the  Pathological  Society  of  London,  vol.  vi.  p.  42. 


350 


INJURIES  OF  THE  BACK. 


actually  emerged,  following  the  subdivision  of  the  first  dorsal  nerve,  so  as  to  spread 
among  the  exterior  parts.  These  burrowings  of  matter  were  cut  into  before  the  [spi- 
nal] canal  was  opened.  .  .  .  The  outer  surface  of  the  [spinal]  dura  mater  was 
roughened  by  inflammatory  deposits  ;  but  none  were  found  within  it ;  nor  was  there  any 
softening,  or  microscopical  change  in  the  spinal  cord.  No  other  disease  was  discov- 
ered." 

The  fracture  of  the  seventh  cervical  vertebra  was  called  latent,  or  concealed, 
in  this  case,  because  it  was  not  attended  by  deformity,  nor  by  any  other 
symptom  of  special  import,  for  a  considerable  number  of  days.  Meanwhile, 
the  connective  tissue  lying  between  the  theca  vertebral  is  and  the  bone  became 
inflamed,  commencing  at  the  fracture,  and  purulent  matter  in  great  quantity 
was  formed  and  collected  in  this  tissue,  whereby  the  spinal  cord  was  com- 
pressed through  the  medium  of  the  theca ;  but  life  was  not  destroyed  until 
the  intra-vertebral  abscess  had  burrowed  upward  far  enough  to  compress  and 
paralyze  the  respiratory  centres,  thus  arresting  completely  the  respiratory 
movements  and  causing  death  by  asphyxia.  The  abscess  external  to  the  spi- 
nal column  was  not  large  in  this  case.  In  other  instances,  however,  the  exte- 
rior abscess  is  found  to  be  quite  large,  and  to  burrow  extensively  in  the  soft 
parts  around  the  spinal  column,  as  was  noted  in  the  following  instance  : — 

Sir  B.  C.  Brodie^  mentions  the  case  of  a  man,  aged  45,  who  fell  from  a  scaffold  and 
injured  his  back.  There  was  paralysis,  foUow^ed  by  convulsions.  Death  ensued  nine 
weeks  after  the  accident.  Dissection  showed  fracture  of  the  fourth  dorsal  vertebra ; 
the  spinal  cord  was  compressed  and  softened  ;  an  abscess  arising  from  the  seat  of  the 
fracture  extended  into  the  posterior  mediastinum.  (Ashhurst.) 

It  is  not  the  fracture  itself  which  destroys  life  in  these  cases  of  latent  ver- 
tebral injury,  but  the  consecutive  inflammation  and  abscess ;  and,  if  these 
untowarcl  consequences  of  such  injuries  be  averted,  complete  recovery  will 
ensue.  The  symptoms  directly  after  the  injury,  in  cases  of.  latent  fracture 
of  the  spinal  column,  closely  resemble  those  which  are  met  with  in  sprains 
or  wrenches  of  the  vertebral  joints,  caused  by  blows  on  the  back,  falling,  etc. 

Mr.  Bryant^  mentions,  in  point,  the  case  of  a  woman  admitted  into  Guy's  Hospital, 
under  Mr.  Cock's  care,  for  some  injury  of  the  back  caused  by  falling  out  of  a  window. 

Beyond  the  contusion,  no  injury  could  be  made  out."  She  died,  however,  of  cerebral 
disease  sixteen  days  after  the  accident.  Dissection  showed  that  the  last  dorsal  and 
three  upper  lumbar  vertebrae  were  fractured  through  their  bodies,  but  not  displaced  ; 
one  or  two  spinous  processes  were  also  fractured.  The  spinal  marrow  was  uninjured. 
The  fact  of  there  being  no  displacement  of  the  broken  bones,  and  no  injury  of  the  spinal 
cord,  had  prevented  the  making  of  a  correct  diagnosis  in  this  case. 

But  examples,  such  as  this,  of  vertebral  fracture  wherein  the  diagnosis  is 
not  made  until  the  post-mortem  examination,  are  not  uncommon.  It  is, 
therefore,  rather  important  for  the  surgeon  to  bear  the  latter  fact  in  mind 
while  treating  cases  of  supposed  sprains,  wrenches,  and  twists  of  the  vertebral 
joints,  and  to  enforce,  in  all  doubtful  cases,  that  absolute  quietude  of  body — that 
freedom  from  all  movement,  particularly  in  the  injured  portion  of  the  spinal 
column — which  is  necessary  in  order  to  secure  consolidation  of  the  fracture 
without  accident,  should  this  lesion  perchance  be  present. 

In  cases  of  vertebral  fracture  occurring  in  the  dorsal  region,  it  should  be 
stated  that  displacement  of  the  fragments  is  measurably  prevented  by  the 
ribs  acting  as  splints  placed  on  each  side  of  the  spinal  column.  In  the  lumbar 
region,  likewise,  the  great  lumbar  muscles  may  act  powerfully  in  the  way  of 
preventing  and  removing  displacement,  in  cases  of  vertebral  fracture,  unat- 
tended by  dislocation,  as  the  following  example  will  show : — 


1  Medico-Chirurgical  Transactions,  vol.  xx. 


2  Op.  cit.,  p.  202. 


FRACTURES  OF  THE  VERTEBRAE. 


851 


Corporal  John  B.,  Company  C,  10th  N(nv  York  Volunteers,  March  11,  1865,  at 


Fig.  86'. 


Pure  or  simple  transverse  fracture  of 
the  first  lumbar  vertebra,  caused  by  the 
limb  of  a  tree  falling  upon  the  loins  and 
back  of  a  soldier.  (Spec.  149,  Sect.  I, 
A.  M.  M. 


Hatcher's  Run,  Va.,  was  struck  across  the  dorsal  and  lumbar  regions  hv  the  fallinff 
limb  of. a  tree  which  liad  been  severed  by  a  sl»ell.  He 
was  knocked  senseless,  and  remained  so  an  liour  or 
more,  until  he  Avas  awakened  by  the  jolting  of  the  am- 
bulance that  carried  him  to  regimental  headquarters. 
On  regaining  consciousness,  he  was  unable  to  move 
the  lower  portion  of  his  body,  and  complained  of  pain 
in  the  same  parts.  He  was  cupped,  and  had  mustard 
applied  to  the  calves  of  his  legs  and  to  the  spinal 
re<yion.  The  symptoms  still  continuing,  he  was  blis- 
tered, and  the  blisters  were  dressed  with  lint.  On  the 
19th,  he  entered  Finley  Hospital,  at  Washington  ;  he 
was  then  semi-comatose  ;  there  was  complete  motor 
paraplegia,  but  sensation  was  perfect.  There  was 
some  febrile  action,  pulse  full  and  bounding,  and  very 
severe  diarrhoea  ;  feces  and  urine  passed  involuntarily; 
botli  legs  were  very  cold,  the  left  slightly  more  than 
the  right ;  skin  moist,  the  blistered  parts  on  each  leg 
were  suppurating  slightly.  The  parts  in  the  region  of 
the  sacrum  were  gangrenous.  Opiates  were  given  at 
night,  and  chlorides  used  to  cleanse  the  gangrenous 
sore  over  the  sacrum.  Under  the  administration  of 
astringents,  the  diarrhoea  ceased  by  the  25th.  The 
patient,  however,  continued  to  sink,  and  died  on  the 
29th,  apparently  from  exhaustion  (septicaemia?). 

Autopsy.— The  first  lumbar  vertebra  was  found  fractured  entirely  through  its  body 
at  the  upper  third  (Fig.  862),  with  each  pedicle  broken,  and  the  left  transverse  and 
spinous  processes  impinging  against  the  spinal  cord,  which  was  lacerated  at  the  lumbo- 
dorsal  junction.  The  spinal  meninges  were  torn  entirely  across,  excepting  a  few  fibres 
anteriorly  and  posteriorly,  and  were  congested  above  and  below  the  rent.  Blood-clots 
were  found  diffused  in  the  tissues  around  the  fracture.  The  spinal  cord  was  lacerated 
in  a  singular  manner,  and  a  wood-cut  representing  it  (Fig.  879)  is  given  on  p.  397. 

In  this  example,  the  fracture  of  the  vertebral  column,  although  it  extended 
completely  through  the  same  (Fig.  862),  and  constituted  a  false  point  of  motion, 
appears  to  have  not  been  recognized  until  the  examination  after  death.  The 
principal  cause  of  this  failure  to  make  a  diagnosis,  appears  to  have  been  the 
fact  that  there  was  no  appreciable  displacement.  Thus,  the  spinal  symptoms 
were  supposed  to  arise  from  concussion  of  the  spinal  cord ;  and  the  illusion 
itself  was  furthered  by  the  fact  that  the  paralysis  was  motor,  but  not  sensory. 
The  occurrence  of  displacement  seems  to  have  been  prevented  by  the  action 
of  the  lumbar  muscles. 

Three  cases  of  pure  fracture  of  the  dorsal  and  lumbar  vertebrae  are  mentioned  by 
Mr.  Bryant.^  In  one  of  them  the  fourth  and  fifth  dorsal  vertebrae  were  comminuted  ; 
in  another,  the  eighth,  ninth,  and  tenth  were  fractured  through  their  bodies  and  lamin-ce  ; 
and,  in  the  third,  the  twelfth  dorsal  and  three  upper  lumbar  vertebrae  were  extensively 
broken.  In  one  of  them  certainly,  and  in  all  of  them  possibly,  no  displacement  was  to  be 
detected  by  an  external  examination.  The  fragments  appear  to  have  been  held  in  posi- 
tion by  the  ribs,  and  by  the  great  muscles  which  are  in  relation  with  the  spinal  column 
in  the  dorsal  and  lumbar  regions. 

Bat  in  other  instances  of  pure  dorsal  and  lumbar  fractures,  the  displace- 
ment of  the  fragments  is  such  that  it  can  readily  be  perceived  on  making  an 
external  examination.    For  example  : — 

Dr.  H.  J.  Bio-elow^  gives  the  case  of  a  young  woman,  aged  19,  who  jumped  from  a 


'  New  Syd.  Soc.  Retrospect,  18fi7-8.  p.  276. 

^  Am.  Journ.  of  tlie  Med.  Sciences,  N.  S.  vol.  xxi. 


362 


INJURIES  OF  THE  BACK. 


second-story  window,  and  alighted  upon  her  buttocks,  thereby  fracturing  her  spine. 
There  was  a  projection  of  the  lower  dorsal  vertebrae  and  paralysis.  The  latter  dinain- 
ished  after  two  weeks,  and  partial  recovery  ensued.  In  eight  and  a  half  months,  how- 
ever, she  died  of  phthisis.  The  autopsy  showed  fractures  of  the  last  dorsal  and  of  the 
first  and  second  lumbar  vertebrae  ;  the  spinal  cord  was  compressed  ;  provisional  callus 
had  formed.  (Ashhurst.)  It  is  worthy  of  special  note,  in  this  case',  that  the  patient  par- 
tially recovered,  and  that  the  disease  which  caused  her  death  was  not  connected  with 
the  injury. 

Fractures  combined  with  dislocation  often  occur  in  the  dorsal  region.  They 
generally  take  place  between  the  tenth,  eleventh,  and  twelfth  dorsal  vertebrae. 
In  such  cases  the  body  of  the  superior  vertebra  is  usually  dislocated  forward, 
and  the  body  of  the  inferior  vertebra  fractured  ;  the  arch  of  the  inferior  ver- 
tebra is,  as  a  rule,  also  broken.  (Bryant.)  A  specimen  showing  dislocation 
of  the  first,  and  fracture  of  the  second  lumbar  vertebra,  taken  from  a  patient 
who  had  survived  the  accident  for  three  and  a  half  years,  is  described  and 
figured  by  Mr.  W.  Wagstafte.^ 

Fractures  of  the  spinous  processes,  unattended  by  dislocation  or  by  frac- 
ture of  any  other  portions  of  the  vertebrae,  that  is,  pure  fractures  of  the 
spinous  processes,  not  unfrequently  occur.  They  are  met  with  in  the  cervical, 
the  dorsal,  and  the  lumbar  regions  alike,  and  are  always  caused  by  the  direct 
application  of  force.  They  may  be  simple  or  compound;  and  compound 
fractures  of  the  spinous  processes  are  often  caused  by  the  impact  of  small- 
arm  missiles.  Grenerally,  pure  fractures  of  the  spinous  processes  are  not 
attended  by  spinal  paralysis.  When,  however,  spinal  symptoms  are  present, 
in  such  cases,  they  usually  arise  from  concussion  of  the  spinal  cord,  though, 
in  some  rare  instances,  they  have  been  found  to  be  due  to  compression  of  the 
spinal  cord  by  extravasated  blood.  Generally,  pure  fractures  of  the  spinous 
processes,  whether  simple  or  compound,  terminate  in  recovery  without  giving 
much  trouble.  I  have  seen  a  considerable  number  of  examples  belonging 
to  the  latter  category ,2  and  cannot  now  call  to  mind  any  case  among  them 
that  did  not  end  favorably.  In  one  instance,  there  was  severe  concussion  of 
the  spinal  cord  also,  and  a  fragment  of  the  broken  spinous  process  exfoliated. 
The  experience  of  other  observers  supports  the  view  that  pure  fractures  of 
the  spinous  processes  generally  terminate  in  recovery  without  much  difficulty. 

Sir  A.  Cooper^  mentions  the  case  of  a  boy  injured  by  thrusting  his  head  between  the 
spokes  of  a  wheel.  There  was  distortion  of  the  spine,  and  fracture  of  three  or  four 
spinous  processes,  but  no  paralysis.  "  He  quickly  recovered  without  any  particular 
attention."    The  deformity,  however,  remained.  (Ashhurst.) 

"  When  I  was  a  dresser,"  says  Mr.  Bryant,  "  I  saw  a  case  of  fracture  of  the  spinous 
processes  of  three  cervical  vertebrae  associated  with  a  temporary  paralysis ;  and,  in  this 
instance,  complete  recovery  ensued ;  I  have  since  successfully  treated  a  case  of  frac- 
ture and  displacement  of  the  spinous  process  of  the  fourth  cervical  vertebra,  without 
paralysis.  .  .  .  I  have  seen  also  a  case  of  fracture  of  the  spinous  processes  of  the 
last  dorsal  and  first  lumbar  vertebrae  with  lateral  displacement,  the  injury  having  been 
treated  for  some  months  previously  as  a  simple  contusion  of  the  back.  In  this  case,  no 
paralysis  existed  or  other  spinal  symptoms."* 

On  the  other  hand,  when  perchance  the  broken-ofF  portion  of  the  spinous 
process  gets  impacted  between  the  laminae,  and  presses  upon  the  spinal  cord, 
death  sometimes  quickly  ensues. 

1  Trans,  of  the  Patholog.  Soc.  of  London,  vol.  xxi.  p.  327. 

2  Am.  Journal  of  the  Med.  Sciences,  October,  1864,  pp.  315,  327. 
^  Disloc.  and  Fract.  of  .Joints. 

*  Practice  of  Surgery,  p.  201. 


FRACTURES  OF  THE  VERTEBRA. 


353 


For  example,  Mr.  Ericbsen  mentions  the  case  of  a  woman  admitted  into  Univer- 
sity College  Hospital,  with  an  injury  of  the  neck,  the  nature  of  which  could  not  be 
accurately  ascertained.  She  was  in  no  way  paralyzed,  but  kept  her  head  in  an  im- 
movably Hxed  position.  A  few  days  after  admission,  wliilst  sitting  up  in  bed,  being 
startled  by  a  noise,  she  suddenly  turned  her  head,  and  fell  back  dead.  Dissection  showed 
that  the  spinous  process  of  the  fifth  cervical  vertebra  was  broken  off  short  at  its  root, 
and  was  impacted  in  such  a  way  between  the  arches  of  this  and  the  arches  of  the  fourth 
vertebra  as  to  compress  the  cord.^  The  impaction  of  the  fragment  and  the  compression 
of  the  spinal  cord  probably  occurred  at  the  instant  of  the  involuntary  movement  of  the 
head. 

I  have  already  presented,  in  a  foot-note,  a  somewhat  similar  case  of  Mr.  Arnott's, 
in  which  a  man,  aged  74,  fell  down  stairs  and  injured  his  neck.  There  was  paralysis 
of  the  upper  extremities,  but  not  of  the  lower.  In  one  hour  death  ensued.  Dissection 
showed  that  the  spinous  process  of  the  axis  was  fractured,  and  that  the  fragment  was 
wedged  in  between  the  axis  and  the  third  vertebra  ;  there  was  also  effusion  of  blood  in 
the  vertebral  canal,  which  probably  caused  death  by  compressing  the  cord.  Notwith- 
standing these  exceptions,  the  rule  concerning  the  result  in  cases  of  pure  fracture  of 
the  spinous  processes,  is  as  already  stated,  namely,  that  they  generally  end  in  recovery. 
Professor  Agnew  mentions  the  case  of  a  young  man,  under  his  own  care,  in  which  the 
detached  portion  of  a  spinous  process- remained  for  several  months  movable,  finally 
became  necrosed,  and  was  discharged  through  a  sinus.^ 

Symptoms  mid  Diagnosis  of  Fractures  of  the  Vertebrce. — When  the  fracture 
is  compound^  as  it  is  in  cases  where  small-arm  missiles  break  the  spinal 
column,  the  diagnosis  can  generally  be  settled  with  certainty  by  exploring 
the  wound  with  the  finger.  In  cases  where  the  aperture  in  the  integuments 
is  not  large  enough  to  admit  a  finger,  e.  g.^  wounds  made  by  buckshot  and 
small  pistol-balls,  the  exploration  may  be  made  with  the  porcelain-tipped 
probe  of  Nelaton,  or  with  the  ordinary  bullet-probe,  and  thus,  likewise,  the 
lesion  of  bone,  if  it  be  present,  can  generally  be  made  out.  In  cases  where 
the  orifice  of  the  wound  is  too  far  away  from  the  spinal  column  to  admit  of 
examining  it  with  a  finger  in  the  wound,  the  exploration  must  be  made  with 
a  probe,  in  order  to  determine  whether  there  is  a  fracture  of  the  vertebrae  or 
not ;  and,  in  case  there  is,  what  part  or  parts  of  the  vertebrae  are  broken. 

Simple  fractures  of  the  spinous  processes  are  attended  by  the  following 
phenomena :  Ecchymosis  of  the  integuments  covering  the  seat  of  fracture, 
pain  and  tenderness  under  pressure,  also  at  the  seat  of  fracture,  with  dis- 
placement and  abnormal  mobility  of  the  broken  spinous  processes.  If 
these  be  grasped  by  the  thumb  and  fingers,  they  can  be  swayed  from  side  to 
side,  and  the  grating  of  the  broken  surfaces  against  each  other  will  be  felt 
by  both  patient  and  surgeon,  as  these  movements  of  the  broken-ofl:'  portions 
of  the  spinous  processes  are  made.  But  abnormal  mobility  may  be  imparted 
to  the  spinous  processes  from  fractures  of  the  corresponding  pairs  of  lami- 
njB  to  which  they  are  attached,  as  was  noted  in  at  least  one  of  the  cases  above 
mentioned.  Mobility  of  the  spinous  processes  arising  from  this  cause,  how- 
ever, is  not  very  liable  to  be  mistaken  for  mobility  arising  from  fracture 
of  the  processes  themselves,  inasmuch  as  there  are  essential  differences  be- 
tween the  false  points  of  motion  in  the  two  cases ;  and  no  one  having  once 
had  his  attention  called  to  the  subject,  would  be  likely  to  mistake  the  abnor- 
mal mobility  of  the  vertebral  spines  which  may  result  from  fractures  of  the 
laminee  they  are  attached  to,  for  that  which  results  from  fractures  of  the 
spinous  processes  themselves.  Again,  when  the  patient  bends  the  injured 
part  of  the  spine  strongly  forward,  and  thus  greatly  increases  the  tension  of 
the  integuments  over  it,  as  well  as  the  disposition  of  the  spinous  processes 

•  Science  and  Art  of  Surgery,  p.  291,  Am.  ed.  1854.  *  Op.  cit.,  vol.  1.  p.  825 


VOL.  IV. — 23 


354 


INJURIES  OF  THE  BACK. 


to  separate  from  each  other,  the  deformity  is  correspondingly  increased  and 
the  sufferings  are  correspondingly  aggravated,  in  cases  where  the  spinous 
processes  are  fractured. 

Simple  fracture  of  the  laminm,  with  displacement  forward  of  the  fragment 
embraced  between  the  two  lines  of  fracture,  may  be  produced  by  a  blow 
upon  the  spinous  process  which  springs  from  them.  This  lesion  is  denoted 
by  ecchymosis  of  the  integuments,  by  local  pain,  stintfess,  and  tenderness 
under  pressure,  by  depression  of  the  broken  laminse  themselves  as  well  as  of 
the  spinous  process  attached  to  them,  and  by  feeling  the  broken  laminae  move 
when  the  corresponding  spinous  process  is  moved  from  side  to  side.  In  such 
cases,  the  spinal  cord  is  liable  to  be  seriously  injured  by  the  depressed  frag- 
ments of  the  broken  laminae  ;  and,  therefore,  the  symptoms  of  spinal  paralysis 
are  usually  present  whenever  the  laminae  are  fractured.  In  such  cases,  too, 
the  patients  themselves  will  feel  the  grating  of  the  fragments,  and  \yill  be 
likely  to  inform  the  surgeon  to  that  effect  if  inquiry  be  made  concerning  it. 
Moreover,  the  surgeon  should  be  very  careful  in  regard  to  making  pressure 
upon  the  spinous  processes  and  bending  them  from  side  to  side,  in  such  cases, 
lest  he  may  himself  crush  the  spinal  cord,  or  do  some  other  irreparable  injury 
to  it.  Oftentimes,  the  spinal  cord  is  severely  injured  by  the  accident  itself,  in 
such  cases,  as  the  following  examples  will  show  :— 

Dr.  T.  B.  Ladd^  reports  the  case  of  a  man,  aged  30,  whose  neck  was  injured  by  being 
thrown  in  wrestling,  etc.  There  were  paralysis,  pain,  fever,  and  dyspnoea  before  death, 
which  occurred  thirty-six  and  one-half  days  after  the  injury.  Dissection  revealed 
a  fracture  of  the  arch  of  the  fifth  cervical  vertebra;  the  spinal  cord  itself  was  com- 
pressed  and  disorganized.  (Ashhurst.)  The  spinal  cord  appears  to  have  been  severely 
compressed  by  the  fractured  laminae,  and  disorganized  by  ascending  myelitis.  No  doubt 
death  was  preceded  by  diaphragmatic  breathing  and  paralysis  of  the  respiratory  muscles, 
in  consequence  of  the  respiratory  centres  being  invaded  by  the  myelitis.  Likewise, 
Professor  Hamilton  mentions  in  his  excellent  Treatise  on  Fractures  and  Dislocations, 
the  case  of  a  man,  aged  40,  injured  by  a  balustrade  striking  on  his  neck  and  head. 
There  was  paralysis,  pain,  etc. ;  and,  in  thirty-six  hours,  death  ensued.  Dissection 
showed  fracture  of  the  arch  of  the  sixth  cervical  vertebra ;  the  cord  was  compressed. 
It  is  not  improbable  that,  in  this  case,  death  was  directly  caused  by  acute  ascending 
myelitis. 

Simple  fractures  of  the  bodies,  ^pedicles,  transverse,  and  articular  processes 
of  the  vertebrae  are  more  deeply  covered  up  by  muscles,  fasciae,  and  integu- 
ments, than  the  fractures  just  discussed ;  and,  therefore,  are  diagnosticated  with 
much  greater  difficulty.  Generally,  they  cannot  be  separated  from  each  other 
with  certainty  daring  life.  They  are  attended  by  the  following  symptoms : 
Impairment  of  function,  pain,  and  tenderness  under  pressure  at  the  seat  of 
fracture,  subtegumentary  extravasation  of  blood,  more  or  less  displacement  of 
the  frao-raents  (sometimes  it  is  very  slight),  and  crepitus.  The  last-mentioned 
is  the  most  important  of  all  the  signs ;  and,  when  distinctly  felt,  it  removes 
all  doubt  as  to  the  diagnosis  of  the  fracture.  But,  while  it  is  not  allowable 
for  surgeons  to  flex  and  extend,  or  to  rotate  and  compress,  the  spinal  columns 
of  their  patients  merely  for  the  purpose  of  ascertaining,  by  a  manual  exami- 
nation, whether  there  be  crepitus,  nevertheless,  this  point  can  generally  be 
settled  by  asking  the  patients  themselves  whether  they  have  felt  the  grating 
of  broken  bones  in  the  injured  part,  and  by  applying  a  flexible  stethoscope, 
or  the  hand,  over  the  hijured  place,  while  the  patient  is  being  turned  over 
in  bed  in  order  for  the  nurse  to  cleanse  the  private  parts,  or  while  he  is 
being  moved  for  any  other  necessary  cause.  Thus,  the  surgeon  by  watching 
for  an  opportunity  to  make  a  manual  examination,  can  generally  settle  the 

I  Boston  Med.  and  Surgical  Journal,  1852. 


FRACTURES  OF  THE  VERTEBRAE. 


355 


question  of  crepitus,  without  violating  any  canon  of  his  art.  The  following 
examples  will  illustrate  in  a  useful  manner  the  symptomatology  of  these 
vertebral  fractures : — 

Dr.  F.  H.  Hamilton,  Jr.,*  reports  the  case  of  a  soldier,  who  fell  twenty  feet,  striking 
his  neck.  There  were  crepitus  over  the  second  and  sixtli  cervical  vertebrae,  witli  slight 
pain  and  paralysis,  and  a  compound  fracture  of  the  thigh,  uni)erceived  by  the  patient. 
Death  ensued  forty  hours  after  tlie  accident.  Dissection  showed  fractures  of  tlie 
spinous  processes  of  the  second  and  tlie  third,  and  a  longitudinal  fracture  of  tlie  body  of 
the  sixth  cervical  vertebra;  the  spinal  cord  was  compressed.  (Ashhurst.)  Dr.  Hiiam 
A.  Prout'  mentions  the  case  of  a  man,  aged  30,  who  was  injured  in  tlie  neck  while 
wrestling.  There  were  paralysis,  pain,  and  crepitus  over  the  fifth  cervical  vertebra;  and, 
forty-eight  hours  after  the  casualty,  death  occurred.  Dissection  revealed  a  fracture 
of  the  fifth  cervical  vertebra,  the  spinal  cord  compressed,  and  an  effusion  of  blood  in  the 
spinal  canal.  (Ashhurst.)  Professor  Hamilton,  in  his  excellent  Treatise  on  Fractures 
and  Dislocations,  refers  to  the  case  of  a  man,  injured  in  the  neck  by  being  thrown  back- 
ward from  a  wagon,  and  striking  his  head.  There  was  paralysis,  with  crepitus  in  the 
upper  part  of  the  cervical  region ;  and  his  breathing  nearly  ceased  when  he  was  turned  over 
-upon  his  face.  Forty-eight  hours  after  the  accident,  death  ensued.  There  was  no  autopsy. 
Paul  Belcher^  relates  the  case  of  a  sawyer,  aged  37,  who  fell  from  a  cart  while  drunk. 
He  was  stunned  and  had  a  scalp-wound.  There  were  pain,  paralysis,  and  priapism.  On 
the  next  day,  crepitus  over  the  first  and  second  dorsal  vertebrae  was  noted.  He  died 
fifteen  days  after  the  injury.  Dissection  showed  fractures  of  the  first  and  second  dorsal 
vertebrae ;  a  small  clot  in  the  spinal  canal ;  the  theca  vertebralis  torn  ;  and  the  spinal 
cord  diffluent.  (Ashhurst.)  In  this  case,  intra-spinal  hemorrhage  arose  from  the  injury, 
as  in  Prout's  case  just  mentioned.  It  seems  that  a  myelitis  also  arose  from  the  injury, 
which  disorganized  the  spinal  cord  and  destroyed  life. 

Simple  fractures  of  the  bodies  of  the  vertebrae  have  been  met  with  most 
often  in  the  parts  of  the  spinal  column  which  allow  the  greatest  range  of 
motion,  to  wit,  between  the  third  and  seventh  cervical  vertebrae,  between  the 
eleventh  dorsal  and  second  lumbar,  and  between  the  fourth  lumbar  and  the 
sacrum. 

The  direction  of  these  fractures  of  the  bodies  of  the  vertebrae  may  be  trans- 
verse, oblique,  or  vertical.  The  oblique  and  vertical  lines  of  fracture  may  pass 
through  the  bodies  of  two  or  three  vertebrae  successively.  Sometimes  the  lines 
run  m  several  different  directions  in  the  same  vertebra,  as,  for  instance,  when 
the  fracture  is  comminuted.  The  lines  of  fracture  may  simultaneously  extend 
through  the  laminae  or  pedicles,  as  well  as  through  the  bodies  of  the  vertebrae. 
"When  the  direction  is  oblique,  Malgaigne  thinks  that  the  fracture  always 
extends  from  above  downward  and  "from  behind  forward,  and  constitutes  a 
sort  of  inclined  plane,  down  which  the  upper  fragment  slides,  unless  it  is 
restrained  by  the  vertebral  ligaments.  Malgaigne's  views  on  this  point  are 
supported  by  the  observations  of  other  surgeons.  This  is  the  chief  way  in 
which  displacement  results  from  fractures  through  the  bodies  of  the  vertebrae. 

It  is  scarcely  necessary  to  say  that  the  displacement  arising  from  fractures 
is  quite  distinct  from  that  wdiich  arises  from  luxations  of  the  bodies  of  the 
Tertebrae.  It  is  likewise  scarcely  necessary  to  say  that  the  displacement  aris- 
ing from  fractures  may  be  attended  w4th  an  overlapping  of  the  lower  fragment, 
caused  by  the  sliding  downward  and  forward  of  the  upper  fragment,  and  that 
an  appreciable  shortening*  of  the  spinal  column  may  be  produced  in  this 
manner.  When  shortening  of  any  part  of  the  spinal  column  is  caused  by  ver- 
tebral injury,  it  affords  undoubted  evidence,  not  onU^  that  there  is.  fracture, 
but  also  that  the  fracture  involves  the  body  of  one,  or  more  than  one,  vertebra 
SiX  that  part.    The  following  example  will  usefully  illustrate  this  point: — 


*  American  Med.  Times,  N.  S.,  vol.  viii. 
»  British  Med.  Journal,  18G2. 


*  American  Journ.  Med.  Sciences,  1837. 


358 


INJURIES  OF  THE  BACK. 


Dr.  T.  G.  Morton^  reports  the  case  of  a  young  man,  aged  19,  injured  by  falling  into 
the  hold  of  a  vessel,  and  striking  his  head  and  neck.  The  neck  was  shortened,  and  the 
head  thrown  forward.  There  were  pain,  paralysis,  and  priapism,  with  "symptoms  of 
concussion."  In  ten  days  death  ensued.  Dissection  showed  fractures  of  the  fourth, 
fifth,  and  sixth  cervical  vertebrae  ;  partial  dislocation  of  the  fifth  ;  the  spinal  cord  was 
compressed,  and  there  were  blood-clots  in  the  vertebral  canal.  (Ashhurst.)  To  the 
symptoms  of  fracture  of  the  bodies  of  the  vertebrae  already  mentioned,  shortening  of  the 
spinal  column,  when  it  is  caused  by  vertebral  injury,  must,  therefore  be  added. 

By  the  displacement  of  the  fragments,  which  results  from  certain  fractures 
of  the  bodies  of  the  vertebrae,  the  spinal  cord  may  be  bruised,  compressed,  or 
even  severed ;  and,  in  this  way,  spinal  paralysis^  p7i,apism,  retention  of  urine 
andfeces^  bed-sores^  etc.,  are  not  unfrequently  produced.  But  spinal  paralysis, 
appearing  coincidently  with  the  accident  which  causes  the  fracture,  is  quite 
as  likely  to  arise  from  concussion  of  the  spinal  cord  as  from  compression 
thereof ;  for  fractures  of  the  bodies  of  the  vertebrae  are  often  attended  by  con- 
cussion of  the  spinal  cord — much  oftener,  I  fancy,  than  luxations.  When 
spinal  paralysis  begins  a  few  hours  after  the  accident,  in  the  lower  extremities, 
and  creeps  gradually  upward,  it  is  generally  due  to  extravasation  of  blood 
within  the  theca  vertebralis.  Many  examples  have  already  been  presented.^ 
When  spinal  paralysis  begins  at  a  later  period,  it  is  often  caused  by  spinal 
meningitis  or  myelitis.^  But  much  displacement  of  the  fragments,  without 
the  occurrence  of  spinal  paralysis,  has  often  been  observed  in  cases  where  the 
lower  dorsal  and  the  lumbar  vertebrae  were  fractured.  For  example,  Mr. 
Shaw*  reports  four  cases  in  w^hich  the  lower  dorsal  and  the  upper  lumbar 
vertebrae  were  fractured,  and  the  fragments  much  displaced,  without  causing 
any  spinal  paralysis.  These  patients  all  recovered  more  or  less  completely. 
It  will  be  remembered  that  the  spinal  cord,  having  progressively  dimi- 
nished in  size  in  the  dorsal  region,  terminates  in  adults  in  a  rounded 
point  at  the  first  or  second  lumbar  vertebra,  after  sending  off  the  cauda 
equina ;  in  children,  at  birth,  it  extends  to  the  middle  of  the  third  lumbar 
vertebra,  and,  in  the  embryo,  is  prolonged  as  far  as  the  coccyx.  Dr.  Bennett* 
relates  a  case  of  fracture  of  the  third  lumbar  vertebra  from  direct  violence, 
without  the  spinal  canal  suffering  from  encroachment. 

Local  pain^  as  already  stated,  is  usually  present  in  cases  where  the  bodies 
and  pedicles,  etc.,  of  the  vertebrae  are  broken.  But  when  the  spinal  nerves 
also  are  injured  by  fracture-splinters,  especially  during  their  passage  through 
the  intervertebral  foramina,  severe  pain  is  excited  in  their  terminal  branches, 
which  appears  to  the  unfortunate  patient  to  be  fixed  in  the  parts  supplied  by 
the  injured  nerves.  For  instance,  when  the  sixth,  seventh,  or  eighth  dorsal 
nerve  is  thus  irritated  at  the  intervertebral  foramen,  pain  and  perhaps  cramps, 
corresponding  to  the  irritation,  will  be  felt  in  the  part  of  the  abdominal  walls 
where  the  terminal  branches  of  the  injured  nerve  are  distributed.  The  pres- 
ence of  such  a  pain  not  unfrequently  furnishes  important  aid  in  diagnosticat- 
ing a  vertebral  fracture. 

The  symptoms  and  diagnosis  of  the  so-called  latent  fractures  of  the  bodies 
of  the  vertebrae  yet  remain  to  be  considered.  These  cases  are  not  attended  by 
appreciable  displacement  of  the  fragments  during  life,  nor  by  crepitus,  nor  by 
shortening  of  the  spinal  column,  nor,  at  the  outset,  by  spinal  paralysis.  They 
bear  a  close  resemblance  to  instances  of  sprains  or  wrenches  of  the  vertebral 
joints.    Like  sprains,  they  are  caused  by  blows  on  the  back,  or  by  falls,  etc. 

•  Proceedings  Pathol.  Soc.  Philadelphia,  vol.  i. 

2  For  a  further  discussion  of  these  inaportant  topics,  see  Injuries  of  the  Spinal  Cord,  infra. 

3  See  Traumatic  Meningitis  and  Traumatic  Myelitis,  infra. 

*  Med.  Gazette,  vol.  xvii.,  and  Trans.  Pathol.  Soc.  London,  vol.  iii. 
6  Dublin  Quart.  Journal,  February,  1869. 


FRACTURES  OF  THE  VERTEBRAE. 


B57 


Like  sprains  or  wrenches,"  they  are  attended  hy  local  pain  and  tenderness 
under  pressure,  hy  tumefaction,  hy  ecchymosis,  and  hy  impaired  function  of 
the  injured  part.  There  are,  however,  some  important  differences  :  1.  In  the 
cases  of  spinal  fracture  the  tenderness  is  usually  restricted  to  one  or  two  ver- 
tehrje,  whilst  in  the  cases  of  sprain  it  is  diffused  over  the  joints  of  several 
contio:uous  vertebrae  which  have  suffered  almost  alike.  2.  The  functions  of 
the  spinal  column,  as  an  instrument  for  mechanically  supporting  the  body,  are 
usually  affected  to  a  much  greater  extent  by  latent  fractures  than  by  sprains. 
In  an  instance  of  the  former,  which  came  under  my  own  observation,  there 
was  utter  inability  on  the  part  of  the  patient  to  sit  upright  in  a  chair  or  bed 
without  assistance,  although  there  was  no  paralysis.  Had  the  case  been 
merely  a  sprain,  and  not  a  fracture  of  the  spinal  column,  the  patient  would 
have  been  able  to  sit  upright,  unaided,  wdien  placed  in  a  chair  or  raised  up  in 
bed.  In  a  case  of  Abernethy's,  mentioned  above,  the  patient  could  not  raise 
himself  in  bed,  and  there  was  no  reason  apparent  for  this  inability  until^  the 
fracture  was  revealed  by  the  autopsy.  By  attending  to  these  two  points, 
then,  latent  fractures  can  sometimes  be  distinguished  from  sprains  or  wrenches 
of  the  vertebral  column. 

Prognosis. — In  cases  of  vertebral  fracture  the  prognosis  is  never  favorable, 
unless  the  lesion  chance  to  be  restricted  to  the  spinous  processes,  as  already 
stated.  But  fractures  occurring  in  the  cervical  region  are  more  dangerous 
than  those  in  the  dorsal  region,  and  these  in  turn  are  more  hazardous  than 
those  occurring  in  the  lumbar  region.  Generally,  the  nearer  the  broken 
vertebra  is  to  the  roots  of  the  phrenic  nerves,  the  greater  the  danger  becomes. 
In  like  manner,  fractures  of  the  lumbar  and  dorsal  vertebrae,  attended  by  dis- 
placement of  the  fragments  and  injury  of  the  spinal  cord,  with  para[)legia,  are 
less  speedily  fatal  than  those  of  the  cervical  vertebrae.  Moreover,  in  all  parts 
of  the  spinal  column,  fractures  of  the  vertebrae  which  are  not  complicated 
with  injury  of  the  spinal  cord,  are  less  dangerous  than  those  which  are  attended 
by  such  injury. 

The  proximate  causes  of  death  in  fractures  of  the  spinal  column,  aside  from 
pithing  the  spinal  cord  by  the  odontoid  process,  or  by  some  fragment  of  the 
iirst  tlfree  vertebne,  are  the  following  :  (1)  intra-thecal  extravasation  of  blood  ; 
(2)  spinal  meningitis  ;  (3)  ascending  myelitis;  (4)  intra-spinal  abscess,  that  is, 
an  accumulation  of  purulent  matter  formed  between  the  theca  vertebralis  and 
the  bone  ;  and  (5)  trophic  disorders  of  the  paralyzed  parts,  for  example,  gluteal 
eschars  or  acute  bed-sores,  with  vesical  and  renal  inflammations.  These  tro- 
phic disorders  arise  quite  as  much,  perhaps  even  more,  from  the  inflammatory 
disorganizations  of  the  spinal  cord  which  result  from  vertebral  injuries,  than 
fromdie  traumatic  lesions  of  the  cord  itself,  ^s'ow,  the  gravity  of  the  prog- 
nosis is  always  increased  by  the  appearance  of  any  signs  of  these  various  com- 
plications or  accidents  which  constitute  the  proximate  causes  of  death  in  the 
cases  of  vertebral  fracture  which  end  badly.  Hence,  the  appearance  of  spi- 
nal paralysis  in  cases  wdiere  it  did  not  attend  the  original  injury,  or  the  pass- 
age of  a*^ partial  paralysis  into  a  complete  paraplegia,  but,  particularly,  the 
creeping  steadily  upward  of  a  spinal  paralysis  that  began  in  the  legs,  until 
the  sensibility  as  well  as  the  voluntary  motility  is  destroyed  as  far  as  the  nip- 
ples, or  even  the  root  of  the  neck,  are  all  signs  of  extreme  danger  to  life. 
The  persistence  of  an  abnormally  high  or  low  degree  of  body-temperature, 
and  the  flushing  of  the  face  which  results  from  vaso-motor  paralysis,  espe- 
cially if  it  be  combined  with  dyspnoea,  are  fatal  symptoms,  and  they  likewise 
denote  that  the  end  is  nigh.  Priapism  is  an  unfavorable  symptom,  but  not 
ahva\^s  a  fatal  one. 

On  the  other  hand,  the  prognosis  becomes  less  unfavorable  when  the  symp- 
toms of  spinal  paralysis  grow  less  strongly  marked,  when  the  patient  recovers 


358 


INJURIES  OF  THE  BACK. 


the  power  to  micturate  at  will  and  to  defecate  naturally,  when  the  respiratory 
movements,  after  being  solely  diaphragmatic,  are  again  performed  in  a  nor- 
mal manner,  when  the  sensibility  and  power  of  voluntary  motion  are  seen  to 
be  returning  to  the  paralyzed  parts  in  general,  etc.  ^  These  signs,  and  others 
like  them,  are  of  good  omen  in  all  cases  of  spinal  injury. 

Fractures  of  the  cervical  vertebrae,  if  attended  by  symptoms  which  show 
that  the  spinal  cord  is  injured,  are  almost  always  fatal.  Several  illustrative 
cases,  as  well  as  the  causes  of  the  great  fatality  of  these  lesions,  have  already 
been  presented  and  described  with  sufficient  minuteness  of  detail  to  answer 
all  practical  purposes.  Of  ten  patients  with  fracture  of  the  five  lower  cervical 
vertebrae,  whose  cases  are  collected  by  Professor  Hamilton,^  one  survived 

twenty-four  hours,  one  eleven  days,  one  fifteen 
Fig.  863.  weeks  and  six  days,  one  four  months,  and  only 

one,  whose  case  I  shall  presently  relate  and 
illustrate  with  a  wood-cut,  lived  fourteen  years. 
To  the  sad  rule  which  is  thus  portrayed  there 
are,  however,  some  notable  exceptions  on 
record,  for  example : — 

Ollivier  d' Angers^  reports  the  case  of  a  man  who 
injured  his  neck  by  falling  backward  from  a  wheel, 
and  striking  the  ground  with  it.  There  was  para- 
lysis, with  mobility  about  the  seventh  cervical  ver- 
tebra. After  two  months  the  paralysis  began  to 
diminish  under  general  treatment.  At  the  end  of 
three  years  he  was  nearly  well.  (Ashhurst.) 

Again,  the  same  author^  relates  the  case  of  a  car- 
man, aged  21,  injured  by  falling  and  striking  the 
back  of  his  neck.  There  was  paralysis,  etc-.  In 
two  and  a  half  months  he  recovered.  Six  months 
after  the  original  accident  his  neck  was  broken 
afresh,  by  being  pushed  down  while  he  was  taking 
a  long  walk.  There  was  sudden  paralysis,  etc.  ; 
and  in  thirty-four  days  death  ensued.  Dissection 
showed  that  the  original  injury  consisted  of  fractures 
of  the  fourth  and  fifth  cervical  vertebrae,  the  body 
of  the  fourth  having  been  broken  ;  and  that  the 
callus  had  been  fractured  by  the  second  fall.  (Ash- 
hurst.) Had  there  been  no  second  accident,  this 
man  (there  is  but  little  doubt)  would  have  recovered 
entirely  from  the  original  fractures. 

Mr.  Hutchinson,*  likewise,  reports  two  cases,  the 
one  being  that  of  a  woman  and  the  other  that  oi"  a 
man,  in  which  there  was  fracture  of  the  lower  cer- 
vical vertebra?,  with  partial  paralysis,  and  yet  both 
patients  recovered. 

Mr.  Hilton  has  reported  a  case,  with  a  wood-cut 
(Fig.  863),  in  which  there  were  fractures  of  the  fifth, 
sixth,  and  seventh  cervical  vertebrie,  with  complete 
paralysis  from  the  neck  downward,  and  yet  the  pa- 
tient survived  in  a  paralyzed  condition  for  fourteen 
years,  ultimately  perishing  from  injury  of  another 
aged  21,  on  a  Sunday  morning  in  May,  1830,  fell  from  a  tree,  about 


Showing  a  vertical  section  of  the  first  nine 
vertebrje,  excepting  the  atlas,  from  Mr.  Hil- 
ton's case,  in  whicli  there  were  fractures  of 
the  bodies  of  the  fifth,  sixth,  and  seventh 
cervical  vertebra;,  and  the  patient  survived 
for  fourteen  years.  The  fractured  vertehrse 
are  seen  to  be  consolidated  by  bone,  both  at 
their  bodies  and  at  their  arches. 


part : 


-John  Carter, 


forty  feet,  upon  his  back,  or,  more  probably,  upon  his  head.    He  was  stunned  to  un- 


•  Fractures  and  Dislocations,  p. 
»  Ibid. 


155. 


2  Traite  d(!S  Maladies  de  la  Moelle  Epiniere,  t.  i. 
*  London  Hospital  Reports,  vol.  iii.  pp.  347,  348. 


FRACTURES  OF  THE  VERTEBRA.  359 


consciousness,  and  completely  paralyzed  up  to  the  neck  as  to  both  sensation  and  volun- 
tary motion.  The  neck  was  very  stiff,  but  no  irregularity  of  the  vertebrai  could  be  per- 
ceived  He  was  treated  by  venesection  and  by  cupping  the  back  of  the  neck,  "  and,  using 
proper'remedies,  a  capability  of  moving  tlie  liead  gradually  returned."  The  bladder  \vas 
paralyzed,  and  catheterization  required.  After  some  weeks,  the  ability  to  micturate  at 
will  appears  to  have  returned,  and  he  was  able  to  defecate  by  taking  sc?nna.  After 
some  weeks,  also,  "  a  certain  amount  of  motion  was  restored  to  the  head  and  neck, 
and  sensibility  to  the  same  extent ;  but  the  rest  of  the  body  remained  perfectly  para- 
lyzed and  insensible."  Many  years  afterward,  it  was  noted  that  there  was  nothing 
abnormal  to  be  felt  about  the  spine;  that  no  costal  movements  occurred  durnig  respi- 
ration ;  that  there  was  perfect  loss  of  voluntary  motion  in  tiie  lower  and  upper  extremi- 
ties, with  almost  perfect  loss  of  sensation  in  the  same  ;  that  his  bowels  were  never 
moved  without  medicine  (senna)  ;  and  that  his  urine  was  very  offensive  when  he 
caught  cold,  at  other  times  not  so  offensive,  but  always  a  little  so.  His  urine  was  acid. 
Helelt  a  distinct  pain  in  the  bowels  occasionally,  and  now  and  then  an  aching  in  the 
loins.  When  sick,  he  vomited  with  great  difficulty.  Erections  of  the  penis  were  frequent, 
and  lasted  a  quarter  of  an  hour,  with  slight  escape  of  seminal  Huid  occasionally.  Four- 
teen  years  after  the  original  injury,  he  was  upset  whilst  being  dragged  about  in  little 
four-wheeled  cart  by  a  boy,  and,  as  he  could  not  put  out  his  hands  to  save  himself,  he 
fell  to  the  ground  with  great  violence;  this  led  to  some  chest  affection,  which  caused 
death  in  a  few  days.  A  complete  autopsy  could  not  be  obtained  ;  but  the  specimen  was 
procured,  which  is  portrayed  in  the  accompanying  wood-cut  (Fig.  863).  In  it  the 
bodies  and  arches  of  the  fifth,  sixth,  and  seventh  cervical  vertebrai  are  seen  b  ended 
tocrether  by  bone.  The  body  of  the  sixth  vertebra  is  displaced  and  projects  backward 
into  the  spinal  canal.  The  intervertebral  substances  have  disappeared,  but  their  out- 
lines are  still  marked,  and  their  places  occupied  by  bone.  Every  one  must  admire  the 
perfect  union  which  has  taken  place  by  new  bone  ;  and  if  nature  could  have  done  as 
well  with  the  spinal  cord,  this  patient  might  have  perfectly  recovered.^ 

Mr.  Bryant,  likewise,  mentions  the  case  of  a  gentleman,  aged  29,  whom  he  saw, 
November  25,  1870,  with  complete  paralysis  of  the  whole  body  below  the  fifth  cervical 
vertebra,  caused  by  a  fall  upon  the  neck,  who  was  still  alive  in  1877,  breathing  solely 
by  the  diaphragm  'f  exactly  as  the  man,  whose  case  Mr.  Hilton  has  reported,  did  tor 
fourteen  yearSj^and  until  he  perished  in  consequence  of  another  accident. 

These  examples  of  recovery  from  cervical  fracture  have  been  presented  in  order  to 
encourage  surgeons  to  give  every  possible  care  and  attention  to  the  treatment  of  cervical 
injuries'attended  by  paralysis,  with  the  hojje  of  obtaining  the  same  happy  result. 

Recoveries  from  fractures  of  the  dorsal  and  lumbar  vertebrae  have  beeii 
recorded  in  so  many  instances,  that  these  lesions  now  are  often,  perhaps  gene- 
rally, considered  to  be  quite  amenable  to  appropriate  treatment.  This  results 
in  great  part  from  the  fact  that  the  spinal  cord,  in  adults,  not  only  ends  m  a 
rounded  point  at  the  first  or  second  lumbar  vertebra,  but  also  becomes,  m  the 
lower  part  of  the  dorsal  region,  a  leash  of  nerves,  the  cords  of  which  are 
wrapped  in  a  strong  fibrous  covering ;  and,  for  this  anatomical  reason,  being 
able  to  freely  slide  on  each  other,  tliey  glide  out  of  the  way  of  the  displaced 
fragments  of  broken  vertebrae,  and  thus  escape  serious  damage. 

As  for  successful  examples,  Mr.  Hulke'  records  a  very  interesting  case  of  recovery 
from  fracture  of  a  dorsal  vertebra.  Baron  Dupuytren*  gives  two  cases  observed  at  the 
Hotel-Dieu.  The  first  was  that  of  a  mason,  aged  28,  who,  by  a  fall,  fractured  his  spinal 
column  about  the  tenth  dorsal  vertebra.  Paralysis  came  on  in  two  days.  He  was  treated 
by  cupping,  by  rest  in  bed,  etc. ;  and,  in  two  months,  he  recovered.  The  second  case 
was  that  of  a  washerwoman,  who  fell  from  a  second  story  upon  her  feet,  and  then  upon 
her  back.  The  tenth,  eleventh,  and  twelfth  dorsal  vertebrae  projected  backward,  and  her 
right  lower  extremity  was  paralyzed.  She  was  treated  by  bleeding,  by  rest  in  bed, 
etc. ;  and,  in  four  months,  she  recovered. 

»  Op.  cit.,  pp.  65-67.  '  *  Op.  cit.,  pp.  203,  204. 

•  »  Medical  Times  and  Gazette,  February,  1674.  ^ 
♦  Diseases  and  Injuries  of  Bones,  Sydenham  Society's  translation,  pp.  356,  3o/. 


360 


INJURIES  OF  THE  BACK. 


Five  cases  of  vertebral  fracture  in  the  lower  dorsal  and  lumbar  regions,  with  para- 
lysis, are  recorded  in  the  London  Hospital  Reports.^  Recovery  in  every  instance  was 
obtained,  in  from  four  to  six  months. 

Dr.  Lente^  relates  the  case  of  a  man,  aged  20,  injured  by  falling  from  a  roof  upon  his 
buttocks  and  loins.  There  was  fracture  of  the  third  or  fourth  lumbar  vertebra,  with 
paralysis.  Bed-sores  and  exfoliation  from  the  filth  lumbar  vertebra  followed.  After- 
ward he  improved.  At  the  end  of  four  years  he  could  not  quite  stand  alone  ;  but  he 
went  about  the  country  as  a  peddler.  Dr.  Lente  likewise  reports  another  case  of  the 
same  sort,  in  which  recovery  took  place,  and  the  man  was  able  to  work  again. 

Professor  Agnew^  mentions  a  case  seen  by  himself  two  years  before,  in  which  the 
twelfth  dorsal  vertebra  was  fractured,  with  complete  paralysis  of  the  lower  extremities. 
The  patient  recovered  sufficiently  to  make  a  sea-voyage,  and  was  still  living. 

Professor  Ashhurst*  has  collected  from  the  Pennsylvania  Hospital  Record  the  follow- 
ing instances  of  fracture  of  the  dorsal  or  lumbar  vertebrae,  in  each  of  which  a  more  or 
less  complete  recovery  occurred  :  (1)  A  harness-maker,  aged  37,  injured  his  back  by  fall- 
ino-  from  a  roof.  The  twelfth  dorsal  vertebra  was  fractured,  and  its  spinous  process 
projected  backward.  He  recovered  in  ninety-four  days,  though  slight  deformity  and 
paralysis  of  the  right  limb  still  remained.  (2)  A  sailor,  aged  40,  was  injured  by  fall- 
ing upon  his  back.  A  dorsal  vertebra  was  fractured,  with  backward  projection.  In 
seventy-seven  days  he  recovered,  excepting  slight  deformity.  (3)  A  seaman,  aged  25, 
was  injured  by  falling  from  a  third  story.  He  was  found  to  have  a  contusion,  a  scalp- 
wound,  and  pain  in  the  back.  After  some  days,  projection  of  the  twelfth  dorsal  vertebra 
backward  was  observed,  but  no  paralysis.  In  sixty-eight  days  he  recovered,  and  slight 
deformity  only  remained.  (4)  A  laborer,  aged  55,  fell  against  a  fence.  He  had  con- 
tusion of  the  brain,  fractures  of  the  first  and  second  lumbar  vertebrae,  with  backward 
projection,  retention  of  urine  followed  by  incontinence  thereof,  and  paralysis.  At  the 
end  of  three  hundred  and  thirty-three  days  the  power  of  motion  had  become,  in  some 
degree,  restored,  but  the  deformity  remained.  (5)  A  laborer,  aged  69,  fell  from  a 
third  story  window,  and  fractured  the  vertebrae  at  the  dorso-lumbar  junction.  He 
recovered  in  one  hundred  and  twelve  days,  notwithstanding  that  the  prognosis  of  his 
case  was  complicated  by  an  attack  of  mania  a  potu.  (6)  A  laborer,  aged  20,  fell  from 
a  tree,  and  fractured  a  vertebra.    In  seventy-seven  days  he  recovered. 

Mr.  Syme^  reports  the  case  of  a  man,  aged  32,  who  fell,  striking  on  his  buttocks,  and 
thus  injured  his  spine.  The  vertebrae  projected  at  the  dorso-lumbar  junction  ;  there  were 
also  pain  and  spinal  paralysis.  On  the  second  day  he  began  to  improve  ;  and  in  forty 
days  he  recovered,  so  as  to  walk  with  a  cane. 

Mr.  Stanley^  had  the  case  of  a  sawyer,  aged  23,  who  fell  twenty-four  feet.  There 
were  pain  and  ecchymosis  in  the  back,  and  a  fractured  calcaneum.  After  a  week,  pro- 
jection of  the  twelfth  dorsal  and  first  lumbar  vertebrse  was  observed.  He  recovered  in 
two  months.    There  were  no  spinal  symptoms.  (Ashhurst.) 

Mr.  T.  Wakley'  reported  two  cases  of  lumbar  fracture,  with  recovery.  The  first  was 
that  of  a  man,  aged  34,  crushed  in  driving  through  an  archway.  There  were  projection 
of  the  second  lumbar  vertebra  and  spinal  paralysis.  In  thirteen  weeks  he  was  able  to 
walk  with  a  cane.  In  four  and  a  half  months  he  recovered,  and  resumed  his  occupation. 
The  second  was  tliat  of  a  carriage-maker,  aged  31,  who  received  a  blow  on  the  back  from 
a  ton-weight.  There  was  projection  of  the  second  and  third  lumbar  vertebrae,  with 
pain,  andspinal  paralysis.  He  recovered  in  five  and  a  half  months.  He  walked,  but 
not  very  well. 

Sir  Charles  BelP  relates  a  case  of  recovery  from  fracture  of  the  spine,  treated  by  Mr. 
Joberns.  The  patient  was  a  young  woman,  aged  18,  thrown  from  a  second  story  window 
on  her  back.    There  was  great  tumefaction  over  the  lower  dorsal  vertebrae  ;  the  spinous 

1  Vol.  Hi.  pp.  326,  346. 

2  American  Journal  of  the  Medical  Sciences,  October,  1857,  p.  361. 

3  Op.  cit.,  vol.  i.  p.  828.  ,  '  Op.  cit.,  pp.  108-119. 

6  Edinburgh  Medical  Journal,  vol.  xxxvii.  ^  Ornierod,  Clinical  Collections. 

'  Lancet,  1849.  *  Op-  ^it. 


FRACTURES  OF  THE  VERTEBRiE. 


361 


processes  were  crushed,  but  there  was  no  paralysis  ;  there  was  a  wound  over  the  sacrum. 
She  was  treated  by  rest,  etc.,  and  in  ten  and  a  half  months  recovered.  She  lay  for 
eight  months  with  body  bent  and  legs  drawn  up  ;  but  had  regained  the  erect  posture 
when  discharged. 

Dr.  Dorrance^  relates  the  case  of  a  cooper,  who  was  struck  by  a  falling  tree.  There 
were  fn  cture  and  backward  projection  of  the  eleventh  dorsal  vertebra,  with  spinal  para- 
lysis. He  recovered  in  one  year,  and  resumed  his  occupation  ;  but  slight  deformity 
remained. 

Mr.  Shaw^  reports  four  cases  of  vertebral  fracture  in  the  dorso-lumbar  region,  but 
without  paralysis,  in  which  each  patient  recovered  sufficiently  to  resume  work  again. 

But  Mr.  Teale'  has  recorded  the  most  interesting  cash  of  all.  In  it  the  body  of  the 
second  lumbar  vertebra  was  crushed,  and  there  was  spinal  paralysis  ;  still,  the  patient 
made  a  complete  recovery,  but  with  angular  curvature,  and  survived  twelve  years  in 
good  health,  when,  having  died  of  typhus,  the  diagnosis  was  verified  by  an  autopsy. 
The  patient  was  an  adult  man..  His  injury  was  caused  by  a  beam  falling  across  his 
back.  When  admitted  to  the  infirmary,  all  the  usual  signs  of  vertebral  fracture,  with 
displacement,  were  present  in  the  lumbar  region.  He  was  unable  to  move  his  legs  ; 
and,  for  three  weeks  after  admission,  required  the  use  of  a  catheter  to  empty  his  blad- 
der. Sensation  was  not  wholly  lost  at  any  time.  At  the  end  of  three  weeks,  he  mic- 
turated without  assistance,  and  could  walk  across  the  floor  with  the  aid  of  a  stick.  Six 
weeks  after  the  accident,  he  walked  well,  and  was  discharged  cured.  A  projection  of 
the  spinous  process  of  the  first  lumbar  vertebra  had  been  felt  from  the  first,  and  w^as 
still  present  when  he  left  the  hospital.  After  twelve  years'  good  health,  he  was  again 
admitted  for  typhus  fever,  of  which  he  died,  and  then  the  specimen  was  obtained.  It 
showed  an  obtuse  bend  forward  in  the  upper  part  of  the  lumbar  region.  The  body  of 
the  second  lumbar  vertebra  had  been  crushed  ;  and,  at  the  anterior  border,  had  not 
more  than  half  the  normal  thickness.  Anchylosis  had  occurred  between  the  first  and 
second  lumbar  vertebrae. 

Some  seven  or  eight  additional  cases  of  fracture  of  the  dorsal  and  lumbar 
vertebrae,  in  each  of  which  recovery  ensued,  wiW  presently  be  mentioned  or 
referred  to  under  the  head  of  treatment. 

In  France,  besides  the  cases  of  Dupuytren  mentioned  above,  several  successful  exam- 
ples belonging  to  the  same  category  have  been  reported,  two  by  Begin,*  four  by  J.  Clo- 
quet,^  and  at  least  one  by  Malgaigne.^  In  most  of  these  cases  there  was  complete 
spinal  paralysis,  but  it  gradually  disappeared  ;  and,  after  some  months,  or  even  years, 
of  treatment,  recovery  ensued.  Mar>y  other  successful  examples  of  the  same  sort,  if 
time  permitted,  could  doubtless  be  collected. 

!N"umerous  other  cases  of  vertebral  fracture,  in  the  dorsal  and  lumbar  regions, 
in  which  the  patients  survived  a  long  time,  notwithstanding  that  the  spinal 
cord  was  severed,  or  that  the  broken  bones  were  much  displaced,  might  like- 
wise be  collected.    But  few  of  them,  however,  will  be  presented. 

Professor  Hamilton '  mentions  a  case  under  Mr.  Key's  care,  in  which  the  first  lum- 
bar vertebra  was  fractured.  The  patient,  a  boy,  survived  the  accident  for  one  year  and 
two  days.    Necroscopy  showed  bony  union,  and  the  spinal  cord  completely  divided. 

Sir  A.  Cooper^  gives  the  case  of  a  man,  aged  28,  under  Mr,  Harold's  care,  with  frac- 
tures of  the  first  and  second  lumbar  vertebrie  caused  by  a  mass  of  chalk  falling  upon 
him.    There  was  spinal  paralysis,  which  affected  the  bladder  and  intestines  as  well  as 

^  American  Journal  of  the  Medical  Sciences,  0.  S.  vol.  xvi. 

*  London  Med.  Gazette,  vol.  xviii.  p.  936  ;  Trans.  Patholog.  Soc.  London,  vol.  iii.  p.  420. 
'  Brit,  and  For.  Medico-Chirurg.  Review,  October,  1869,  and  New  Syd.  Soc.  Retrospect,  1869- 
70,  pp.  247,  248. 

CEuvres  Chirnrg.,  t.  ii. 

5  Dictionnaire  de  Medecine,  t.  ix.  ;  Maisonnabe,  Journal  des  Difformit^s,  t.  i. 

6  Op.  cit.,  t.  ii.  '  Op.  cit. 
8  Dislocations  and  Fractures  of  Joints. 


362 


INJURIES  OF  THE  BACK. 


other  parts.  He  died  from  a  slougli  (bed-sore)  on  the  nates,  one  year  and  eleven  days 
after  the  accident.  Necroscopy  showed  union  by  bone,  and  the  spinal  cord  nearly 
severed  by  a  fragment  of  bone  which  had  pierced  the  theca  vertebralis. 

An  instance  of  dislocation  of  the  first,  and  fracture  of  the  second  lumbar  vertebra, 
in  which  the  patient  survived  the  lesion  for  three  and  one-half  years,  and  the  specimen 
from  which  was  exhibited  at  the  Pathological  Society  of  London  by  Mr.  W.  WagstaflPe, 
has  already  been  mentioned  above. 

Professor  Agnew^  gives,  with  a  wood-cut  illustrating  the  lesion,  the  case  of  a  young 
man  who  was  caught  at  the  Kensington  Depot,  Philadelphia,  between  the  platform 
and  a  car,  in  such  a  way  as  to  fracture  the  spinal  column  in  the  mid-dorsal  region, 
with  comminution  ;  yet,  notwithstanding  that  the  spinal  cord  was  completely  divided 
by  a  permanently  displaced  vertebra,  he  survived  the  accident  for  six  months,  and 
perished  at  last  from  sloughing  of  the  nates. 

Le  Gros  Clark  ^  relates  a  very  instructive  case  in  which  the  fourth  lumbar  vertebra 
was  fractured  through  both  pedicles,  while  its  processes  were  all  comminuted,  and  its 
ligaments  ruptured,  so  that  the  body  of  this  vertebra  was  dislocated  forward  and  down- 
ward, and  took  up  a  new  position  in  front  of  the  fifth  lumbar  vertebra,  the  upper  and 
lower  surfaces  of  both  vertebrae  being  in  the  same  planes  ;  although  the  injury  was  at 
first  attended  by  complete  paraplegia,  the  sensibility  was  restored  entirely,  and  the 
motility  partially,  in  five  weeks.  Death  ensued  in  the  seventh  week,  in  consequence 
of  sloughing  or  acute  bed-sores.  A  highly  suggestive  feature  of  this  case  is  the  fact 
that,  notwithstanding  the  enormous  displacement  which  occurred  between  the  fourth 
and  fifth  lumbar  vertebrae,  the  spinal  cord  was  not  much  injured,  and  the  paraplegia 
soon  passed  away. 

The  following  is  in  the  same  vein  :  "  In  one  case,"  says  Mr.  Hutchinson,  "I  found 
the  trunks  composing  the  cauda  equina  lifted  a  third  of  an  inch  on  a  bridge  of  bone, 
formed  by  the  displacement  of  a  fractured  lumbar  vertebra;  but  they  were  in  no  degree 
compressed,  and,  excepting  a  little  ecchymosis  in  their  pia  mater,  showed  scarcely  any 
trace  of  injury."^ 

A  very  practical  inference  from  facts  such  as  these  is  that,  however  great 
the  displacement  and  the  paralysis  may  be  in  cases  of  fracture  or  dislocation 
of  the  spinal  column,  we  have  no  right  to  assume  at  the  outset,  during  life, 
that  the  spinal  cord  is  irreparably  or  even  severely  injured  thereby. 

These  clinical  histories  and  accounts  of  autopsies  have  been  presented,  aside 
from  their  general  value,  with  a  special  intent  to  show  that,  in  cases  of  ver- 
tebral fracture  and  dislocation,  the  surgeon  is  justly  entitled  to  approach 
the  question  as  to  what  their  treatment  should  be,  with  something  more  of 
hope  for  obtaining  a  happy  issue  by  appropriate  treatment,  than  most  text- 
books on  surgery  would  seem  to  encourage. 

Treatmeyd  of  Fractures  of  the  Vertebrce. — The  successful  management  of  cases 
in  which  the  spinal  column  is  fractured,  chiefly  depends  on  the  follow^ing 
points :  (1)  On  preventing  those  intra-thecal  extravasations  of  blood  which 
destroy  life  by  compressing  the  spinal  cord.  (2)  On  preventing  or  subduing 
spinal  meningitis,  and  abscess  between  the  theca  vertebralis  and  the  bone. 
(3)  On  preventing  or  subduing  ascending  myelitis,  and  all  inflammatory  dis- 
organizations of  the  spinal  cord.  (4)  On  conducting  the  bed-sores,  and  the 
vesical  and  renal  inflammations,  which  are  apt  to  complicate  such  cases,  to  a 
favorable  issue. 

The  victim  should  be  carefully  picked  up,  and  carried  from  the  scene  of  the 
accident  home,  or  to  a  hospital,  on  a  stretcher,  on  one  extemporized  from  a 
settee  or  a  shutter,  etc.,  or  in  an  ambulance,  every  precaution  being  taken 
against  increasing  the  injury  of  the  spinal  cord,  that  was  mentioned  while 

1  Op.  cit.,  vol.  i.  pp.  827,  828.  2  British  Med.  Journal,  October  3,  1868. 

3  London  Hospital  Reports,  vol.  iii.  p.  3G0. 


FRACTURES  OF  THE  VERTEBRAE. 


363 


describing  the  treatment  of  luxations  of  the  vertebrce,  especially  if  the  frac- 
ture be  seated  in  the  cervical  region.  The  surgeon  should  make  his  diag- 
nosis as  complete  as  possible,  at  his  first  examination  of  the  case,  in  order 
to  avoid  the  doing  of  harm  by  moving  the  imtient  to  make  any  subsequent 
examinations.  The  patient  should  be  placed  on  a  water-bed ;  but,  if  it  is  not 
practicable  to  do  that,  upon  a  soft,  thick  hair-mattress.  The  fractured  ver- 
tebrae should  then  be  "  set,"  that  is,  their  fragments  should  be  restored  to  as 
nearly  a  normal  position  as  possible:  (1)  by  attending  to  the  patient's  posture 
in  bed,  for  sometimes  a  dorsal  or  even  an  abdoiaiiial  decubitus  will  quite  remove 
the  deformity,  as  well  as  greatly  lessen  the  patient's  sufferings ;  (2)  by  em- 
ploying extension  and  counter-extension  (whenever  necessary),  made  with  the 
hands  of  skilled  assistants,  at  the  same  time  coaptating  the  fragments  with 
the  hands;  and  (3)  by  applying  extension  continuo\isly  w^ith  w^eights,  in 
cases  where  there  is  shortening  of  the  spinal  column.  The  following  ex- 
amples are  in  point : — 

Malo-aigne^  gives  the  case  of  a  clerk,  aged  22,  who  was  treated  by  himself  at  the- 
Hopital  des  Cliniques,  in  1843.  The  man  had  fjillen  from  a  second  story,  alighting  on 
his  heels  and  buttocks.  Both  calcanea  were  fractured.  The  spinous  process  of  the 
twelfth  dorsal  vertebra  was  also  fractured,  and  displaced  toward  the  right  side.  There 
was  paraplegia  with  great  pain  in  the  back  on  motion,  and  it  was  thought  that  a  lumbar 
vertebra  was  likewise  broken.  The  patient  was  treated  by  rest  in  bed  alone,  and  the 
paralysis  gradually  passed  away.  When  he  got  up,  the  displaced  spinous  process  had 
resumed  its  proper  position. 

In  some  cases  of  vertebral  fracture,  the  fragments  readily  subside  into  a  nor- 
mal position  when  the  patient  is  confined  to  bed  \\\  dorsal  decubitus.  This 
doubtless  occurred  in  the  example  just  mentioned.  In  other  instances  the 
deformity  has  been  removed  by  making  the  patient  lie  on  his  belhy,  and  a  com- 
plete cure  has  been  obtained  by  making  him  keep  that  posture  until  the  frac- 
ture has  united. 

Sir  B.  Brodie^  mentions  the  case  of  a  boy,  who  was  injured  in  the  lower  part  of  the 
back.  There  were  fracture  and  displacement  of  the  third  and  fourth  lumbar  vertebrae, 
and  spinal  paralysis.  Attempts  at  reduction  were  made,  and  proved  partially  success- 
ful. After  the  first  month,  voluntary  motion,  as  well  as  sensation,  gradually  returned. 
At  the  end  of  three  or  four  months  the  patient  was  much  relieved. 

Mr.  Higginson'  mentions  a  case  in  which  there  was  fracture,  with  displacement,  of  a 
dorsal  vertebra.    The  patient  was  treated  by  extension,  and  recovery  ensued. 

Mr.  Luke*  relates  the  case  of  a  man  having  fracture  of  the  seventh  dorsal  vertebra. 
The  displacement  was  corrected  by  making  extension,  and  the  reduction  was  accom- 
panied by  an  audible  sound.  Erysipelas,  however,  supervened,  and  caused  death  seven 
days  after  the  accident.  At  the  autopsy,  the  spinal  cord  was  found  to  be  softened  and 
disorganized,  and  to  contain  purulent  matter. 

The  fatal  issue  of  this  case  does  not  appear  to  have  been  in  even  the  least 
degree  due  to  making  extension,  and  effecting  reduction  of  the  displaced  frag- 
ments of  the  seventh  dorsal  vertebra.  Moreover,  I  have  not  found  a  record 
of  any  case  of  spinal  fracture  in  which  the  efforts  at  reduction  proved  at  all 
hurtful.  But  reduction  by  extension  is  not  to  be  employed  in  every  instance  ; 
certainly  not  in  cases  where  the  deformity  can  be  removed  hy  adjusting  the 
patient's  posture  in  bed.  Reduction  by  extension,  however,  is  allowable  when 
much  deformity,  and  especially  shortening,  of  the  spinal  column  exists ;  and, 
likewise,  when  severe  pain  arises  from  the  fragments  of  bone  pressing  upon 


1  Treatise  on  Fractures,  etc.,  p.  342.    Packard's  translation. 
»  Medico-Chirurgical  Transactions,  vol.  xx.  p.  159. 

8  British  Medical  Journal,  1862.  4  Lancet,  1850. 


364 


INJURIES  OF  THE  BACK. 


the  spinal  nerves.  Bryant  has  seen  several  cases  in  which  marked  relief 
has  been  afforded  by  this  means  '}  and  the  records  of  surgery  contain  many 
others.  AVhen  practised  with  discretion,  the  reduction  of  vertebral  fractures 
b}'  extension  is  undoubtedly  a  valuable  mode  of  treatment.  When  the  dis- 
placement shows  a  decided  tendency  to  recur,  and  likewise  when  there  is 
marked  shortening,  it  will  often  be  advisable  to  make  the  extension  continu- 
ous by  means  of  weights  attached  to  the  patient  by  strips  of  adhesive  plas- 
ter, and  suspended  from  the  htad  of  the  bed,  in  the  manner  already  described 
while  discussing  the  treatment  of  vertebral  dislocations. 

When  there  is  much  pain  at  the  seat  of  fracture,  or  in  the  terminal 
branches  of  the  spinal  nerves  which  issue  from  the  spinal  column  through  the 
intervertebral  foramina  at  the  seat  of  fracture,  opium  or  morphia  must  be 
administered  in  full  doses,  and  at  sufficiently  short  intervals  to  subdue  the 
pain  and  keep  it  in  subjection.  Afterward,  the  patient  should  be  kept  mode- 
rately under  the  influence  of  morphia  as  a  precautionar\'  measure  against  con- 
secutive spinal  meningitis  and  m3'elitis,  and,  by  the  way,  opium  or  mor- 
phia thus  administered,  is  one  of  the  most  efficient  agents  for  this  purpose  in 
the  materia  medica. 

If,  in  a  few  hours  after  the  accident,  signs  of  compression  of  the  spinal  cord 
from  extravasation  of  blood  within  the  theca  vertebralis  should  a^Dpear,  the 
fluid  extract  of  ergot  should  be  given  in  full  doses,  and  at  short  intervals,  and 
an  ice-bag  should  be  applied  over  the  spinal  column,  with  a  view  to  suppress 
the  bleeding. 

Efforts  to  abate  the  inflammation  of  the  injured  structures  at  the  seat  of 
fracture,  and  thus  to  prevent  the  occurrence  of  consecutive  meningitis  and 
myelitis,  should  be  made  by  abstracting  blood  with  leeches,  by  applying  cold 
lotions,  and  by  keeping  the  fractured  bones  as  nearly  immovable  as  possible. 
The  attentive*^  reader,  doubtless,  has  already  noted  that,  in  many  of  the  suc- 
cessful cases  of  spinal  fracture  related  above,  blood  was  abstracted,  either 
generally  by  venesection  or  locally  by  cupping,  that  cooling  lotions  were 
applied  to  the  injured  part,  and  that  the  patient  lay  quietly  in  bed. 

Should  spinal  paralysis  begin  one,  or  two,  or  more  days  after  the  accident, 
or  should  a  pre-existing  paralj- sis  then  begin  to  increase  or  invade  new  parts, 
or  should  any  other  symptoms  denoting  the  presence  of  spinal  meningitis  or 
myelitis  appear,  the  surgeon  should  seek  to  control  the  inflammation  of  the 
membranes  and  substance  of  the  spinal  cord,  by  administering  ergot  and 
potassium  iodide  in  full  doses,  and  by  insisting  on  having  perfect  rest  for 
the  injured  parts,  if  this  remedial  measure  have  not  already  been  thoroughly 
enforced. 

Should  there  be  inability  to  micturate,  catherization  must  be  employed 
morning  and  evening,  and  oftener  if  necessary.  Should  there  be  constipation, 
the  bowels  must  be  moved  at  appropriate  intervals  by  giving  senna,  and  by 
administering  enemata.  The  alimentation  of  the  patient  must  be  attended 
to,  and  a  nourishing  but  easily  digestible  diet  allowed.  Every  possible  pre- 
caution, in  the  way  of  cleanliness,  etc.,  should  be  taken  against  the  formation 
of  bed-sores. 

In  regard  to  the  use  of  mechanical  contrivances  to  keep  the  broken  parts 
of  the  spinal  column  in  apposition,  and  free  from  all  motion,  thus  performing 
the  offices  that  splints  do  in  fractures  of  the  extremities,  it  is  obvious  that  it 
these  ends  could  be  accomplished  by  any  mechanical  contrivance,  the  patient's 
recovery  would  be  considerably  expedited,  and  the  risk  of  consecutive  menin- 
gitis and  myelitis  would  be  considerably  lessened  by  employing  it.  As  such 
an  apparatus,  the  plaster-of-Paris  jacket,  devised  by  Professor  Sayre,  has 


1  Op.  cit.,  p.  204, 


GUNSHOT  INJURIES  OF  THE  VERTEBRAE. 


365 


recently  been  applied  in  a  number  of  instances.  Professor  Konig,  of  Got- 
tingen,  bas  an  article  in  No.  7  of  tbe  Cevtralblatt  fur  Chinirgic,  for  1880,  on 
the  application  of  the  "  Thorax  Gypsverband"  for  fractures  of  the  spine,  and 
recounts  therein  three  cases,  in  all  of  which  there  was  considerable  displace- 
ment, with  but  very  slight,  if  any,  nervous  symptoms.  In  each  of  these  three 
cases,'  the  [)atient  was  suspended  sufficiently  to  correct  the  deformity,  and  a 
long 'jacket  reaching  down  to  the  trochanters  was  put  on  ;  and  every  one  of 
them' made  a  complete  and  rapid  recovery.  The  cases  were  all  recent  and 
simple.  Dr.  W.  Wagner,  however,  reports  two  similar  cases  in  which,  after 
the  application  of  the  jacket,  intense  pain  in  one  instance,  and  paralysis  in  the 
other,  appeared  in  the  lower  extremities,  so  that  it  was  necessary  to  remove 
the  apparatus.  In  one  case  it  was  reapplied  subsequently,  with  comfort  to 
the  patient.  Both  patients  recovered.^  Possibly,  the  failure'  of  the  first 
application  of  the  jackets,  in  the  last  two  instances,  was  due  to  not  exactly 
reducing  the  displacement  of  the  fragments  prior  to  fitting  the  jackets,  so 
that  the' apparent  want  of  success  was  caused  not  so  much  by  the  apparatus 
itself,  as  by  the  failure  to  apply  it  properly.  At  all  events,  no  great  harm 
was  done,  for  recovery  was  not  prevented  in  either  instance.  Obviously,  this 
plan  of  treatment  is  not  appropriate  for  cases  in  which  there  are  bed-sores,  or 
hi  which  inflammatory  disorganization  of  the  spinal  cord  is  already  far  ad- 
vanced. But,  for  simple,  uncomplicated  cases  of  spinal  fracture,  in  which  the 
injury  is  recent,  it  seems  likely  to  prove  of  great  service,  and  undoubtedly  is 
in  improvement  on  any  of  the  old  methods  of  treatment  now  in  vogue  for 
such  cases. 

When  the  body-temperature  rises  to  102°  F.,  or  more,  and  persists,  what 
is  to  be  done?  Possibly,  in  cases  where  the  mercuiy  stands  at  102°  or  103°, 
the  trunk  and  extremities  may  be  sponged  with  diluted  alcohol,  from  time 
to  time,  with  advantage;  and,  in  cases  where  it  rises  to  105°,  or  more,  and 
the  extinction  of  life  is  threatened  by  the  body-heat  itself,  it  may  be  advisable 
to  use  the  "  cold-water  pack,"  carefully  noting  its  eftects,  meanwhile. 

When  the  body-temperature  sinks  below  the  normal  limit,  whether  the 
coldness  be  confined  to  the  paralyzed  parts  or  diftused  over  the  whole  system, 
care  must  be  taken  in  applying  artificial  heat— e.  g.,  bottles  of  hot-water, 
heated  bricks,  or  sad-irons,  etc.— lest  the  parts  to  which  they  are  applied 
become  burned  from  the  negligence  of  the  attendants. 


Gunshot  Injuries  of  the  Vertebra. 

Soldiers  are  sometimes  killed  in  battle  by  gunshot  injuries  of  the  cervical 
vertebrae.  Dr.  Otis^  reports  two  instances  of  this  sort  that  he  had  himself 
seen,  in  which  the  ball  lodged  in  the  cervical  spine,"  among  the  bodies  of 
those  lying  dead  on  the  field  of  battle  before  Kew  Berne.  Gunshot  injuries 
of  the  spinal  column  may  thus  quickly  destroy  life :  (1)  By  dividing  or  crush- 
ing the  spinal  cord  above  the  third  cervical  vertebra,  that  is,  above  the  roots 
of  the  phrenic  nerves,  thereby  completely  and  instantaneously  arresting  the 
respiratory  movements  ;  and  (2)  By  opening  the  vertebral  artery,  in  some  part 
of  its  course  within  the  canal  formed  by  the  vertebral  foramina  in  the  trans- 
verse processes  of  the  six  upper  cervical  vertebrae. 

Mr.  Shaw3  has  placed  on  record,  together  with  a  wood-cut,  the  tollowing 
example,  which  admirably  illustrates  the  first  of  these  two  modes  in  which 

'  Medical  Times  and  Gazette,  December  18,  1880. 

2  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Volume,  p.  603. 
*  Holmes's  System  of  Surgery,  vol.  ii.  p.  395. 


366 


INJURIES  OF  THE  BACK. 


gunshot  lesions  of  the  spinal  column  may  destroy  life  with  great  sudden- 
ness : — 

A  gentleman  was  wounded  by  a  pistol-shot  in  the  back  of  his  neck  while  lying  asleep 
on  his  side  ;  his  mistress,  who  was  awake  at  the  time,  stated  that  he  did  not  stir  a  limb 
nor  move  in  any  way,  although  the  report  was  loud.  Death,  therefore,  must  have  been 
instantaneous.  Necroscopy  showed  that  the  missile  entered  at  the  median  line,  passed 
horizontally  forward  between  the  arches  of  the  atlas  and  the  axis,  severed  the  spinal 
cord,  and  stuck  fast  in  the  odontoid  process  near  its  base,  having  fissured  the  same.  The 
specimen  is  preserved  in  the  museum  of  Middlesex  Hospital. 

In  regard  to  the  second  of  these  two  modes  in  which  life  may  be  suddenly 
destroyed,  it  should  be  stated  that  gunshot  fractures,  involving  any  of  those 
transverse  processes  of  the  cervical  vertebrse  through  whose  foramina  the 
vertebral  artery  runs,  may  readily  lay  the  artery  widely  open,  and  that  the 
primary  hemorrhage  therefrom  would  soon  prove  fatal;  certainly,  death  would 
ordinarily  ensue  before  a  man  thus  wounded  could  be  removed  from  a  field 
of  battle.  In  this  connection  it  may  be  well  to  state  also  that  gunshot  frac- 
tures of  these  transverse  processes  are  not  unfrequently  attended  by  secondary 
hemorrhage  of  a  fatal  character,  which  usually  appears  some  ten  or  twelve 
days  after  the  casualty  has  occurred. 

For  instance.  Baron  Dupuytren^  mentions  the  case  of  a  carpenter,  aged  31,  who  re- 
ceived a  gunshot  wound  of  the  face  and  neck.  The  ball  entered  his  nose.  The  wound 
did  well  for  ten  days,  when  secondary  hemorrhage  set  in,  and  caused  death.  Necro- 
scopy showed  that  a  transverse  process  of  the  second  cervical  vertebra  was  fractured, 
and  that  the  hemorrhage  arose  from  the  corresponding  vertebral  artery. 

Usually,  in  such  cases,  the  laying  open  of  the  artery,  so  that  the  blood  may 
issue  therefrom,  is  caused  either  by  the  separation  of  a  slough  consisting  of 
the  tissues  which  have  been  bruised  by  the  missile  in  its  passage,  or  by  the 
perforation  of  the  arterial  tunics  by  an  ulcerative  process.  In  the  following 
instance,  however,  it  was  caused  by  the  beating  of  the  vertebral  artery  itself 
against  a  sharp  fragment  of  the  transverse  process  which  had  been  fractured : — 

Samviel  S.  was  wounded  at  the  battle  of  Williamsburg,  May  5,  1862,  by  a  musket- 
ball  which  entered  his  face  to  the  left  of  the  symphysis  of  the  inferior  maxilla,  smashed 
that  bone,  and  carried  away  several  teeth,  with  a  part  of  the  tongue  and  of  the  posterior 
wall  of  the  pharynx,  and  lodged.  He  had  extreme  dysphagia.  On  the  13th,  the  ball 
and  several  teeth  were  removed  from  an  abscess  above  the  clavicle.  On  the  IGtli, 
copious-  hemorrhage  from  the  original  wound  occurred,  which  was  arrested  by  tying  the 
common  carotid  artery  under  ether.  Seven  days  after  that,  a  fresh  hemorrhage  set  in 
from  the  aperture  through  which  the  missile  had  been  extracted  ;  an  unsuccessful 
attempt  was  made  to  find  the  bleeding  vessel.  He  died  on  the  same  day  (May  23)  of 
ansemic  exhaustion  resulting  from  the  hemorrhage.  Necroscopy  showed  that  a  trans- 
verse process  of  the  third  cervical  vertebra  had  been  fractured  by  the  ball,  and  that  the 
vertebral  artery  had  rubbed  against  a  spiculum  thus  produced  until  it  was  worn  through  ; 
hence  the  secondary  hemorrhage  arose. ^  The  first  hemorrhage,  doubtless,  sprang  from 
some  branch  of  the  external  carotid  artery  in  the  face,  mouth,  or  throat,  which  had  been 
injured  by  the  missile,  and,  therefore,  it  was  possible  to  suppress  it  by  ligaturing  the 
common  carotid  artery. 

Gunshot  contusions  of  the  spinal  column  were,  I  believe,  first  mentioned 
by  Dr.  Louis  Stromeyer,  while  writing  from  his  experience  as  surgeon-in-chief 
of  the  Schleswig-Holstein  army,  in  1849.    He  says : — 

In  two  cases  the  cervical  vertebrae  were  contused  by  bullets  which  entered  on  the 
outer  side  of  the  sterno-mastoid  muscle,  and  likewise  bruised  the  brachial  {)lexus  of 

»  Op.  cit. 

2  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Sul-gical  Volume,  p.  355. 


GUNSHOT  INJURIES  OF  THE  VEKTEBR.E. 


307 


nerves ;  the  paralysis  of  the  corresponding  arm  was  at  first  so  complete  tliat  I  considered 
the  brachial  plexus  must  have  been  torn  by  the  bullet ;  but,  gradually,  sensation  and 
motion  almost  fully  returned. 

"  In  a  case  of  contusion  of  the  cervical  vertebrne  by  a  similar  shot,  there  has  remained 

till  this  moment  a  period  of  four  months — stiffness  and  pain  in  the  neck  on  motion. 

In  all  these  cases  small  sequestra  escaped."^ 

In  cases  where  the  vertebrae  are  contused  by  gunshot  missiles,  the  bodies 
are  the  portions  thereof  which  are  usually  found  to  be  affected.   Indeed,  I  am 
not  acquainted  with  any  instance  where  this 
lesion  was  confined  to  the  vertebral  apophyses.  Fig-  ^64. 

The  consequences  of  gunshot  contusions  of 
the  vertebrae  are:  1,  necrosis  of  the  bruised 
parts  ;  2,  caries  of  the  same  ;  and  3,  inflamrna- 
tton  of  the  injured  bone,  which  may  spread  to 
the  membranes  and  substance  of  the  spinal 
cord. 

1.  As  examples  of  necrosis,  Stronieyer's 
three  cases  just  mentioned  above,  in  each  of 
which  small  sequestra  escaped  from  the 
wound,  may  be  appropriately  cited. 

2.  As  an  instance  of  caries  arising  from 
this  cause,  the  following  abstract,  together 
with  the  accompanying  wood-cut  (Fig.  864), 

may  be  presented  :   showing  caries  of  the  last  two  cervical 

vertehrse   caused   by  gunshot  contusion. 

Private  George  A.  A.,  20th  New  York  Volun-    (Spec.  1867,  See  i,  a.  m.  m.) 
teers,  aged  40,  was  wounded  at  Gettysburg,  July  2, 

1863,  by  a  conoidal  ball,  which  fractured  the  right  lower  jaw,  struck  the  bodies  of  the 
sixth  and  seventh  cervical  vertebrae,  and  lodged.  It  is  said  that  the  missile  was  after- 
ward ejected  by  the  patient  from  his  mouth.  But  pyaemia  supervened  and  caused 
death.  It  is  stated  that  the  patient  had  dyspna3a,  but  no  paralysis ;  that  he  walked 
about  until  a  few  days  before  his  death,  which  occurred  on  the  21st  (nineteen  days  after 
the  casualty  occurred)  ;  that  he  had  complained  only  of  a  slightly  uneasy  feeling  in  the 
neck  when  turning  his  head  ;  and  that  the  injury  of  the  cervical  vertebriB  was  not  sus- 
pected during  life.  Necroscopy  showed  that  the  bodies  of  the  sixth  and  seventh  cervical 
vertebrae  were  carious  in  the  parts  where  they  had  been  struck  and  bruised  by  the  mis- 
sile (see  Fig.  864),  and  that  a  fissured  fracture  extended  tlirougli  the  body  of  the  sixth 
vertebra.  Pycemic  lesions,  too,  were  found  ;  that  is,  the  right  lung  was  in  a  condition 
of  recent  pneumonia,  and  filled  with  a  multitude  of  small  abscesses,  the  presence  of 
which  fully  accounted  for  the  occurrence  of  dyspnoea.  The  oesophagus,  the  trachea,  and 
tlie  bronchial  mucous  membrane  were  inflamed.^  In  this  case,  the  contusion  of  the 
cortex  or  outer  lamella  of  the  body  of  the  sixth  cervical  vertebra  was  complicated  by  a 
fissured  fracture  of  the  vertebral  body;  the  body  of  the  seventh  cervical  vertebra, 
however,  was  not  fractured,  but  only  bruised  and  carious.  The  carious  condition  of 
both  vertebrte  is  well  shown  in  Fig.  864.  The  specimen  which  it  represents  is  pre- 
served in  the- Army  Medical  Museum. 

3.  The  spreading  of  inflammation  from  the  injured  bone  to  the  membranes 
and  substances  of  the  spinal  cord,  with  a  fatal  result  in  consequence  thereof, 
may  be  illustrated  in  a  useful  maimer  by  presenting  another  example  taken 
from  Stromeyer  : — 

"  In  a  case  where  a  bullet,  entering  laterally,  severely  bruised  the  third  and  fourth 
cervical  vertebrte,  and  was  not  extracted,  death  followed  in  consequence  of  the  advance 
of  inflammation  into  the  spinal  cord  and  brain  ;  there  was  at  first  palsy  of  the  arm 

»  Stromeyer  on  Uaiishot  Fractures,  translated  by  S.  F.  Stathara,  pp.  37,  38.    Am.  ed. 
«  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Vol.,  p.  431. 


368 


INJURIES  OF  THE  BACK. 


belonging  to  the  injured  side  ;  it  was  followed  by  incomplete  paralysis  of  all  the  limbs, 
ending  in  stupor.    Antiphlogistic  treatment  had  been  entirely  neglected."^ 

Etiology,  The  impact  of  gunshot  missiles  upon  the  bodies  of  the  vertebrae 

causes  contusion  thereof  only  when  the  force  of  the  missiles  is  nearly  spent, 
on  the  one  hand,  or  when  the  direction  of  their  flight  is  very  oblique,  so  that 
they  strike  a  glancing  blow,  on  the  other  hand.  When  endowed  with  less 
force,  they  do  no  injury  ;  and  with  greater  force  they  produce  fractures. 

Treatment. — The  principal  indication  in  the  therapeusis  of  gunshot  con- 
tusions of  the  spinal  column  is  to  prevent  the  occurrence  of  inflammation  in 
the  injured  bone,  and  the  spread  of  the  inflammatory  process  therefrom  to 
the  meninges  and  medulla  spinalis.  This  can  best  be  accomplished  by  the 
extraction  of  all  foreign  bodies  from  the  wounds,  by  the  employ ment  of  anti- 
septic dressings,  by  thorough  drainage  by  means  of  appropriate  tubes,  inserted 
for  the  purpose  whenever  necessary  to  prevent  the  collection  of  purulent 
secretions,  and  by  enforcing  perfect  rest  of  the  injured  spinal  column. 

Gunshot  fractures  of  the  vertebra  are  caused  by  the  impact  of  shell- 
fragments,  spent  cannon-balls,  and  small-arm  missiles,  but  chiefly  by  the 
impact  of  the  last  named,  after  they  have  penetrated  the  integuments  and 
other  structures  that  cover  the  spinal  column  at  the  place  of  injury,  or  have 
reached  it  by  passing  through  the  great  cavities  of  the  body  and  organs 
which  lie  in  front.  In  some  rare  instances,  however,  the  fractures  produced 
by  cannon-balls  and  shell-fragments  are  simple,  the  integuments  covering 
them  being  unbroken.  Gunshot  fractures  of  the  vertebrae  are  usually  com- 
minuted in  character  as  well  as  compound  ;  and  they  are  very  often  com- 
plicated with  injury  of  the  spinal  cord  and  other  important  organs. 

For  descriptive  purposes,  gunshot  fractures  of  the  vertebrae  may  advan- 
tageously be  divided  into  two  classes — namely,  those  which  are  restricted  to 

the  apophyses,  and  those  which  involve  the 
Fig-  vertebral  bodies  also.    The  former  are  some- 

times, perhaps  frequently,  unattended  by  in- 
jury of  the  spinal  cord ;  the  latter  are  but 
seldom  uncomplicated  with  such  injury.  The 
former,  too,  are  less  fatal,  as  a  rule,  than  the 
latter. 

The  chief  characteristics  pertaining  to  gun- 
shot fractures  of  the  spinal  column,  in  general, 
are  well  shown  by  the  following  abstract,  and 
by  the  wood-cut  (Fig.  865)  which  accompanies 
it:— 

Showing  a  gunshot  fracture  of  the  body 

and  left  transverse  process  of  the  ninth       ^  soldier  was  wounded  by  a  conoidal  pistol-ball 

dorsal  vertebra.   The  niissile  and  nine  frag        ^^^.^^^  ^^^.^j^  ^  j^^j^  -^^j^^^ 

ments  of  bone  are  also  shown,    (bpec.  5738,      V   ,  ,  ,  ,     .  .  ,      /•   i     i   p.     •  i 

Sect.  I,  A.  M.  M.)  below  and  a  httle  to  the  inner  side  of  the  left  nipple, 

passed  backward,  grazing  the  apex  of  the  heart, 
through  the  left  lung,  and  onward  through  the  body  and  left  transverse  process  of  the 
ninth  dorsal  vertebra  ;  it  lodged  in  the  subcutaneous  tissue  of  the  back,  from  which  it 
was  extracted,  together  with  some  small  fragments  of  bone,  through  a  small  incision. 
The  patient  was  paralyzed  below  the  middle.  He  died  of  traumatic  pericarditis  and 
j)neumonia,  four  days  after  the  wound  was  inflicted.^  The  deep  groove  across  the  spinal 
column  which  was  punched  out  by  the  missile,  and  the  comminution  of  the  injured  bone, 
are  well  depicted.  The  occurrence  of  paraplegia,  of  course,  denotes  that  the  spinal 
cord  was  also  injured. 

I  Op.  cit.,  p.  38.  2  Circular  No.  3,  S.  G.  0.,  August  17,  1871. 


GUNSHOT  INJURIES  OF  THE  VERTEBRA. 


360 


Sometimes  the  missile  punches  a  ragged  hole  through  the  vertebral  colunm 
obliquely  from  behind  forward,  and  emerges  from  the  body  of  a  vertebra, 
having  crushed  the  spinal  cord  in  its  course;  as,  for 
instance,  it  did  in  a  specimen  which  the  writer  con-  Fig-  ^66. 

tributed  to  the  Army  Medical  Museum,  and  which 
is  represented  by  the  annexed  wood-cut  (Fig.  86()) : 

The  missile  entered  through  tlie  left  intervertebral 
foramen  between  tlie  third  and  fourth  lumbar  vertebrce, 
chipping  the  superior  articular  process  of  the  iifth  and  the 
adjacent  portion  of  the  spinous  process  of  the  fourth,  and 
fracturing  the  left  transverse  process  of  the  fourth,  passed 
obliquely  forward  and  toward  tlie  right,  and  emerged  from 
the  body  of  the  third  lumbar  vertebra  on  its  right  side. 
The  patient  'survived  long  enough  for  incipient  caries  to 
appear  in  the  injured  bones.* 

In  the  celebrated  and  historical  case  of  President 
Garfield,  the  ball  penetrated  the  first  lumbar  ver- 
tebra in  the  upper  part  of  the  right  side  of  its  body 
(Fig.  867):- 

The  aperture  by  which  it  entered  involved  the  inter- 
vertebral cartilage  next  above,  and  was  situated  just  below 
and  anterior  to  the  intervertebral  foramen,  from  which  its 
upper  margin  was  about  one-fourth  of  an  inch  distant. 
Passing  obliquely  to  the  left  and  forward  through  the 
upper  part  of  the  body  of  the  first  lumbar  vertebra,  the 

bullet  emerged  by  an  aperture,  the  centre  of  which  was  about  half  an  inch  to  the  left  of  the 
median  Hne,  and  which  also  involved  the  intervertebral  cartilage  next  above  (Fig.  807). 


Showing  gunshot  fracture  of  the 
third  lumbar  vertebra  with  the  mis- 
sile (a  conoidal  musket-ball)  attach- 
ed.   (Spec.  2.532,  Sect.  I,  A.  M.  M.) 


Fig.  867. 


12th  Dorsal 
vertebra. 


1st  Lumbar 
vertebra. 


2d  Lumbar 
vertebra. 


Showing  the  hole  made  by  the  missile  (a  conoidal  pistol-ball)  through  the  body  of  the  first  lumbar  vertebra, 
in  the  case  of  President  Garfield.    A  probe  penetrates  each  orifice.  2.^ 

The  cancellated  tissue  of  the  body  of  the  first  lumbar  vertebra  was  very  much  com- 
minuted, and  the  fragments  were  very  much  displaced.  Several  deep  fissures  extended 
from  the  track  of  the  bullet  upward  into  the  lower  part  of  the  body  of  the  twelfth  dor- 
sal vertebra.  Others  extended  downward  through  the  first  lumbar  vertebra  into  the 
intervertebral  cartilage  between  jt  and  the  second  lumbar  vertebra.  Both  this  cartilage 
and  that  next  above  were  partly  destroyed  by  ulceration.  A  number  of  minute  frag- 
ments from  the  fractured  lumbar  vertebra  were  driven  into  the  adjacent  soft  parts.  On 
sawing  through  the  vertebme  from  behind,  a  little  to  the  right  of  the  median  line 
(Fig.  868),  it  was  found  that  the  spinal  canal  was  not  involved  by  the  track  of  the  mis- 
sile.   The  spinal  cord  and  other  contents  of  the  spinal  canal  presented  no  abnormal 

^  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Volume,  p.  446. 

VOL.  IV. — 24 


370 


INJURIES  OF  THE  BACK. 


appearance.  The  fractured  spongy  tissue  of  the  vertebrse  was  suppurating.  The  mis- 
sfle  was  lodged  behind  the  pancreas.  Secondary  henaorrhage  from  the  splenic  artery 
had  luperve^ed,  causing  death  seventy-eight  days  after  the  infhct.on  of  the  wound.' 


.Fig.  868. 


Fig. 


Interior  view  of  the  last  dorsal  and  first  two  lumbar  ver-  Showing  two  lumbar  vertebrae  that  were  per- 

tebr^  in  the  case  of  President  Garfield.    They  have  been  laid  forated  from  behind  forward  and  were  fissured 

open  'from  behind  by  sawing  vertically  through  their  lamin.  vertically,  through  thexr  bod.es    by  a  cono^a 

and  bodies,  a  little  to  the  right  of  their  spinous  processes.  musket-ball  which  passed  :nto  the  perxtoneal 

The  intervertebral  substances  have  been  destroyed  by  the  in-  cavity.    (  Spec.  3583,  Sect.  I,  A.  M.  M.  ) 

flammatory  process.  The  cancellated  tissue  of  the  bodies  is 
extensively  disorganized  by  suppurative  osteomyelitis,  as 
well  as  by  the  impact  of  the  missile.  |.. 

In  the  case  of  President  Garfield,  the  shot  fractures  of  the  last  dorsal  and 
first  two  lumbar  vertebrK  were  followed  by  suppurative  osteo-niyehtis  and  de- 
struction by  ulceration  of  the  corresponding  intervertebral  disks,  from  which 
disorders  arose  the  symptoms  of  septicaemia  that  presented  themselves  at  one 
time  in  the  history  of  his  case,  and,  finally,  the  secondary  hemorrhage  that 
destroyed  his  life.  The  prognosis  in  cases  of  suppurative  osteo-myehtis  arising 
from  vertebral  fractures  is  always  very  bad ;  in  fact,  such  cases  are  scarcely 

amenable  to  any  treatment.  ,    ^  j  i.i    i  i,„.. 

In  the  following  example,  a  conoidal  musket-ball  penetrated  the  lumbar 
portion  of  the  spinal  column  from  behind,  passed  forward  through  the  bodies 
of  the  vertebrai,  having  crushed  the  spinal  cord,  and  entered  the  abdominal 
cavity,  where  it  wounded  the  liver,  and  likewise  caused  peritonitis,  which 
proved  fatal  in  four  days: — 

A  corporal,  having  been  wounded  in  front  of  Petersburg,  on  July  30  1864,  was 
sent  to  Washington,\nd  admitted  to  Douglas  Hospital,  on  August  3,  with  complete 
paraplegia  and  peritonitis.  He  died  on  the  same  day  Necrosc<ypy  reve^Jed  the  pas- 
Lge  of  the  missile  into  the  abdommal  cavity  through  the  spmal  column,  lacerataon 
of  the  liver,  with  peritoneal  inflammation  and  the  products  thereof  The  fractured 
vertebree  and  the  missile  are  represented  in  the  adjoinmg  wood-cut  (Fig.  8by>. 

Small-arm  missiles,  as,  for  instance,  musket  and  pistol  balls,  etc  of  ten  lodge 
in  the  bodies  or  apophyses  of  the  vertebrse,  m  such  a  manner  that  e  t  ier  heii 
position  cannot  be  emctly  ascertained,  or  they  cannot  be  extracted  in  eonse- 
auence  of  the  firmness  of  their  impaction.  This  important  class  of  spmal 
?njurLs  will  be  illustrated  in  a  useful  mariner  by  the  next  half  dozen  abstracts 
and  wood-cuts : — 

A  soldier,  aged  20,  was  wounded  in  the  back  at  Monocacy,  Md.,  July  9,  1864,  and 
admitted  to  hospital  atFrederick,  on  the  next  day.  The  missile  (a  conoidal  musket-ball) 


GUNSHOT  INJURIES  OF  THE  VERTEBRiE. 


371 


i  t7  ^ 

iii  i  ik  ' 


held  entered  at  the  inferior  border  of  the  left  scapula,  passed 
inward  and  backward,  struck  the  spinal  column,  and  lodged, 
having  instantaneously  caused  complete  paraplegia  below  the 
wound,  with  inability  to  micturate.  On  the  12th,  the  urine 
began  to  dribble  away  spontaneously,  and  defecation  occurred 
involuntarily.  He  made  no  complaint  of  pain.  Bed-sores 
over  the  sacrum,  etc.,  depending  upon  the  mal-nutrition  of 
the  parts  which  resulted  from  the  injury  of  the  spinal  cord, 
soon  followed.  Nevertheless,  he  survived  until  October  13, 
and  then  died  of  pleuro-pneumonia.  Necroscopy  showed 
that  the  missile  had  passed  through  the  left  intervertebral 
foramen  between  the  ninth  and  tentli  dorsal  vertebras,  pro- 
ducing only  a  very  slight  fracture  ;  and,  turning  upward  in 
the  spinal  canal,  had  lodged  in  it  opposite  the  body  of  the 
fifth  dorsal  vertebra.  The  upper  end  of  the  spinal  cord  was 
much  softened.  The  lodgment  of  the  missile  is  well  shown 
in  the  adjoining  wood-cut  (Fig.  870).^ 

A  soldier,  aged  26,  was  wounded  at  Cold  Harbor,  Va., 
June  3,  1864,  by  a  conoidai  musket-ball,  which  penetrated 
the  right  side  of  his  back,  shattered  the  right  transverse  and 
articular  processes  of  the  eighth  and  ninth  dorsal  vertebra?, 
and  entered  the  spinal  canaL  He  immediately  lost  all  sen- 
sation and  voluntary  motion  below  the  wound.  On  the  Uth, 
he  was  admitted  to  general  hospital.  There  was  then  psy- 
chical depression,  with  slow  pulse,  labored  respiration,  cold, 
clammy,  and  cyanosed  skin,  and  involuntary  passage  of  the 
excretions.  Gastric  irritability  supervened,  with  rejection 
of  all  kinds  of  nourishment,  and  he  died  on  July  2.  'Necros- 
copy revealed  the  missile  imbedded  in  the  spinal  canal,  as 

shown  in  Fig.  871.  The  spinal  cord  was  severed  and  disorganized  above  and  below 
the  missile.^ 

Corporal  G.  W.  M.,  aged  19,  was  wounded  at  Cold  Harbor,  Va.,  June  3,  1864,  and 
admitted  to  general  hospital  on  the  7th.    He  was  suffering  from  paraplegia  with  reten- 


Showing  the  fifth,  sixth, 
seventh,  and  eighth  dorsal  ver- 
tebrae, with  the  body,  etc.,  of 
the  fifth  horizontally  divided, 
and  a  conoidai  musket-ball 
(also  divided)  lodged  in  the  spi- 
nal canal.  (Spec.  3984,  Sect.  I, 
A.  M.  M.) 


Fig.  871. 


Fig.  872. 


Showing  a  conoidai  musket-ball  lodged  in  the  spinal 
canal  between  the  eighth  and  ninth  dorsal  vertebra;. 
(Spec.  2939,  Sect  I,  A.  M.  M.) 


Showing  gunshot  fracture  of  the  left  transverse  pro- 
cess and  body  of  the  seventh  dorsal  vertebra,  with  the 
missile  in  situ.    (Spec.  3030,  Sect.  1,  A.  M.  M.) 


tion  of  urine  and  traumatic  pneumonia.  A  conoidai  musket-ball  had  entered  his  back 
near  the  inferior  angle  of  the  left  scapula,  and  passinir  downward,  inward,  and  forward 
through  the  left  lung,  had  fractured  the  transverse  process  of  the  seventh  dorsal  verte- 
bra, and  lodged  in  the  body  of  the  same.    Owing  to  his  extreme  prostration,  no  anti- 


»  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Vol.,  p.  440. 
2  Ibid.,  p.  439 


372 


INJURIES  OF  THE  BACK. 


Fig.  873. 


phlogistic  measures  of  an  active  character  were  employed.  Stimulating  frictions  were 
frequently  applied  to  the  legs  and  hips,  and  the  chest  was  enveloped  in  an  oil-skin  jacket. 

He  died  on  the  19th.    Necroscopy  The  ball  was  found  imbedded  in  the  body  of  the 

seventh  dorsal  vertebra,  encroaching  upon  the  medulla  spinalis,  as  represented  in  the 
accompanying  wood-cut  (Fig.  872).  The  lungs  were  hepatized  at  their  bases ;  and, 
near  their  apTces,  were  filled  with  a  dark,  frothy  liquid.^ 

A  colored  soldier,  aged  about  25,  was  wounded  at  Brownsville,  Texas,  January  28, 
1866,  by  a  pistol-shot%nd  died  in  thirty-eight  hours,  from  shock  and  internal  hem- 
orrhage. Necroscopy  showed  that  the  missile  had 
entered  two  inches  below  and  outside  of  the  left 
nipple,  gouged  its  calibre  from  the  upper  border  of 
the  eighth  rib,  passed  downward,  inward,  and  back- 
ward, through  the  lower  lobe  of  the  right  lung,  the 
diaphragm,  and  the  right  lobe  of  the  liver,  and  had 
lodged  in  the  body  of  the  last  dorsal  vertebra,  frac- 
turing it  as  shown  in  the  adjoining  wood-cut  (Fig. 
873),  which  represents  the  specimen  now  preserved 
in  the  Army  Medical  Museum.^ 

A  quartermaster's  sergeant,  aged  36,  was  wounded 
at  Compton,  La.,  April  4,  1864,  by  a  grape-shot, 
which  entered  his  loins  one  inch  to  the  right  of  the 
spinous  processes,  and  about  two  inches  below  the 
last  rib,  and,  passing  forward  and  slightly  downward  and  inward,  struck  the  spinal 
column,  and,  lodging,  was  not  extracted.  On  the  10th  he  was  admitted  into  University 
Hospital,  at  New^'Orleans.  There  was  no  paralysis.  The  symptoms  of  pyaemia,  however, 
supervened,  and  he  died  of  that  disease  on  the  18th.  Necroscopy  revealed  a  round 
iron  ball,  about  one  inch  in  diameter,  lodged  on  the  left  psoas  magnus  muscle.  The 
spinous  processes  and  laminae  of  the  last  dorsal  and  first  lumbar  vertebra  were  frac 
tured  and  displaced,  and  thus  the  spinal  canal  was  laid  open.  The  specimen  is  repre- 
sented  by  the  accompanying  wood-cut  (Fig.  874).    Purulent  infiltration  was  found  in 

the  psoas  muscles,  with  their  investments,  and 


Showing  a  pistol-ball  (calibre  37)  lodged 
in  the  body  of  the  last  dorsal  vertebra,  hav- 
ing fractured  the  same  with  much  commi- 
nution    (Spec.  3780,  Sect.  1,  A.  M.  M.) 


Fig.  874. 


in  the  peritoneal  cavity.  Tw^o  small  circum- 
scribed metastatic  abscesses  were  found  in  the 
right  lobe  of  the  liver.  There  were  no  signs 
of  paralysis  present  during  life.^ 

A  sergeant  of  infantry  was  wounded  at 
Opequon  Creek,  near  Winchester,  Va.,  Sep- 

Fig.  875. 


Showing  fractures  of  the  spinous  processes  and 
laminseof  the  last  dorsal  and  first  lumbar  vertebrae, 
caused  by  a  round  iron  ball  about  one  inch  in  diam- 
eter.   (Spec.  3739,  Sect.  I,  A.  M.  M.) 


Showing  a  conoidal  musket-ball  imbedded  in  the 
intervertebral  substance  between  the  third  and  fourth 
lumbar  vertebrae.    (Spec.  3796,  Sect.  I,  A.  M.  M.) 


tember  19,  1864,  by  a  conoidal  musket-ball,  which  penetrated  the  lumbar  region  through 
the  erector-si)inae  muscles,  a  few  inches  above  the  posterior  crest  of  the  ilium,  and  lodged. 


1  Med.  and  Hiivg.  History  of  the  War  of  the  Rebellion,  First  Surgical  Vol.,  p.  438. 

2  Ibid.,  p.  441.  '  Ibid.,  p.  443. 


GUNSHOT  INJURIES  OF  THE  VERTEBRA. 

The  left  ankle  and  lower  third  of  the  femur  were  shattered,  for  which  amputation  of 
the  thigh  was  performed.  The  only  symptom,  indicating  that  the  spinal  cord  or  spinal 
nerves  were  injured,  was  paralysis  of  the  right  leg.  Necroscopy.— The  missile  was 
found  imbedded  in  the  intervertebral  substance  between  the  third  and  fourth  lumbar 
vertebra?,  as  shown  in  the  adjacent  wood-cut  (Fig.  875),  which  represents  the  speci- 
men.   There  was  very  little  pus  in  the  wound.* 

Prognosis. — Gunshot  lesions  of  the  sphial  cokimn  are  very  serious  injuries. 
They  proved  fatal  in  more  than  one-half  of  the  instances  which  came  under 
treatment  during  our  late  civil  war ;  and  many  who  sustained  such  injuries 
must  have  perished  on  the  tield  before  any  treatment  could  be  adopted. 

Six  hundred  and  forty -two  cases  of  gunshot  injury  of  the  vertebrpe  were 
reported  by  our  military  surgeons  during  the  late  civil  war.  Of  these,  three 
hundred  and  forty-nine,  or  55.5  per  cent.,  proved  fatal;  one  hundred  and 
seventy-five  soldiers  were  discharged  from  the  service;  one  hundred  and  four 
were  returned  to  duty  ;  while,  in  fourteen  instances,  the  result  is  not  known. 
Again,  of  these  six  hundred  and  forty-two  cases,  the  cervical  vertebnie  were 
injured  in  ninety-one,  with  a  mortality  of  sixty-three,  or  70  per  cent. ;  the 
dorsal  vertebrge,  in  one  hundred  and  thirty-seven,  with  a  mortality  of  eighty- 
seven,  or  63.5  per  cent. ;  the  lumbar  vertebrae,  in  one  hundred  and  forty-nine, 
with  a  mortality  of  sixty-six,  or  45.5  per  cent. ;  the  cervical  and  dorsal,  in 
two  instances,  of  which  one  proved  fatal;  and  the  dorsal  and  lumbar,  in  three 
instances,  which  all  proved  fatal.  In  two  hundred  and  sixty  cases,  where  the 
injured  vertebrae  were  not  specified,  one  hundred  and  twenty-nine,  or  49.4  per 
cent.,  proved  fatal.  .    ,  .  .    .     .  , 

The  percentaa:e  of  mortality  above  stated  is,  for  vertebral  injuries  in  the 
cervical  region,"70,  for  those  in  the  dorsal  region,  63.5,  and^  for  those  in  the 
lumbar  region,  45.5.  Other  things  being  equal,  the  prognosis  is  less  unfavor- 
able in  cases  where  the  dorsal  vertebrae  are  wounded  by  gunshot  missiles, 
than  it  is  in  cases  where  the  cervical  vertebrae  are  injured  in  this  manner ; 
and,  in  cases  wdiere  the  lumbar  vertebrae  are  affected,  it  is  much  less  unfavor- 
able than  it  is  in  cases  where  the  dorsal  vertebrae  are  involved,  and  very 
much  less  unfavorable  than  it  is  in  cases  where  the  cervical  vertebrae  are 
injured. 

Gunshot  fractures  of  the  cervical  vertebrae,  when  attended  by  complete 
paraplegia,  are  almost  always  fatal ;  and,  generally,  death  occurs  before  the 
fourth  day  in  such  cases.  I  had  under  my  care  at  the  battle  of  Fair  Oaks, 
May  31  and  June  1,  1862,  two  cases  in  which  there  were  fractures  of  the 
lower  cervical  vertebrae  caused  by  musket-balls. 

In  both  cases,  the  upper  as  well  as  the  lower  extremities,  and  all  the  parts  and  organs 
that  were  suppUed  with  spinal  nerves  which  issued  from  the  spinal  column  at  or  below 
the  seat  of  the  lesions,  were  completely  paralyzed  in  respect  to  both  sensation  and 
voluntary  motion.  There  was  retention  of  urine  and  feces,  and  catheterization  iiad  to 
be  resorted  to.  The  respiration  was  entirely  diaphragmatic,  for  all  the  respiratory 
nerves,  excepting  the  phrenic,  were  paralyzed.  The  inferior  margin  of  the  thorax  was 
also  drawn  inward,  whenever  the  diaphragm  contracted,  thus  reducing  the  antero-pos- 
terior  and  lateral  diameters  of  the  chest,  as  well  as  increasing  the  vertical  diameter 
thereof,  at  the  end  of  every  movement  of  inspiration.  The  muscular  wall  of  the  abdo- 
men was  relaxed  and  flaccid  till  tympanites  supervened,  which  added  much  to  the 
respiratory  embarrassment.  Both  patients  died  asphyxiated ;  one  of  them  on  the 
third,  and  the  other  on  the  fourth  day  after  the  injury  was  inflicted.  The  intellect  was 
clear  in  both  cases,  and  there  were  no  head-symptoms  w^hatever,  until  the  stupor  of 
asphyxia  approaching  a  fatal  termination  appeared.  No  autopsies  were  held,  from 
want  of  time  to  make  them. 


1  Ibid.,  p.  450. 


374  INJURIES  OF  THE  BACK. 


A.  M.  Soteldo  was  wounded,  on  Thursday  night,  February  9,  1882,  at  the  editorial 
rooms  of  a  Washington  newspaper,  by  a  cylindro-conoidal  pistol-ball,  which  entered 
the  back  of  his  neck  four  inches  below  the  occipital  protuberance  and  slightly  to  the 
left  of  the  median  line,  passed  forward  and  slightly  upward,  fractured  the  lamina  of  the 
fourth  cervical  vertebra  a  little  to  the  left  of  the  spinous  process  thereof,  penetrated  the 
spinal  dura  mater  (theca  vertebralis),  and  imbedded  itself  in  the  left  intervertebral 
foramen  between  the  fourth  and  fifth  cervical  vertebrae,  having  bruised  and  slightly 
lacerated  the  spinal  cord,  and  driven  into  its  substance  a  small  splinter  of  bone.  He 
immediately  became  "  paralyzed  from  the  head  down,"  that  is,  all  of  his  extremities 
and  the  whole  of  his  body  below  the  neck,  were  completely  deprived  of  sensibility  and 
voluntary  motility.  The  respiratory  movements  were  performed  by  the  diaphragm 
alone.  He  died  at  10  h.  25  m.  on  the  night  of  Saturday,  the  11th,  about  forty-eight 
hours  after  the  casualty  occurred.  The  autopsy  revealed  the  course  and  place  of  lodg- 
ment of  the  missile,  and  the  injuries  done  by  it,  which  have  just  been  described.  The 
missile  weighed,  after  extraction,  eighty-seven  grains. 

There  is,  however,  recorded  in  the  first  surgical  volume  of  the  Medical  and 
Surgical  History  of  the  late  Civil  War,  at  page  430,  a  case  of  gunshot  fracture 
of  the  body  of  the  third  cervical  vertebra,  with  lodgment  of  the  missile  and 
complete  paraplegia,  in  which  recovery  was  secured  by  persevering  treatment 
A  brief  abstract  of  this  case  should  be  presented  in  this  place,  because  it  will 
encourage  surgeons  to  give  more  attentive  treatment  to  such  cases,  by  show- 
ing that  they  are  not  always  hopeless : — 

An  infantry  soldier,  aged  20,  was  wounded  at  Gettysburg,  July  2, 1863,  by  a  conoidal 
ball,  which  entered  the  right  upper  Hp  at  the  second  incisor,  destroyed  all  the  teeth 
save  the  last  molar,  on  the  same  side  of  the  upper  jaw,  passed  below  the  soft  palate  into 
the  pharynx,  and  penetrated  the  body  of  the  third  cervical  vertebra,  where  it  lodged 
and  was  not  extracted.  But  in  the  following  August,  the  position  of  the  ball  was  ascer- 
tained by  a  Nekton's  probe,  and  it  was  then  extracted.  "  There  was  paralysis  in  all 
four  hmbs,  from  which,  however,  he  rapidly  recovered  ;  and,  for  a  time,  did  duty  as 
hospital  attendant."  On  March  14,  1864,  this  patient  was  transferred  to  Turner's  Lane 
Hospital,  at  Philadelphia.  Acting  Assistant-Surgeon  W.  W.  Keen,  Jr.,  on  duty  at 
that  hospital,  states  that  "  nearly  the  entire  body  of  the  third  cervical  vertebra  has  come 
away,  including  the  anterior  half  of  the  transverse  process  and  the  vertebral  foramen. 
No  injury  to  the  vertebral  artery  has  been  disclosed.  What  supports  his  head  ante- 
riorly I  cannot  conceive.  On  May  3,  he  was  transferred  to  Washington  to  be  assigned 
to  a  company  in  the  Veteran  Reserve  Corps.  The  only  remnant  of  his  paralysis  is 
some  rioss]  of  sensation  over  a  surface,  say  three  by  four  inches,  at  the  back  of 
ricrht  neck.  Some  bone  still  is  occasionally  discharged."  In  April,  1871,  this  man 
was  yet  alive  ;  and  the  pension-examiner  reports  that  the  right  side  of  his  tongue  is 
distorted,  leaving  his  speech  affected  ;  that  the  right  side  of  his  throat  is  contracted ; 
and  that  his  right  shoulder  and  arm  are  diminished  in  size  and  partially  paralyzed. 
Disabihty  three-fourths  and  permanent. 

But  gunshot  fractures  of  the  spinal  column,  and  particularly  those  in  the 
cervical  and  upper  dorsal  regions  thereof,  are  generally  mortal,  unless  the 
lesions  be  confined  to  their  apophyses.^  In  the  Schleswig-Holstem  campaign 
of  1849,  Stromeyer  observed  that  "injuries  of  the  spinous  processes  frequently 
occurred  without  serious  consequences— without  accidents  from  concussion  of 
the  spinal  marrow."^  During  the  late  civil  war  I  saw  a  considerable  number 
of  cases  in  which  the  spinous  processes  alone  had  been  broken  off  by  the  im- 

i  In  the  British  army,  during  the  Crimean  war,  "all  the  fractures  of  the  vertebra  were 
promptly  fatal,  except  two  among  the  officers  and  two  among  the  men,  all  of  which  were  either 
fractures  of  the  transverse  processes  in  the  neck,  or  of  the  spinous  processes  only.  (Medical  and 
Surgical  History  of  the  British  Army  in  the  War  in  the  Crimea,  etc.,  vol.  ii.  p.  33/.)  Ihus  it 
appears  that  the  only  cases  of  shot  fractures  of  the  vertebrae  which  terminated  m  recovery  among 
the  British  soldiers  and  officers  wounded  in  the  Crimean  war,  were  those  in  which  the  lesions 
were  restricted  to  the  spinous  and  transverse  processes. 

«  Op.  cit.,  p.  37. 


GUNSHOT  INJURIES  OF  THE  VERTEBRA. 


met  of  small-arm  missiles,  withovit  any  apparent  Assuring  of  the  Jaminae  or 
Cdies  etc.,  of  the  i.yured  vertebra,  and  without  any  serious  lesion  of  he 
sr  inal  cord  These  mtients  all  recovered.'  In  some  of  these  case.,  4>mal 
mralvBis  too,  was  prLent  at  the  outset,  but  it  probably  arose  from  coucus- 
fon  Klie  spi^^^  c^ord,  for  it  soon  passed  away.  Professor  Ashhurst  men- 
t  onsrin  point,  the  case  of  a  soldier,  seen  by  himself,  who  was  wounded  by  a 
murket-ball  in  the  lumbar  region.  The  missile  entered  to  the  left  side  of  the 
rnal  eolumn,  carried  awav°the  spinous  process  of  a  lumbar  vertebm,  and 
lodS ;  t  was  extracted  f^m  the  right  hip  many  months  afterward  At 
fiSere  was  spi.ial  paralysis.  This  soldier  recovered 
to  the  Veteran  Reserve  Corps.    Near  y  two  y-ears  ^o  jj|  '^^^l 

his  back  was  yet  stiiF,  and  occasionally  pamtul.    Most  ot  the  T04  patients 
Savin-  -uI4o^t  lesions  of  the  spinal  column,  who  recovered  and  were  returned 
to  duty  m  our  army  during  the  late  civil  war,  doubt  ess  sustain 
turefof  the  spinous  or  transverse  processes.    Indeed,  the  abstracts  ot  the 
uccesstl  cL^  belonging  to  this  oategoryswhich  are  P-^tef -  die  sur- 
gical history  of  the  war,  strongly  support  this  view.    It  is,  tlieietoie,  Dui 
feasonable  to  conclude,  that  in  cashes  of  gunshot  fracture  ot  the  vertebra  the 
pro.'nosis  is  verv  much  less  unfavorable  when  the  lesion  is  restricted  to  the 
sDinous  or  transVerse  processes,  than  when  other  parts  are  involved. 
'^^A  few,  however,  of  the  on^  hundred  and  four  patients  having  gunshot 
fratturel  of  the  vertebrae  got  more  or  less  completely  well  again  when  he 
SeTor  the  lamiu.,  or  fhe  vertebral  pedicles  were  broken  -he^^J^^ 
sDinal  cord  was  at  the  same  time  considerably  injured.    For,    in  httj-tour 
ca  es  of  ^uiilhot  injury  of  the  vertebra,  complicated  by  traumatic  lesions  of 
?he  cord  °forty-two  were  fatal,  and  twelve  partially  recovered  and  were  dis- 
SarS-^th  various  degrees'of  physical  disability.    The  -^e^  of  eontusK,n 
and  Sommotionof  the  spinal  cord  are  not  included  in  this  °f  W.'  .^,f 
at  least  of  those  who  were  returned  to  duty  must  have  been  attected  with 
contuti^n  and  commotion  of  the  spinal  cord,  and  with  lesions  oi  the  vertebrae 
more  severe  than  fractures  restricted  to  their  apophyses. 

Professor  Paul  F.  Eve'  reports  two  cases  of  gunshot  injury  of  the  spinal  column, 
whTcU  the  Vict  ms  long  survived,  and  in  which  the  missiles  remamed  lodged  n,  he 
nine  A^ain!  Surgeon  C.  S.  Tripler,  U.  S.  Army ,^  relates  the  case  of  an  otHcer  who, 
rr839  dSg  the'last  Seminole'campaign  in  Florida,  -""/tction'orAe  iLt 
rifle-ball,  which  penetrated  on  the  right  side,  ,n  a  line  w,  h  the  junction  ot  the  last 
dorsal  and  first  lumbar  vertebrae,  struck  the  spinal  column,  lodged,  and 
There  were  complete  paraplegia  and  pr  aprsm   w,tl>  ■''''^f  T  '"'oved  The 

He  survived  for  welve  years.    The  paralys.s,  however,  but  slightly  ™1'™^'^';'. 
catheter,  and  laxatives  o/enemata,  had  to  be  used  for  fout  two  years   ha       -  "t^U  m 
1841,  h^  found  that  he  could  stimulate  th«Wadder  and  rectum  t^coM^^^^^^ 
the  side  of  his  penis  behind  the  corona  glandis  '    M.  Hulin,  ot  the  F;"^'' "^'^y' 
tions  the  case  of  a  soldier,  aged  20,  who,  in  183o,  was  wounded  in  '  «  "  ^'f^^^^ 

The  ball  entered  on  the  right  side,  near  the  first  and  second  lumbar       «^      and  lod^^ 
therein,  was  not  extracted.    There  was  immediate  paraplegia.     In  t    ee  jn*=  he 
wound  healed.    This  soldier  survived  the  injury  burteen  years  ^"f  f ^^'^^ 

^  American  Journal  of  the  Medical  Sciences,  July,  1868,  pp.  lOd-107. 

p.  438,  of  the  First  Surgical  Volume  of  the  Med.  and  Surg.  History  of  ^^^^^^^^f^^^J^J^f^^^^^^^^^ 
in  which  tickling  of  the  glans  penis  likewise  produced  i"-;"ation  f  "^/^^f  .^^.^"'''^^^ 
bladder,  by  exciting  the  detrusor  urinse  muscle  to  contract,    (bee  page  40/.  e«/ra.) 
^  Lancet,  1849. 


376 


INJURIES  OF  THE  BACK. 


disorganized.  M.  Louis,  the  most  celebrated  French  surgeon  of  the  eighteenth  cen- 
tury,^ relates  the  case  of  a  soldier  who,  in  1762,  received  a  gunshot  wound  of  the  dorsal 
spine,  in  consequence  of  which  he  became  completely  paralyzed  in  the  lower  limbs ;  the 
wound  was  enlarged  at  once,  and  the  ball  taken  out.  Louis  saw  the  patient  on  the 
fifth  day  after  the  casualty  ;  he  found  that  there  were  several  fragments  of  bone  press- 
ing upon  the  spinal  cord.  He  removed  these  fragments  ;  and,  although  there  was  a 
considerable  suppuration  after  this  operation,  the  paraplegia  slowly  but  gradually  disap- 
peared, and  the  patient  was  completely  cured,  excepting  a  slight  weakness  which  remained 
in  his  lower  limbs.  Twelve  years  afterward,  however,  he  still  had  to  walk  with  a  cane. 
These  facts  and  examples  are  mentioned  niainly  with  a  view  to  encourage  surgeons  to 
conduct  in  a  thorough  manner  the  treatment  of  gunshot  fractures  of  the  spinal  column, 
in  all  instances  which  come  under  their  care,  by  showing  that,  even  in  cases  where  re- 
covery is  impossible,  life  may  be  greatly  prolonged  by  careful  treatment. 

The  prognosis  of  these  cases  is  rendered  much  more  unfavorable  by  the 
occurrence  of  inflammation  of  the  spinal  membranes  or  spinal  cord,  as  doubt- 
less happened  in  the  following  instance : — 

A  soldier,  aged  19,  was  admitted  to  Emory  Hospital,  Washington,  August  25,  1862, 
for  a  gunshot  wound  of  the  back,  received  on  the  night  of  the  22d.    He  was  then  in 

great  pain  and  very  restless,  but  not  paralyzed  in  any  part. 
Fig.  876.  An  anodyne  was  prescribed,  with  cold  applications  to  the 

wound.  He  passed  a  restless  night,  and  morning  found 
him  wearied  and  anxious,  very  restless,  with  an  occasional 
tetanic  spasm,  though  not  severe.  An  anaesthetic  was 
administered,  the  wound  was  enlarged,  and  the  missile  (a 
conoidal  musket-ball)  was  found  impacted  between  the 
laminae  of  the  first  and  second  lumbar  vertebrae,  the 
spinous  process  of  the  second  having  been  broken  ofi*,  as 
shown  in  the  accompanying  wood-cut  (Fig.  876)  which 
represents  the  specimen.  The  missile  was  extracted  with 
much  difficulty.  All  spiculae  of  bone  were  then  carefully 
removed,  the  wound  was  drawn  together  by  adhesive 
straps,  and  cold-water  dressings  were  applied.  The  oper- 
ation of  an  enema  of  assafoetida  and  turpentine  left  the 
patient  in  a  profound  sleep,  disturbed  occasionally,  how- 
ever, by  slight  spasms  of  short  duration.  His  bowels  acted 
twice  that  night ;  the  micturition  was  free,  and  there  were 
no  symptoms  of  paralysis.  On  the  27th,  there  was  marked 
increase  in  the  severity  of  the  tetanic  symptoms.  The 
enema  was  repeated,  but  without  effect.  Chlorolbrm  was 
now  brought  to  his  relief,  and  its  use  continued  until  10 
A.  M.,  when  he  died.  Necroscopy. — The  ball  was  found  to  have  destroyed  the 
spinous  process  of  the  second  lumbar  vertebra,  and  to  have  buried  r.self,  apex  foremost, 
between  the  laminae  of  the  first  and  second,  in  the  spinal  canal,  braising  and  pressing 
upon  the  spinal  cord.^ 

The  condition  of  the  spinal  membranes  does  not  appear  to  have  been  noted 
at  the  autopsy.  Nevertheless,  the  symptoms  which  characterized  this  case, 
e.  g.,  the  intense  rachialgia,  the  extreme  degree  of  restlessness,  and  the  tetanic 
spasms,  are  symptoms  which  often  present  themselves  in  cases  of  idiopathic, 
as  well  as  in  cases  of  epidemic,  spinal  meningitis ;  and,  no  doubt,  there  was 
traumatic  spinal  meningitis  of  an  acute  character  in  this  case.  The  patient 
survived  the  onset  of  the  acute  symptoms,  less  than  two  days.  It  also  ap- 
pears that  chloroform  was  administered  continuously  for  several  hours  before 
death  occurred.    Was  the  proximate  cause  of  death  the  disease,  or  the  chlo- 

1  Mcmoire  postlmmo.  Archives  Gen.  de  Medecine,  etc.,  Aout,  183G,  p.  397  ;  Brown-Sequard's 
Lectures  on  the  Central  Nervous  Hystem,  p.  251. 

2  Medical  and  Surgical  History  of  the  War  of  tlie  Rebellion,  First  Surgical  Volume,  p.  444. 


Showinsf  gunshot  fracture  of  the 
spinous  process  of  the  second  lum- 
bar vertebra,  with  the  missile  im- 
pacted between  the  laminae  of  the 
first  and  second.  (Spec.  611,  Sect.  I, 
A.  M.  M.) 


GUNSHOT  INJURIES  OF  THE  VERTEBRA. 


377 


roform  which  was  administered  in  order  to  relieve  the  symptoms?  In  six 
additional  cases  of  gunshot  injury  of  the  vertebral  column,  during  the  late 
civil  war,  analogous  symptoms  were  reported ;  and  it  appears  that  these  cases 
were  all  fatal. 

Another  bad  prognostic  in  gunshot  injuries  of  the  spinal  column  is  the 
occurrence  of  bed-sores^  especially  wlien  they  arise  from  the  trophic  disorder 
of  the  tissues  which  results  from  lesions  of  the  spinal  cord. 

A  still  more  evil  poi'tent  in  such  cases  is  the  appearance  of  metastatic 
abscesses,  especially  when  they  spring  from  the  septicoemia  that  results  from 
suppurative  inflammation  of  the  cancellated  tissue  (osteo-myelitis)  of  the 
fractured  vertebree.  A  considerable  number  of  instances  of  this  sort  were 
reported  during  the  late  civil  war;  and  metastatic  abscesses  arising  from  this 
cause  were  more  recently  observed  in  the  case  of  President  Garfield,  already 
mentioned  above,  where  it  is  stated  that  the  fractured  spongy  tissue  of  the 
injured  vertebrae  was  suppurating,  and  that  the  adjoining  intervertebral  car- 
tilages were  partly  destroyed  by  ulceration. 

Diagnosis. — The  presence  of  an  open  wound  that  has  been  made  by  a  gun- 
shot missile,  the  track  of  which  extends  in  a  direct  line  to  the  vertebral 
column,  the  impairment  of  function  evinced  by  the  stricken  portion  of  the 
Vertebral  column,  and  the  exploration  of  the  wound  with  a  finger,  whenever 
practicable,  by  which  the  fragments  of  the  broken  vertebrae  themselves  can 
be  felt,  usually  suffice  to  establish  the  diagnosis  in  a  satisfactory  manner.^ 

Treatment.— If  the  missile  has  lodged,  it  should  be  found  and  extracted,  if 
possible.  All  foreign  bodies,  e.  g.,  bits  of  clothing  and  of  accoutrements, 
blood-clots,  and  detached  or  quite  loosened  splinters  or  fragments  of  bone, 
should  likewise  be  extracted.  The  utmost  cleanliness  should  be  observed, 
antiseptic  dressings  should  be  applied,  drainage-tubes  should  be  used  to  pre- 
vent any  collections  of  matter  from  being  formed  in  the  wounds,  and  necrosed 
fragments  of  bone  should  be  removed  as  soon  as  they  become  detached. 
Fragments  of  the  vertebrae  were  extracted,  after  gunshot  fractures  thereof, 
in  twenty-four  instances  during  the  late  civil  war.  Of  these  cases  only  ten 
were  fatal.^  In  all  of  the  fourteen  cases  which  did  not  prove  fatal,  there  was 
recovery  more  or  less  complete.  In  seven  of  the  nine  instances  in  which  the 
spinous  process  alone,  or  portions  of  it  only,  were  extracted,  the  patients 
recovered  speedily  as  well  as  completely,  and  were  returned  to  duty,  or  ex- 
changed. In  one  instance  belonging  to  this  category,  which  was  under  my 
care  for  two  and  a  half  months  at  Stanton  Hospital,  there  was  paraplegia  from 
concussion  of  the  spinal  cord,  as  well  as  gunshot  fracture  of  the  spinous  pro- 
cess of  the  second  lumbar  vertebra.  Several  fragments  which  became  detached 
were  promptly  removed,  and  the  paralysis,  all  things  considered,  rapidly 
passed  away.^  This  man's  recovery  was  complete,  for  his  name  is  not  on 
the  pension-list,  nor  have  his  heirs  made  application  for  pension.''^  But,  in 
five  successful  cases  wherein  portions  of  the  laminae  or  of  the  transverse  pro- 
cesses w^ere  removed,  the  results  were  much  less  satisfactory ;  nearly  all  of 
these  patients  were  still  suffering  from  serious  disabilities  in  1872.^ 

^  There  is,  however,  on  record  the  case  of  an  officer,  in  which  a  pistol-ball,  after  fracturing  the 
right  humerus,  passed  into  the  chest,  and,  lodging,  was  not  extracted  ;  fifteen  days  afterwards,  he 
died  of  pneumonia  and  secondary  hemorrhage.  Necroscopi/  showed  the  missile  firmly  imbedded 
m  the  body  of  the  fifth  dorsal  vertebra,  nearly  the  whole  of  which  was  shattered.  Nevertheless, 
no  spinal  symptoms  had  been  develoj^ed,  and  the  lesion  itself  had  not  been  suspected  during  life. 
The  specimen  is  preserved  in  our  Army  Medical  Museum  (No.  3515,  Sect.  I).  (Medical  and 
Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Vol.,  p.  436.) 

'•^  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Vol.,  p.  459. 

^  American  Journal  of  the  Medical  Sciences,  October,  1864,  p.  327. 

*  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Vol.,  p.  459. 
5  Ibid. 


378 


INJURIES  OF  THE  BACK. 


A2:ain,  in  order  to  prevent  the  occurrence  of  inflammatory  lesions  in  the 
spinal  membranes  and  spinal  cord,  absolute  quietude  should  be  enjoined  on 
the  patient.  Catheterization,  and  laxatives,  or  enemata,  as  well  as  the  pre- 
cautions against  bed-sores  and  vesical  and  renal  inflammation  which  have 
already  been  mentioned,  should  be  promptly  employed  whenever  their  use  is 
indicated.  Whatever  complications  may  arise,  e.  g.,  osteo-myelitis  of  the 
fractured  vertebra,  spinal  meningitis,  spinal  myelitis,  septicaemia,  bed-sores, 
nephritis,  cystitis,  etc.,  should  be  promptly  met  by  appropriate  treatment. 


On  Trephining  (so  called),  or  Eesection  of  the  Spinal  Column. 

The  operation  of  excising  parts  of  the  vertebrae  with  a  trephine,  a  saw, 
a  bone-forceps,  or  a  chisel  and  mallet,  and  removing  the  same,  when  they 
are  fractured  and  displaced  so  as  to  cause  paralysis  by  compressing  the  spinal 
cord,  has  been  sug2:ested  by  many  surgical  writers,  the  earliest  of  whom  was 
Paulus  ^gineta.  ^It  was  'flrst  perforaied,  however,  by  Henry  Cline,  at  St. 
Thomas's  Hospital,  June  16,  1814,  in  the  case  of  a  man,  aged  26,  who,  by 
falling  from  a  second-story  window,  on  the  previous  day,  had  received  an 
injury  of  the  dorsal  vertebra,  with  considerable  displacement,  and  had  become 
paraplegic. 

The  man  having  been  put  upon  the  operating  table  with  his  face  downward,  an 
incision  was  made  through  the  skin  over  the  projecting  spinous  processes,  of  sufficient 
length  to  expose  them  completely.  The  muscles  were  then  divided  on  each  side,  and, 
being  drawn  outward,  two  spinous  processes,  which  were  broken  at  their  roots,  were 
removed.  It  was  attempted  (but  ineffectually)  to  remove  the  eleventh  vertebral  arch 
by  sawing  it  through  with  Machell's  circular  saw  ;  a  chisel  and  maflet  were  then  em- 
ployed, and  also  a  trephine,  by  means  of  which  the  separation  was  effected,  and  the 
arch  lifted  out  with  an  elevator.  The  operation  was  considerably  embarrassed  by  the 
unfitness  of  the  instruments,  and  occupied  considerable  time,  but  afforded  no  relief. 
In  the  evening  he  complained  of  pain  in  the  wound;  pulse  114.  June  17,  2  P.  M. 
Had  not  slept  since  the  operation  ;  pulse  130.  At  6  P.  M.  he  had  a  fit,  and  was  thought 
to  be  dyincr.  June  18,  1  P.  M.  Had  another  fit ;  had  great  difficulty  ot  breathing, 
with  much  restlessness;  pulse  140  ;  upper  part  of  body  in  a  cold  sweat,  lower  part 
warm,  but  not  perspiring.  At  4  P.  M.  the  spasms  had  abated.  June  19.  He  was 
more  tranquil,  but  gradually  sank,  and  died  at  5  P.  M.  without  convulsions,  and  sen- 
sible to  the  last.    Autopsy  The  fore  and  upper  part  of  the  body  of  the  twelfth  dorsal 

vertebra  was  fractured  obliquely  from  above  and  behind,  downward  and  forward.  The 
upper  fragment  remained  attached  by  the  intervertebral  substance  to  the  body  of  the 
eleventh  dorsal,  which  had  moved  forward  and  a  little  downward,  tearing  off  the  pos- 
terior haff  of  the  intervertebral  cartilage  from  the  top  of  the  twelfth  dorsal  vertebra. 
The  theca  vertebralis  was  lacerated,  opposite  the  seat  of  injury,  in  four  places,  two  of 
which  would  admit  the  little  finger.  The  spinal  cord  was  three-fourths  torn  through, 
and  the  remaining  portion  was  bruised.^ 

Mr.  Cline  himself  candidly  stated  that  he  thought  the  operation  had  hast- 
ened the  death  of  his  patient.  The  lesions  for  which  he  operated  consisted 
of  fracture  of  the  body  of  the  twelfth  dorsal  vertebra  with  displacement 
(partial  dislocation)  of  the  body  of  the  eleventh  (to  which  the  fragment  ot 
the  twelfth  still  adhered),  forward  and  slightly  downward,  and  extensive, 
laceration  of  the  spinal  cord.  He  removed  two  spinous  processes,  and  the 
laminai  of  the  twelfth  dorsal  vertebra.  The  foregoing  abstract  shows  the 
true  character  of  this  operation,  the  difiiculties  which  attend  its  performance, 
and  its  positive  harmfulness  as  well  as  its  inutility,  more  clearly  and  m  fewer 


i  South's  Notes  to  Chelius's  Surgery,  vol.  i.  pp.  590,  591,  Am.  ed. 


GUNSHOT  INJURIES  OF  THE  VERTEBRA. 

words,  than  any  (lisquisition  on  the  subject  could  do.  Moreover,  this  opera- 
tion has  been  repeated  many  times,  without  success.  Trofessor  Ashhurst  has 
collected  and  tabulated  41  cases  in  which  it  has  been  performed.  Of  the 
whole  number  of  patients,  30  died,  3  were  relieved,  and  3  received  no  beneht, 
while  of  5  cases  the  result  is  unknown.  There  is  no  example  of  a  cure  achieved 
by  it  on  record.  Surely  the  general  results  in  these  cases  would  ^  have  been 
much  better  if  the  operation  "had  not  been  performed.  It  is  not  improbable 
that  even  the  few  who  were  apparently  relieved  by  it  would  have  done  better 
w^ithout  it.  The  operation  of  resection  or  trephining  the  vertebnie  is  unjusti- 
fiable, because  it  does  not  offer  a  reasonable  prospect  of  improving  the  patient's 
condition  in  any  case,  while,  on  the  other  hand,  there  is  always  reason  to  fear 
that  it  may  increase  the  chances  of  a  fatal  termination. 

M.  Louis's  operation,  w^hich  was  performed  in  1762,  is  sometimes  referred 
to  as  the  first  instance  in  wdiich  the  spinal  column  was  resected,  but  it  w^as 
not  a  resection  at  all.  It  consisted  merely  in  extracting  some  loose  fragments 
of  bone,  on  the  fifth  day,  in  a  case  of  gunshot  fracture  involving  a  dorsal 
vertebra.  The  patient  improved,  but,  twelve  years  later,  still  had  to  walk  with 
a  cane,  as  has  already  been  stated  above.  Moreover,  the  same  operation  w^as 
performed  in  twenty-four  instances  during  our  civil  war,  and  with  quite  satis- 
factory results.  But  resection  of  the  vertebrae  is  not  admissible  in  gunshot  in- 
juries of  the  spine.  Mr.  G  uthrie '  mentions  a  patient  Avho  had  received  a  pistol- 
shot  which  lodged  in  the  last  dorsal  or  upper  lumbar  vertebra,  and  caused 
complete  paralysis  of  both  limbs,  and  who  searched  London  and  Paris,  in 
vain,  to  find  a  surgeon  willing  to  operate  on  him.  Professor  Paul  F.  Eve,  of 
^^'ashville,  Tenn.,  however,  once  did  attempt  to  perform  such  an  operation,^ 
in  the  case  of  a  Confederate  soldier,  who  had  been  wounded  by  a  pistol-ball 
that  entered  to  the  left  of  the  spinal  column,  about  one  inch  from  the  spinous 
process  of  the  sixth  dorsal  vertebra,  in  the  cavity  of  which,  or  of  the  seventh, 
it  was  supposed  to  be  lodged.  Paraplegia  immediately  ensued,  and  the  para- 
lysis proved  to  be  permanent.  Concerning  the  operation  of  resecting  the 
dorsal  vertebra,  which  was  attempted,  Profi  Eve  says:  "After  due  prepara- 
tion, a  free  incision  was  made  through  the  cicatrix,  and  an  attempt  made  to 
follow  this  into  the  vertebral  cavity  ;  but  so  deep  was  the  vertebral  groove 
down  to  the  transverse  processes,  so  indistinct  the  track  of  the  missile — 
indeed,  we  could  not  trace  it — so  deceptive  the  intervertebral  foramina,  etc., 
but,  above  all,  so  great  the  risk  of  exciting  infiammation  by  wounding  the 
sheath  of  the  spinal  cord,  that  we  concluded,  after  using  one  crown  of  the 
trephine,  of  medium  size,  over  what  all  believed  to  be  the  hole  made  by  the 
bullet,  to  desist  from  further  application  of  it.  I  am  satisfied,"  he  continues, 
"that  this  operation,  in  the  dorsal  vertebrae,  if  not  almost  impracticable,  is 
certainly  one  of  the  most  difficult  in  surgery." 

That  the  operation  of  trephining  the  spinal  column  or  resecthig  the  verte- 
brae will  not  relieve  the  spinal  cord  from  compression,  when  it  is  exerted  by 
the  extravasation  of  blood,  is  proved  by  the  case  of  a  derrick-man,  aged  41, 
in  whom  the  laminae  of  the  tenth  dorsal  vertebra  were  resected,  at  P>ellevue 
Hospital,  by  Dr.  Stephen  Smith;  for,  notwitlistanding  that  from  8  to  12 
ounces  of  extravasated  blood,  having  a  dark  color,  escaped  from  tbe  spinal 
canal  after  the  depressed  bone  had  been  extracted,  the  compression  of  the 
cord  from  extravasated  blood,  and  the  paraplegia,  steadily  crept  upward,  and 
finally  caused  death  by  asphyxia.^ 

1  Commeutaries,  etc.,  p.  541,  Am.  ed. 

2  American  Journal  of  the  Medical  Sciences,  July,  1868,  p.  106. 
5  New  York  Journal  of  Medicine,  1859,  pp.  87,  88. 


380 


INJURIES  OF  THE  BACK. 


III.  Il^JUEIES  OF  THE  SPIRAL  MEMBKA^N-ES,  SPmAL  CORD, 

AND  SPmAL  iTERYES. 


Injuries  of  the  Theca  Vertebralis,  and  Meninges  of  the  Spinal  Cord. 

The  spinal  dura  mater,  although  but  loosely  connected  with  the  bodies  of 
the  vertebrse,  is  elsewhere  strongly  attached  to  the  vertebral  walls,  at  frequent 
intervals,  by  means  of  processes  sent  out  through  the  intervertebral  foramina 
around  the  spinal  nerves.  Consequently,  when  the  vertebrae  are  fractured,  or 
displaced  in  luxations,  the  spinal  dura  mater  is  extremely  liable  to  be  stretched, 
bruised,  or  torn.  I  assisted,  on  one  occasion,  at  the  autopsy  in  a  case  in  which 
there  were  fissured  fractures  of  the  fifth,  sixth,  and  seventh  cervical  vertebrae; 
there  was  little  displacement,  yet  the  theca  vertebralis  was  found  smeared  with 
blood  opposite  the  fractures,  and  torn  open  so  widely  as  to  allow  the  index- 
finger  to  pass  through  with  ease.  (See  page  301.)  So  too,  in  Mr.  Cline's  case, 
which  has  just  been  related,  the  theca  vertebralis,  at  the  autopsy,  was  found 
lacerated  in  four  places,  two  of  which  would  admit  the  little  finger.  But  to 
multiply  examples  of  this  sort  would  be  useless ;  for  it  is  quite  obvious  that, 
in  all  fractures  of  the  vertebral  rings  with  displacement,  whether  the  frag- 
ments spring  back  into  place  again  or  not,  and  in  all  luxations  of  the  vertebrae, 
the  theca  vertebralis  mast  be  correspondingly  injured  by  the  stretching,  bruis- 
ing, or  tearing  which  it  of  necessity  sustains  from  the  sudden  displacement,  or 
from  the  sharp  edges  and  splinters  of  the  broken  or  dislocated  bones.  ^ 

But  aside  from  strains,  bruises,  and  lacerations,  the  theca  vertebralis  may 
be  penetrated  by  incised  and  punctured  wounds  of  the  back.    Many  instances 
are  on  record  in  which  such  wounds  of  the  theca  vertebralis  were  made  by 
knives,  daggers,  swords,  lances,  arrows,  and  bayonets,  and  with  such  imple- 
ments of  industry  as  chisels,  etc.    Several  examples  have  already  been  men- 
tioned in  this  article.  (See  page  270.)    When  such  wounds  are  attended  by  a 
discharge  of  cerebro-spinal  fluid,  there  is  no  doubt  that  the  theca  vertebralis 
has  been  opened.  When  the  wound  is  situated  in  the  loins,  and  the  discharge 
of  the  cerebro-spinal  fluid  is  profuse,  the  nature  of  the  lesion  may  be  mis- 
taken, and  it  may  be  supposed  that  the  ureter  has  been  laid  open.    There  is 
published  in  the  sixtieth  volume  of  the  Medico-Chirurgical  Transactions,  a 
case  in  which  a  copious  flow  of  limpid  fluid  occurred  from  a  wound  in  the 
back,  and  in  which  it  was  believed  that  the  ureter  had  been  laid  open,  although 
it  was  admitted  to  be  possible  that  the  fluid  might  be  cerebro-spinal.^  Mr.  T. 
Holmes^  relates  two  cases  in  which  a  similar  copious  discharge  of  watery 
fluid  was  caused  by  a  wound  of  the  spinal  membranes,  which  did  not  involve 
the  spinal  cord  nor  the  large  nerves,  as  was  proved  by  the  post-mortem 
examination  in  one  case,  and  by  the  position  of  the  puncture  in  the  other. 
Incised  or  punctured  wounds  of  the  back,  which  open  the  theca  vertebralis 
without  injuring  the  spinal  cord  or  spinal  nerves,  do  not,  of  themselves,  pro- 
duce any  nervous  phenomena,  inasmuch  as  the  loss  of  the  cerebro-spinal  fluid 
is  usually  but  gradual,  and  the  fluid  itself  is  rapidly  resecreted.  Secondary 
inflammation  of  such  wounds,  however,  may  interfere  ^yith  the  functions  of 
the  spinal  cord  or  spinal  nerves,  and  may  even  destroy  life  in  that  way.  But 
when  such  wounds  are  uncomplicated,  the  prognosis  is  generally  favorable. 
There  may,  however,  be  great  difficulty  in  getting  permanent  closure  of  the 
wound  in  such  cases ;  but  there  will  be  more  chauce  of  getting  it  if  treat- 

1  Lancet,  April  29,  1882;  American  Journal  of  the  Medical  Sciences,  July,  1882,  p.  294. 


INJURIES  OF  THE  SPINAL  CORD  AND  SPINAL  NERVES. 


381 


merit  to  that  end  be  employed  at  once,  than  if  it  be  postponed  to  a  later 
period. 

Gunshot  wounds  of  the  spinal  dura  mater  not  unfrequently  occur.  ^  In  cases 
where  they  are  present,  the  vertebne  are  always  fractured,  and  the  spinal  cord, 
likewise,  is  generally  injured.  Many  examples  have  been  presented  in  the 
foreo-oino;  pai^^es  in  which  the  theca  vertebralis  was  torn  by  gunshot  mis- 
siles? Sometimes,  as  in  the  case  of  Soteldo  (p.  374),  the  bullet  penetrates  the 
theca  and  lodges  tberein.  In  others,  it  perforates  that  membrane,  and  leaves 
behind  an  orifice  of  emergence  as  well  as  of  entrance.  In  others  still,  it 
tears  a  furrow  transversely  across  the  tube  which  the  theca  vertebralis  forms 
when  in  situ,  and  partially  divides  the  same.  The  amount  of  thecal  inflamma- 
tion aroused  by  gunshot  injuries  is  in  most  instances,  I  think,  not  great.  At 
an  autopsy  which  I  made  some  years  ago,  in  a  case  in  which  the  last-named 
form  of  injury  was  found,  I  was  rather  surprised  at  the  absence  of  inflamma- 
tion, although  the  patient  had  survived  the  casualty  twelve  days,  and  I  made 
the  following  note  at  the  time  concerning  it :  "There  was  moderate  hiflani- 
matory  action,  adhesive  in  character,  of  the  theca  vertebralis.  It  was  confined 
to  the  immediate  neighborhood  of  the  wound.  There  was  no  pus."  It  is 
my  belief  that  the  spinal  dura  mater  is  normally  endowed  with  a  wonderful 
ability  to  resist  traumatic  lesions  and  their  consequences.  But  injuries  of  the 
spinal  arachnoid  and  pia  mater  not  unfrequently  cause  inflammations  of  a 
destructive  character  therein,  which  will  be  discussed  under  tlie  head  of 
Traumatic  Spinal  Meningitis. 

Moreover,  suppurative  inflammation  of  the  connective  tissue,  and^  abscess, 
may  occur  between  the  spinal  dura  mater  and  the  vertebral  column,  in  conse- 
quence of  the  injury  thereof,  especially  when  the  latter  has  sustained  a  simple 
fracture  without  displacement ;  two  examples  of  this  have  already  been  pre- 
sented under  the  caption  of  latent  fractures  of  the  vertebrse.   (See  p.  349.) 

Injuries  of  the  spinal  meninges  are  often  attended  by  extravasation  of 
blood  within  the  theca  vertebralis,  and  compression  of  the  spinal  cord  result- 
ins;  therefrom.  Many  instances  have  been  mentioned  in  the  foregoing  pages, 
and  eight  additional  examples  will  be  presented  in  the  next  section  of  this 
article 

Treatment. — Incised  and  punctured  wounds  of  the  back,  which  penetrate 
the  theca  vertebralis  and  let  out  the  cerebro-spinal  fluid,  should  be  treated  by 
immediate  closure  and  antiseptic  dressings  for  the  wounds  themselves,  and 
by  absolute  quietude  for  the  patients. 

Gunshot  wounds  involving  the  theca  vertebralis  require  for  treatment  the 
removal  of  all  foreign  bodies,  such  as  blood-clots  and  loose  fragments  of  bone, 
as  well  as  bullets  and  bits  of  clothing,  the  employment  of  antiseptic  dressings, 
with  drainage-tubes,  and  perfect  rest  for  the  injured  spine. 

Simple  fractures  or  dislocations  of  the  vertebrae,  which  do  injury  to  the 
theca  vertebralis,  should  first  be  "set"  or  reduced  if  possible,  and  then  in- 
flammatory action  in  the  injured  parts  should  be  restrained  by  abstracting 
blood  with  leeches  or  cups,  by  applying  cold,  and  by  securing  perfect  rest 
for  the  injured  structures. 


Injuries  of  the  Spinal  Cord  and  Spinal  ITerves. 

The  histological  elements  of  the  spinal  cord,  its  nerve-fibres,  ganglion-cells, 
minute  bloodvessels,  and  connective  tissue,  are  so  lacking  in  strength  and 
solidity  that,  were  the  cord  as  a  whole  not  protected  from  the  eflfects  of  exter- 
nal violence  by  an  elastic  medium,  the  cerebro-spinal  fluid,  Avhich  everywhere 
surrounds  it,  the  elementary  structures  that  compose  it  would  be  disintegrated 


382 


INJURIES  OF  THE  BACK. 


by  every  sudden  shock,  as  well  as  by  every  sudden  pressure  and  the  impact 
of  every  vulnerating  body,  which  might  be  brought  to  bear  upon  it. 

The  traumatic  lesions  to  which  the  spinal  marrow  is  exposed  are  (1)  con- 
cussion^ (2)  contusion^  {S)  compression^  and  (4)  wounds  (incised,  punctured,  and 
lacerated),  which  partially  or  completely  sever  it. 

Concussion  of  the  Spinal  Cord. — As  the  symptoms  of  concussion  of  the 
brain  result  directly  from  cerebral "  shock,''  so  the  symptoms  of  concussion  of 
the  spinal  marrow  result  directly  from  sudden  "  shock" 
Fig.  877.  of  that  organ ;  as  concussion  of  the  brain  is  nearly 

always  attended  by  minute  extravasations  of  blood,  or 
ecchymoses,  so  probably  concussion  of  the  spinal  marrow 
is  usually  accompanied  by  minute  effusions  of  blood  into 
its  substance  and  as  the  symptoms  of  concussion  of 
the  brain  consist  of  a  more  or  less  complete  suspension 
of  the  cerebral  functions,  so  the  symptoms  of  concussion 
of  the  spinal  marrow  consist  of  a  more  or  less  complete 
spinal  paralysis,  which,  however,  is  usually  ephemeral  in 
character. 

But  concussion  of  the  spinal  cord,  when  extremely  se- 
vere, may  instantaneously  destroy  life.   For  instance  : — 

Major  Mills,  an  officer  serving  on  the  staff  of  Major-General 
Humphreys,  then  commanding  the  Second  Army  Corps,  was 
killed,  March  .31,  1865,  during  a  reconnoisance,  by  a  cannon- 
ball  (round)  which  grazed  his  left  lumbar  region  in  such  a  way 
as  to  open  the  abdominal  cavity  and  let  out  some  intestine. 
General  Humphreys  says  "he  rolled  up  his  eyes  and  fell  from  his 
horse  dead."  Surgeon  Charles  Page,  U.  S.  Army  (Medical 
Director,  2d  Corps),  to  whom  I  am  indebted  for  the  case,  thinks 
he  must  have  died  from  "  shock,"  for  there  was  no  solution  in 
the  continuity  of  any  organ  found  on  post-mortem  inspection 
which  would  cause  immediate  death  per  se.  While  this  view 
is  doubtless  correct,  it  is  not  improbable  that  the  "  shock"  itself 
caused  death  by  producing  concussion  of  the  spinal  cord  of  so 
severe  a  kind,  that  all  the  respiratory  muscles,  including  the 
diaphragm,  were  at  once  completely  paralyzed  thereby. 

Again,  death  from  this  cause  may  ensue  in  a  few 
hours.    For  example  : — 

Morgagni'^  relates  the  case  of  a  man  injured  by  falling  from  a 
vine.  He  was  speechless  and  paralyzed,  and  bled  from  the  nose 
and  mouth.  The  urine  and  feces  escaped  involuntarily.  Death 
ensued  in  four  hours.  Necroscopi/  revesded  fractures  of  the  six 
upper  dorsal  vertebrae,  ribs,  and  skull.  (Ashhurst.) 

Ordinarily,  in  cases  of  vertebral  fracture  or  disloca- 
tion attended  with  spinal  paralysis,  there  is  at  first 
retention  of  urine  and  feces,  because  the  sphincter 
muscles  still  remain  active,  while  the  muscular  coats 
of  the  bladder  and  intestines  are  paralyzed.    I^ot  so  in 


Showin-g  the  spinal  cord 
and  the  roots  of  the  31  pairs 
of  spinal  nerves,  with  the 
cervical,  axillary,  lumbar, 
and  sacral  plexuses.  Also 
one  of  the  two  chains  of  ver^ 
tebral  ganglia  (nervi  syni- 
pathici),  and  the  commu- 
nicating threads. 


1  There  is,  however,  a  case  of  concussion  of  the  spinal  cord  on  record  in  which  there  was  para- 
plegia that  persisted  (for  three  weeks)  until  death  was  produced  by  other  causes,  and,  on 
autopsu,  no  lesion  of  the  cord  could  he  discerned.  "  No  fracture  of  the  vertebra  existed,  nor 
were  any  appearances  found  in  the  spinal  column  sufficient  to  account  for  the  persistent  para- 
plegia." Medical  and  Surgical  History  of  the  British  Army  in  the  Crimean  War,  vol.  11.  pp. 
337,  338. 

2  De  Sedibus  et  Caisis  Morborum,  t.  iii. 


INJURIES  OF  THE  SPINAL  CORD  AND  SPINAL  NERVES. 


383 


this  case,  however,  for  the  sphincter  muscles,  too,  weie  i>aralyze(l  from  the 
outset;  and  this  circumstance  shows  that  tlie  nervous  centres  upon  wliich 
their  activity  depends,  together  witli  the  syini)athetic  ganglia  —  tlie  iiervl 
sympathici — suffered  from  concussion  as  well  as  the  spinal  cord. 

Fractures  of  the  spinal  column  are  often  attended  hy  concussion  of  the 
spinal  cord,  much  oftener,  I  fancy,  than  dislocations  are. 

Occasionally,  concussion  of  the  spinal  cord  is  attended  hy  a  peculij^iy 
violent  shock  to  the  nervi  syinpathtci^  as  was  noted  hi  the  following  iiighly 
instructive  example : — 

Surgeon  A.  F.  Mechem,  U.  S.  Army,  was  injured  by  jumping  from  a  railway  train 
while  Tn  motion,  June  21,  1870.  The  fall  caused  partial  concussion  of  the  spinal  cord, 
and  severe  shock  to  the  sympathetic  nervous  system.  Wlien  seen,  shortly  afterw^ard, 
slight  reaction  had  come  on  ;  still,  there  was  extreme  hyperajsthesia  of  the  chest,  neck, 
and  upper  extremities,  which  were  of  a  cyanotic  hue  ;  cerebral  functions  undisturbed. 
The  heart's  action,  almost  suspended  when  first  seen,  rose  under  stimulants.  Wlien  reac- 
tion had  fairly  taken  place,  there  was  violent  arterial  action  at  the  wrist,  but  unaccom- 
panied by  similar  action  in  the  temporal  and  carotid  arteries  ;  in  fact,  the  action  of  these 
vessels  coincided  in  neither  force  nor  frequency  with  that  of  the  radial  and  ulnar  arte- 
ries. Nor  was  the  action  of  the  heart,  at  any  time  after  the  pulsations  became  normal, 
other  than  healthy,  although  the  extraordinary  throbbing  at  the  wrist  continued  several 
days.  Excepting  slight  paralysis  of  the  bladder,  there  was  no  loss  of  motor  power.  At 
first,  the  terrible  hyperaesthesia  of  tlie  hands  and  arms  caused  a  suspicion  that  there  might 
be  a  fracture  or  a  dislocation  of  the  cervical  vertebrae,  which,  by  pressing  upon  the  spi- 
nal nerves,  produced  the  terrible  pain.  However,  a  careful  examination  showed  that 
there  was  neither  fracture  nor  dislocation,  but  that  the  cause  of  the  symptoms  was  to  be 
found  only  in  the  spinal  cord  and  sympathetic  nervous  system.  Morphia  was  adminis- 
tered hypodermically,  and  afforded  much  relief.  Cupping,  with  hot  applications  of  lead- 
water  and  laudanum,  alternating  with  fomentations  of  hops  and  laudanum,  to  the  arms, 
hands,  and  thorax,  assisted  materially  in  mitigating  the  pain.  Some  three  days  after 
the  injury,  the  use  of  morphia  was  in  a  great  measure  dispensed  with,  Indian  hemp  and 
hyoscyamus  being  substituted.  The  hop-fomentations  were  superseded  by  applications 
of  chloroform  and  camphor,  alternated  witli  morpliia  and  simple  cerate.  Tonics,  nour- 
ishing diet,  and  stimulants,  contributed  much  toward  recovery  ;  but  his  health  remained 
delicate.  In  January,  1871,  he  availed  himself  of  a  leave  of  absence  for  one  month, 
which  was  extended  six  months  longer,  for  the  benefit  of  his  health.  He  died  July  14, 
1871,  in  consequence  of  the  accident;  no  autopsy  reported.^ 

Concussions  of  the  spinal  cord  are  often  caused  by  gunshot  injuries.  I 
have  reported  three  examples  in  the  American  Journal  of  the  Medical  Sci- 
ences,2  in  an  article  on  Injuries  of  the  Spine.  In  one  of  them  the  spinous 
process  of  the  second  lumbar  vertebra  was  fractured.  The  symptoms  were 
spinal  paralysis  (paraplegia),  both  motor  and  sensory ;  the  former  being  more 
pronounced  than  the  latter,  which  gradually  subsided.  Dry  cups  applied 
daily  over  the  spinal  column  were  found  useful. 

The  abstract  of  another  case,  taken  from  my  field  note-book,  will  consider- 
ably aid  in  illustrating  the  symptoms  of  this  accident : — 

April  6,  1865,  I  examined  a  fine  cavalry  soldier,  aged  19,  at  the  field  hospital  near 
Jetersville,  Va.,  who  had  been  wounded  at  Amelia  Court  House,  on  the  5th,  by  a 
conoidal  musket-ball,  which  passed  through  the  back  part  of  his  lumbar  region,  obliquely 
from  side  to  side,  injuring  the  spine.  He  had  paralysis,  as  to  motion,  of  the  parts  below. 
The  sensibility,  too,  was  diminished,  but  not  entirely  destroyed.  He  complained  of 
hypersesthesia  in  the  front  and  inner  part  of  each  thigh.  He  said  that  he  had  been  hurt 
in  these  parts  by  the  fall  of  his  horse,  and  by  being  trampled  upon,  during  the  cavalry 
charge  at  Amelia  C.  H.  on  the  5th.  He  said  that  both  lower  extremities  felt  benumbed. 
His  bladder  was  paralyzed,  and  catheterization  indispensable.    He  also  said  that  he  did 

1  Circular  No.  3,  S.  G.  0.,  Aiisnst  17,  1871,  pp.  112,  113. 

2  No.  for  October,  1864,  pp.  325-328. 


384 


INJURIES  OF  THE  BACK. 


not  feel  the  catheter  in  the  urethra  until  it  reached  the  prostatic  portion.  He  told  this 
while  the  instrument  was  being  introduced.  Evacuation  of  the  bladder  afforded  much 
relief  from  distress,  for  which  he  expressed  his  gratitude.  Was  the  disorder  in  this  case 
concussion  of  the  spinal  marrow  ?  Yes ;  for  the  persistence  of  sensibility  in  both  lower 
extremities,  when  the  primary  injury  was  caused  by  a  minie  ball,  shows  that  the  con- 
tinuity of  the  spinal  marrow  was  not  seriously  impaired.  April  8.  Saw  this  patient 
again  at  Bul  k's  Junction  ;  condition  as  to  paralysis  unchanged.  April  11.  Still  no 
change ;  he  was  sent  to-day  to  the  depot  field  hospital  at  City  Point,  and  thus  passed 
out  of  my  sight. 

Professor  Ashhurst^  relates  the  case  of  a  soldier,  who  had  sustained  a  gunshot  fracture 
of  the  spinous  process  of  a  lumbar  vertebra,  with  concussion  of  the  spinal  cord.  At 
first,  there  was  spinal  paralysis ;  but  the  man  recovered  and  was  transferred  to  the 
Veteran  Reserve  Corps. 

Dr.  George  McClellan^  mentions  two  cases,  in  which  gunshot  missiles  entered  the 
small  of  the  back  and  lodged,  where  their  impact  caused  concussion  of  the  spinal  cord 
and  "total  paraplegia  of  all  the  parts  below."  The  paralysis,  however,  was  but  tem- 
porary ;  for  both  patients  got  perfectly  well  again  under  the  use  of  laxatives"  and 
counter-irritants. 

The  symptoms  vary  greatly  with  the  case,  and  according  to  the  severity  of  the 
concussion  itself,  from  simple  motor  enfeeblement  of  the  lower  extremities, 
with  numbness"  and  "  pins  and  needles,"  on  the  one  hand,  to  complete  para- 
plegia both  motor  and  sensory,  with  priapism  and  retention  of  urine  and  feces, 
on  the  other.  Not  unfrequently,  intense  hypersesthesia  is  also  present,  as  was 
noted  in  the  following  very  instructive  case  of  concussion  of  the  spinal  cord 
in  the  cervical  region,  with  ecchymosis  of  the  left  posterior  horn  of  gray 
matter,  of  the  right  anterior  horn,  and  of  the  posterior  columns.  The  inju- 
ries resulted  from  a  fall,  and  the  case  is  related  by  Sir  W.  Gull  :^ — 

A  coal-porter,  aged  33,  slipped  and  fell  down  some  cellar-stairs,  with  a  sack  of  coal 
falling  upon  him.  He  was  admitted  at  3  P.  M.,  June  22,  atter  the  accident;  there  was 
loss  of  motion  in  both  legs  and  in  left  arm  ;  the  sphincters  were  paralyzed  ;  sensation  was 
entirely  lost  in  left  arm  up  to  deltoid  ;  sensation  and  motion  in  right  arm  perfect ;  in 
the  lower  extremities,  he  could  feel  about  the  feet  and  on  the  outer  side  of  thighs,  but 
not  on  the  anterior  and  inner  surface  ;  slight  priapism  ;  breathing  diaphragmatic.  Sen- 
sation returned  in  every  part  after  a  few  hours  ;  the  most  distant  parts  apparently  recov- 
ered first.  As  the  skin  became  warm  he  complained  of  pain  when  lightly  touched 
(hyper^esthesia).  For  instance,  when  the  finger-nail  was  lightly  passed  over  the  skin 
he  exclaimed,  "  Don't  prick  me  ;  don't  hurt  me  !"  Next  day,  the  cutaneous  sensibility 
appeared  to  be  excessive,  judging  from  his  exclamations  when  the  skin  was  touched  or 
pinched.  This  was  noticed  especially  in  the  right  arm.  The  priapism  disappeared  in  two 
hours  after  admission,  but  returned  on  the  day  following ;  power  to  move  the  right  arm 
remained  ;  thirty -four  hours  after  the  accident  the  patient  died.  Autopsy — There  was 
no  external  trace  of  injury.  The  membranes  of  the  cord  were  healthy.  The  substance 
of  the  cord  was  contused  opposite  the  fourth  and  fifth  cervical  vertebrae.  On  section, 
there  was  found  ecchymosis  of  the  posterior  horn  of  gray  matter  on  the  left  side,  and  of 
the  adjacent  part  of  the  lateral  and  posterior  columns.  There  were  also  limited  spots 
of  ecchymosis  on  the  right  side,  one  in  the  right  posterior  column,  and  one  in  the  right 
anterior  horn  of  gray  matter.  The  gray  substance  generally  was  hyperaemic.  On 
removing  the  spinal  cord  and  membranes,  nothing  abnormal  was  discovered  in  the  ver- 
tebrae until  the  posterior  ligament  had  been  dissected  off,  when  it  was  seen  that  the  body 
of  the  fourth  w^as  separated  from  that  of  the  fifth,  and  that  the  left  articular  process  of 
the  fourth  had  been  chipped  cfi\ 

The  essential  features  of  this  instructive  case  are :  (1)  the  cord-substance 
was  injured  by  concussion,  and  not  by  any  displacement  of  the  parts  ;  (2)  the 

1  Op.  cit.,  pp.  116,  117.  2  Principles  and  Practice  of  Surgery,  p.  177. 

8  Guy's  Hospital  Reports,  1858,  pp.  191,  192. 


INJURIES  OF  THE  SPINAL  CORD  AND  SPINAL  NERVES. 


385 


injury  was  attended  by  a  number  of  minute  extravasations  of  blood  (ecchy- 
moses)  in  the  gray  substance  ;  (3)  there  were  aniesthesia  and  loss  of  motion  in 
both  lower  extremities  and  in  the  left  arm  ;  (4)  there  was  paralysis  of  the 
sphincter  ani  and  sphincter  vesicae,  which  denoted  that  the  reflex  motor  appa- 
ratus was  also  paralyzed ;  (5)  the  anjesthcsia  passed  away  in  the  course  of 
some  hours,  the  return  of  sensibility  being  noted  first  in  the  parts  most 
distant  from  the  injury;  (6)  hypenesthesia  appeared  synchronously  with  the 
reaction  from  "shock,"  and  steadily  increased  in  severity;  (7)  hypenemia  of 
the  gray  substance  was  found  as  well  as  ecchymosis.  It  should  be  remarked 
that  the  hyperresthesia  was  more  severe  in  the  right  arm  than  elsewhere, 
and  that  this  part  had  not  at  any  time  been  paralyzed. 

It  should  also  be  noted  that  the  byper?esthesia  was  coincident  in  its  appear- 
ance with  the  hypeniemia  of  the  cord-substance  which  followed  the  injury, 
and  that  as  the  inflammatory  excitement  caused  by  the  sanguinolent  extrava- 
sations of  blood  into  the  cord -substance,  or  the  hyper«imia,  etc.,  increased  or 
progressed,  the  hypen^esthesia  also  rapidly  increased  until  thirty-four  hours 
after  the  accident,  Avhen  death  occurred. 

Treatment. — Inability  to  urinate  and  defecate  will  necessitate  the  employ- 
ment of  catheterization,  and  of  enemata,  or  laxatives.  When  hypersesthesia  is 
present,  it  must  be  subdued  by  the  administration  of  belladonna,  or  of  opium 
or  morphia.  Dry-cupping  the  dorsal  and  lumbar  regions  has,  in  my  own 
experience,  proved  very  useful  in  cases  of  gunshot  concussion  of  the  spinal 
cord.  At  a  later  stage,  counter-irritation  by  issues  or  setons  has  appeared  to 
do  good.  But,  quietude  or  rest  for  the  injured  spinal  column  and  cord  is  an 
important  reparative  measure,  in  such  instances,  fully  as  important  as  any 
other.  ISTot  only  should  the  patient  be  debarred  from  attempting  to  over- 
come his  "  numbness"  and  his  "  pins  and  needles"  by  exercise,  which  caprice 
or  habit  might  lead  him  to  do,  but  he  must  be  kept  in  bed  until  these  s^-mp- 
toms  have  passed  away.  Mr.  Hilton^  mentions  the  case  of  a  gentleman  who 
had  sustained  a  moderate  concussion  of  the  spinal  marrow  from  falling  upon 
his  back  at  Epsom,  which  resulted  in  irremediable  paraplegia,  from  inatten- 
tion to  this  curative  measure.  Should  the  symptoms  of  myelitis  supervene, 
they  must  be  combated  by  the  remedies  for  that  disease  which  will  be  men- 
tioned further  on. 

Contusion  of  the  Spinal  Cord. — Bruises  of  the  spinal  marrow,  like  bruises 
of  the  cerebrum,  are  attended  by  disintegration  of  the  elementary  tissues 
thereof,  and  minute  extravasations  of  blood,  or  ecchymoses.  There  is,  how- 
ever, this  important  difference  between  them  ;  for,  inasmuch  as  the  cineritious 
substance  is  mostly  found  on  the  exterior  of  the  cerebrum  and  within  the 
interior  of  the  spinal  marrow,  so  the  ocular  evidences  of  contusion  are  usually 
seen,  most  distinctly,  on  the  exterior  or  cortex  of  the  former,  and  within  the 
interior  of  the  latter ;  and  it  frequently  happens  that  contusions  of  the  spinal 
marrow  are  not  discernible  by  the  unaided  eye,  until  the  parenchyma  thereof 
is  laid  open  by  an  incision,  and  until  the  cineritious  substance  is  thus  exposed 
to  view. 

The  slighter  examples  of  contusion  of  the  spinal  cord,  those  in  which  the 
ecchymoses  are  not  large  nor  numerous,  are  commonly,  and  almost  unavoid- 
ably, classified,  in  practice,  with  the  cases  of  concussion  of  the  spinal  marrow 
which  have  just  been  described,  and  in  wdiich  the  symptoms  of  spinal  con- 
cussion constitute  the  chief  clinical  phenomena,  and  among  which,  at  the  bed- 
side, no  differential  diagnosis  between  concussion  and  contusion  of  the  spinal 


VOL.  IV. — 25 


»  Op.  cit.,  p.  33. 


386 


INJURIES  OF  THE  BACK. 


marrow  can  be  made.    The  following  case,  observed  by  Mr.  Savorj,i  ^.^li 
serve  to  show  what  the  symptoms  are  in  severe  contusions  of  the  cord : — 

A  man  fell  upon  his  head  from  a  railway  van.  During  the  first  few  minutes  he  was 
stunned,  but  this  soon  passed  off.  When  admitted  to  hospital,  there  was  complete  loss 
of  motion  and  sensation  in  the  lower  and  upper  extremities,  and  in  the  trunk  nearly  as 
high  as  the  clavicles.  The  respiration  was  entirely  diaphragmatic,  the  thoracic  walls 
sinking  inward  at  each  inspiratory  effort.  No  reflex  action  could  be  excited  in  the 
lower  extremities,  nor  elsewhere.  The  pupils  were  moderately  and  equally  dilated,  but 
sluggish.    There  was  partial  priapism.    Death  ensued  in  about  thirty  hours.  Autopsy. 

 There  was  no  fracture  nor  displacement  at  any  part  of  the  skull  or  spinal  column  ; 

there  was  also  no  hemorrhage  nor  material  congestion  at  any  part  on  the  surface  of  the 
brain  or  spinal  cord.  But  a  longitudinal  section  of  the  spinal  cord  revealed,  opposite 
the  fourth  cervical  vertebra,  a  clot  of  blood  which  was  extravasated  in  its  substance  to 
the  extent  of  about  half  an  inch.  This  extravasation  was  well  defined,  and  nothing 
wrong  could  be  perceived  in  the  adjoining  or  in  other  parts  of  the  cord. 

In  this  case  the  functions  of  the  spinal  cord  were  completely  abolished  in 
two  important  particulars:  1.  There  was  entire  loss  of  sensation  and  volun- 
tary motion.  2.  There  was  also  total  absence  of  any  reflex  action.  While 
the  clot  of  blood,  the  product  of  contusion,  which  w^as  found  in  the  substance 
of  the  spinal  cord  at  the  autopsy,  accounts  satisfactorily  for  the  former,  it 
does  not  for  the  latter ;  for  while  the  blood-clot  might  completely  destroy 
the  power  of  the  spinal  cord  as  a  conductor  of  impressions,  it  could  not  destroy 
its  functions  as  a  reflector  of  impressions  or  as  a  nervous  centre.  And  inas- 
much as  the  loss  of  reflex  action,  observed  during  life,  was  due  to  destruction 
or  impairment  of  the  spinal  cord  as  a  nervous  centre,  it  must,  as  pomted 
out  by  Mr.  Savory,  have  arisen  from  the  concussion  to  which  the  spinal  cord 
was  subjected  by  the  accident,  although  it  produced  no  efiect  on  the  structure 
of  the  cord  that  was  visible  after  death. 

This  loss  of  reflex  action  in  the  spinal  nerves,  in  consequence  of  concussion 
of  the  spinal  cord,  mentioned  above  by  Mr.  Savory,  I  had  myself  previously 
observed;  and  I  specially  noted  it  at  the  time  of  making*  the  observation, 
although  I  did  not  then  understand  its  rationale.  The  following  abstract  is 
taken  from  the  note-book  in  which  the  minutes  of  the  case  were  written  at 
the  time : — 

Private  John  H.  Rhodes,  Company  A,  16th  Pennsylvania  Cavalry,  aged  22,  was  ad- 
mitted from  our  front  before  Petersburg  to  the  Depot  Field  Hospital,  at  City  Pomt, 
December  14,  1864,  for  injury  of  the  spine  and  paraplegia.  On  the  15th,  I  examined 
him  with  much  interest.  It  appeared  that  he  had  been  hurt,  while  lying  face  down- 
ward on  the  ground,  on  Sunday,  the  11th,  by  the  falling  of  a  tree,  some  branches 
belonaint^  to  the  top  of  which  struck  him  violently  across  the  back  and  shoulders.  He 
was  imm^'ediately  deprived  of  the  use  of  his  legs  and  the  lower  half  of  his  body.  When 
I  saw  him,  all  the  parts  below  the  umbilicus  were  completely  paralyzed,  both  as  to  sen- 
sibility and  voluntary  motility.  The  bladder  required  a  catheter  to  be  introduced  twice 
a  day  ;  the  urine  was  more  abundant  in  quantity  than  natural.  He  passed  a  consistent 
stool  unconsciously  in  bed  on  that  day.  "  I  failed  to  excite  any  sensibility  or  any  reflex 
action  by  tickling  the  soles  of  bis  feet,  or  by  pulling  the  hairs  of  his  legs,  thighs,  or 
groins.  Both  extremities  were  ahke  in  these  respects."  Above  the  umbilicus,  sensi- 
bihty  gradually  appeared  in  the  skin,  at  first  indistinctly,  but  increasing  with  the  upward 
procuress  of  the  examination,  until  it  became  normal  on  the  upper  part  of  the  thorax. 
The  respiration  was  abdominal  (diaphragmatic),  and  superior  thoracic  (superior  inter- 
costal). He  liad  good  use  of  both  upper  extremities,  and  made  no  complaint  of  them 
whatever.  He  was  cautiously  turned  upon  his  right  side,  so  as  to  permit  an  examina- 
tion of  his  back.  The  consistent  stool,  above  mentioned,  was  then  found  m  bed.  Before 
this,  his  bowels  had  not  acted  at  the  hospital.    There  was  no  appearance  of  contusion 

»  St.  Bartliolomew's  Hospital  Reports,  vol.  v.  p.  45. 


INJURIES  OF  THE  SPINAL  CORD  AND  SPINAL  NERVES, 


387 


nor  ecchymosis  on  the  integuments  of  his  back  and  shoulders.  There  was  no  deformity 
nor  abnormal  mobility  found  in  the  spinal  column.  There  was  moderate  tenderness 
under  pressure  when  made  upon  the  vertebrae,  at  the  upper  part  of  the  dorsal  region. 
He  did  not  complain  of  being  hurt  in  any  part  while  being  turned  over  in  bed.  He  had 
considerable  cough,  with  expectoration  ;  sputa  unstained.  His  face  had  a  dusky  hue 
(not  deep).  He  swallowed  both  solids  and  fluids  without  difficulty.  Did  not  complain 
of  distress  in  any  part ;  no  priapism.  He  died  on  Saturday  the  17th,  six  days  after  the 
accident,  from  failure  of  the  respiratory  function. 

Autopsy  Among  the  muscles,  near  the  upper  dorsal  vertebrae,  a  small  quantity  of 

blood  was  found  extra vasated,  but  no  cutaneous  ecchymosis.  The  laminae  of  tiie  first 
dorsal  vertebra  and  the  body  of  the  second  were  fractured,  with  but  little  if  any  dis- 
placement ;  that  is,  there  was  a  fissured  fracture  which  extended  through  the  laminiB  of 
the  first  and  the  body  of  the  second  dorsal  vertebra.  The  anterior  common  ligament 
was  torn  partly  through,  and  the  posterior  common  ligament  was  loosened  or  detached 
to  some  extent  at  the  seat  of  fracture.  Between  the  theca  vertebralis  and  the  bone,  on 
the  left  side  of  the  spinal  canal,  in  the  same  neighborhood,  a  thin  blood-clot  was  found. 
It  was  about  two  inches  long  by  one-fourth  of  an  inch  in  breadth,  and  did  not  compress 
the  spinal  cord.  There  was  no  extravasated  blood  within  the  theca  vertebralis.  The 
spinal  cord,  externally,  presented  no  abnormal  appearance  whatever.  It  was  not  dis- 
colored, nor  notciied,  nor  lacerated.  But,  on  making  a  longitudinal  section,  the  gray 
substance  of  the  interior  was  found  to  present  an  ecchymosed  and  contused  appearance 
opposite  the  fracture,  but  not  elsewhere.  Here  it  was  dark-brown  in  color  from  the  ex- 
travasation of  blood,  and  pulpefied  in  consistence  from  the  force  of  the  contusion.  These 
lesions  were  symmetrically  developed.  The  spinal  membranes  and  spinal  cord  were 
not  inflamed.  The  lungs  (both)  contained  more  than  the  normal  quantity  of  blood, 
that  is,  they  exhibited  passive  hyperaemia,  but  in  other  respects  they  were  sound. 

This  abstract  touches  all  the  essential  points  pertaining  to  concussion  and 
contusion  of  the  spinal  cord.  The  blow  struck  by  the  falling  tree  upon  this 
man's  spinal  column,  as  he  lay  face  downward  on  the  ground,  suddenly  bent 
it  downward  (that  is,  forward)  at  an  acute  angle,  by  severely  stretcliing  and 
so  partly  rupturing  the  anterior  common  ligament,  and  by  making  a  rent  or 
fissured  fracture  which  extended  upward  through  the  body  of  the  second 
and  the  laminae  of  the  first  dorsal  vertebra.  The  fragments  immediately 
sprang  back  into  place  again.  But  the  blow  and  the  abrupt  bending  of  the 
spinal  column  mortally  injured  the  spinal  cord.  The  elementary  tissues 
composing  its  interior  were  disintegrated,  or  reduced  to  a  pulp-like  consist- 
ence, and  were  deeply  stained  with  blood  extravasated  from  the  ruptured 
capillaries.  ^  The  conducting  power  of  the  cord  was  totally  destroyed  either 
by  the  force  of  the  blow  itself,  or  by  the  pressure  which  the  extravasated 
blood  exerted  upon  the  conducting  fibres  of  the  cord.  Moreover,  the  con- 
cussion or  "  shock,"  which  the  spinal  cord  received  from  the  blow,  abolished 
its  ofiice  as  a  distinct  centre  of  the  nervous  system,  over  a  large  space,  with- 
out leaving  any  alterations  of  structure  whatever  to  account  therefor,  that 
were  visible  after  death.  Thus,  the  man  was  wholly  deprived  of  reflex 
motor  activity,  as  well  as  of  sensibility  and  voluntary  motion,  in  all  the  parts 
supplied  with  spinal  nerves  which  depart  from  the  cord  below  the  lesion  of 
its  substance  just  described.  The  loss  of  reflex  motor  action  in  the  paralyzed 
parts  was  as  complete  in  this  case,  as  it  was  in  that  which  precedes  it,  and 
in  both  alike  the  post-mortem  examination  failed  to  reveal  any  anatomical 
cause.  From  the  autopsies  of  cases  such  as  these,  the  statement  appears  to 
be  well  founded,  that  concussion  of  the  spinal  marrow,  unless  it  be  compli- 
cated with  contusion,  is  not  attended  by  any  structural  change  of  the  marrow 
which  is  discernible  after  death,  with  the  unaided  eye. 

Anatomical  Lesions  attending  Bruises  of  the  Spinal  Cord. — In  such  cases, 
the  theca  vertebralis  is  very  rarely  found  torn ;  and,  on  laying  it  open,  one 
might  imagine  the  cord  to  be  uninjured,  in  many  instances,  because  the  pia 


388 


INJURIES  OF  THE  BACK. 


mater  of  the  cord  remains  entire  and  without  ecchymosis,  as  it  did  in  the 
cases  just  related.  On  slicing  the  cord,  however,  its  substance  is  found  to  be 
crushed  more  or  less  completely  through  and  through,  and  blackened  by 
extravasated  blood.  Sometimes  the  co^rd-substance  is  utterly  smashed  and 
broken  down  into  a  diffluent  pulp  throughout  a  space  one  inch  or  more  in 
length,  while  the  pia  mater  over  it  remains  entire.  In  other  instances,  ecchy- 
mosis is  plainly  visible  on  the  outer  surface  of  the  cord.  Occasionally,  this 
ecchymosis  is  very  considerable  in  degree  and  extent. 

For  instance,  Lasalle^  reports  the  case  of  a  man,  aged  36,  and  a  maniac,  who  injured 
his  neck  by  violently  throwing  his  head  forward,  while  struggling  against  restraint. 
His  head  remained  bent  forward,  and  there  was  spinal  paralysis.  Death  ensued  thirty- 
six  hours  afterward.  Necroscopy  showed  that  the  intervertebral  substance  between 
the  bodies  of  the  fifth  and  sixth  cervical  vertebrae  was  torn  through,  without  any  frac- 
ture, and  with  but  slight  displacement  of  the  implicated  bones.  Great  ecchymosis, 
however,  was  found  on  the  spinal  cord. 

Symptoms. — Besides  the  signs  of  spinal  paralysis  already  mentioned,  e.  g., 
the  destruction  of  sensibility,  of  voluntary  motion,  and  of  reflex  motor  action, 
in  the  parts  supplied  by  spinal  nerves  which  issue  from  the  cord  below  the 
bruise,  another  important  symptom,  namely,  hypersesthesia,  is  not  unfre- 
quently  observed. 

For  example,  Mr.  Bryant  ^  relates  the  case  of  a  coal-porter,  aged  33,  who  fell  down 
stairs  with  a  sack  of  coal  on  top  of  him,  and  broke  his  neck.  He  had  spinal  paralysis, 
priapism,  and  diaphragmatic  breathing ;  but,  after  a  few  hours,  hyperaesthesia  came  on. 
In  thirty-four  hours  death  ensued.  Necroscopy  revealed  fracture  and  displacement  of 
the  fourth  and  fifth  cervical  vertebra.  The  cord  was  contused  but  not  compressed. 
The  hyperaesthesia  does  not  appear  to  have  been  caused  by  injury  of  the  spinal  nerves, 
but  by  changes  that  were  taking  place  in  the  bruised  part  of  the  spinal  cord. 

There  are  not  yet  on  record  so  many  examples  of  contusion  of  the  spinal 
marrow,  with  a  full  account  of  the  symptoms  and  post-mortem  appearances 
observed  in  each,  that  we  can  safely  trust  to  generalizations  drawn  from  them, 
and  thus  dispense  with  giving  the  particulars  of  the  cases,  when  discussing 
the  subject.    The  details  of  the  following  example  are  very  instructive  :— 

Mr.  South^  relates  the  case  of  an  old  man,  aged  68,  who  was  injured  and  stunned  by 
falling  down  stairs,  and  who  was  admitted  to  St.  Thomas's  Hospital  a  few  hours  after- 
ward? He  had  pain  at  the  back  of  his  neck,  which  was  increased  by  pressure  ;  all  his  limbs, 
except  the  left  lower  extremity,  which  still  retained  sHght  motion,  were  palsied  ;  the  sen- 
sibility of  the  whole  right  side  of  the  body  was  morbidly  acute,  that  of  the  left  totally 
destroyed,  excepting  on  the  belly,  where  he  felt  slightly,  and  to  which  he  referred  a 
sensation  of  numbness  when  "the  left  thigh  was  pinched.  Next  day  he  complained  of 
pain  in  the  right  arm  ;  the  skin  on  the  left  side  of  the  belly  was  less  sensible.  On  the 
third  day  the  morbid  sensibility  of  the  right  side  had  diminished,  and  sensation  had 
shghtly  returned  on  the  left.  He  complained  of  pain  in  the  right  hypochondrium,  and 
fancied  that  his  arms  lay  across  his  chest.  On  the  following  day  the  belly  became  tym- 
panitic. On  the  fifth  day  there  was  slight  motion  of  the  left  arm,  and  the  capability  of 
moving  the  right  leg  had  increased;  but  he  ^vas  rapidly  sinking,  although  in  good 
heart,  and  died  late  at  night.  On  examination,  it  was  found  that  the  atlas  was  broken 
in  two  places,  the  line  of  fracture  being  diagonal,  and  traversing  the  left  vertebral 
hole.  The  pivot  of  the  axis  was  broken  off  at  its  root,  and  a  small  piece  of  the  body 
also.  The  fifth  vertebra  was  fractured  through  the  body.  With  neither  fracture  was 
there  sufficient  displacement  to  produce  pressure.  On  cutting  through  the  spinal  cord 
a  central  cell  was  found,  containing  a  small  quantity  of  blood,  and  the  substance  of  the 
spinal  cord  was  broken  down  and  disorganized  opposite  the  fifth  vertebra. 


i*Gazette  Medicale,  1841.  ^  Guy's  Hospital  Reports,  3d  series,  vol.  v. 

3  Notes  to  Chelius's  System  of  Surgery,  vol.  i.  p.  585,  Am.  ed. 


INJURIES  OF  THE  SPINAL  CORD  AND  SPINAL  NERVES. 


389 


This  patient  survived  the  accident  something  less  than  six  days.  Both 
the  hypereesthesia  and  the  spinal  paralysis  that  were  observed  in  his  case, 
arose  from  the  contusion  of  the  spinal  marrow,  that  is,  from  the  disintegration 
of  its  elementary  tissues,  and  the  extravasation  of  blood  therein,  and  from 
the  secondary  lesions  of  the  marrow,  hyper^^mia  and  hyperplasia,  which 
w^ere  induced  by  the  injury.  Still,  as  the  absorption  of  the  blood  extra- 
vasated  in  the  bruised  part  of  the  spinal  cord  progressed,  the  symptoms  of 
spinal  paralysis,  e.  g.,  the  loss  of  sensibility  and  voluntary  motion,  decreased  in 
corresponding  degree.    The  hyper^esthesia  also  varied  from  day  to  day. 

To  sum  up  the" symptoms  which  present  themselves  in  cases  of  contusion 
combined  with  concussion  of  the  spinal  cord,  they  are  :  loss  of  sensibility,  loss 
of  voluntary  motion,  and  loss  of  reflex  motor  action  in  all  the  parts  supplied 
by  those  filaments  of  the  spinal  cord  which  are  direcUy  or  indirectly  injured 
by  the  contusion  of  the  cord,  or  which  issue  from  the  spinal  cord  below  the 
seat  of  contusion,  occurring  suddenly  and  coincidentally  with  the  injury  of 
the  cord  itself;  also  hyperoesthesia  which,  not  unfrequently,  comes  on  some 
hours,  or  even  days,  after  the  injury  has  been  inflicted. 

Furthermore,  concussions  and  contusions  of  the  spinal  cord,  like  disloca- 
tions and  fractures  of  the  spinal  column,  may  be  attended  by  very  consider- 
able deviations  of  the  body-heat  from  the  normal,  both  above  and  below,  as 
was  pointed  out  on  page  335.  Mr.  Erichsen,  in  particular,  has  seen  spinal 
concussion  attended  by  marked  and  prolonged  lowering  of  the  vital  tem- 
perature. 

Contusions  of  the  spinal  marrow  with  extravasations  of  blood  into  the 
substance  thereof,  are  of  not  unfrequent  occurrence. 

Besides  the  foregoing  examples,  M.  Brown-Sequard^  mentions  a  case  by  Walker,  in 
which  there  was  dislocation  of  the  fourth  cervical  vertebra  ;  an  incision  showed  that  there 
was  no  fracture.  The  dislocation  was  reduced,  and  the  patient  was  improved  thereby. 
Death,  however,  ensued  in  six  days.  Necroscopy  revealed  hemorrhage  in  the  spinal 
€ord. 

Mr.  Luke^  relates  the  case  of  a  laborer,  injured  by  being  knocked  against  the  side  of 
a  ship,  with  which  the  back  of  his  neck  came  in  contact.  Projection  of  the  vertebrae 
in  the  neck,  spinal  paralysis,  priapism,  etc.  were  noted.  In  two  days  death  occurred. 
Necroscopy  showed  fracture  of  the  sixth  cervical  vertebra ;  the  spinal  cord  was  en- 
larged and  softened ;  it  also  contained  a  blood-clot. 

Mr.  SoUy^  reports  the  case  of  a  plasterer,  aged  40,  who  fell  from  a  scaffolding,  strik- 
ing his  head,  and  being  stunned.  There  were  paralysis  of  the  right  side,  a  scalp-wound, 
and  a  fractured  clavicle.  He  died  in  forty  hours.  Necroscopy  revealed  fractures  of 
the  fourth  and  fifth  cervical  vertebrae  ;  also  hemorrhage  into  the  spinal  cord,  which 
was  soft  and  bruised. 

M.  Colin*  reports  a  case  of  hemorrhage  into  the  spinal  cord. 

Treatment. — The  therapeutical  indications  to  be  fulfilled  in  contusions  of 
the  spinal  marrow  are  the  same  as  in  concussions  of  the  spinal  marrow,  which 
have  already  been  described. 

Compression  of  the  Spinal  Cord. — The  nerve-fibres,  ganglion-cells,  and 
bloodvessels  of  the  spinal  cord,  may  be  fatally  compressed  by  blood  when  it 
is  extravasated  into  the  substance  of  the  cord  itself,  into  the  spinal  menin- 
ges (by  intra-thecal  hemorrhage),  or  into  the  spinal  canal  external  to  the 
theca  vertebralis ;  also  by  the  displacements  of  bone  which  arise  from  dislo- 
cations and  fractures  of  the  veitebrse,  and  by  foreign  bodies  when  they  have 


1  Op.  cit. 

»  Ibid.,  1851. 


2  Lancet,  1850. 

<  L'Union  Medicale,  1862. 


390 


INJURIES  OF  THE  BACK. 


entered  the  spinal  canal ;  finally,  the  spinal  marrow  may^  be  mortally  com- 
pressed by  the  products  of  inflammatory  action  which  are  liable  to  be  eflTused 
in  all  cases  of  spinal  meningitis  or  myelitis. 

Compression  of  the  filaments  and  other  elementary  structures  of  the  cord 
from  blood  extravasated  into  its  substance,  not  unfrequently  occurs,  and  ex- 
amples in  considerable  number  have  been  presented.  But  this  subject  has 
already  been  sufiiciently  discussed  in  connection  with  contusion  of  the  cord. 

Compression  of  the  spinal  marrow  from  hemorrhage  within  or  upon  its 
membranes  has  likewise  been  illustrated  in  many  instances  that  have  been 
presented  in  the  foregoing  pages.  As  extravasations  of  blood  between  the 
cranium  and  the  cerebral  dura  mater,  or  into  the  cerebral  meninges,  often 
destroy  life  by  compressing  the  brain,  so  extravasations  of  blood  between  the 
spinal  column  and  the  theca  vertebralis,  or  inside  of  the  sheath  formed  by 
that  membrane,  not  unfrequently  destroy  life  by  compressing  the  spinal  mar- 
row. Mr.  Hutchinson  ,1  however,  asserts  that  although  much  has  been  said 
about  large  efiusions  of  blood  into  the  spinal  canal  as  a  cause  of  paralysis, 
such  efiusions  are,  he  believes,  the  rarest  of  occurrences,  for  he  has  "  never 
seen  auy  eff'usion  to  the  extent  of  possible  compression,  and  in  the  majority 
of  cases  there  is  little  or  none."  That  this  eminent  writer's  belief  on  this 
important  point  is  singularly  inaccurate,  many  cases,  already  mentioned  in 
this  article,  in  which  large  efi'usions  of  blood  were  found  in  the  spinal  canal, 
on  examination  after  death,  bear  strong  testimony ;  and  this  evidence  can  be 
corroborated  by  presenting  many  others  of  a  like  nature.    For  instance: — 

(1)  Dupuytren^  mentions  the  case  of  a  soldier  having  a  gunshot  wound  of  the  neck. 
There  was  almost  complete  paralysis.  Death  ensued  twenty-four  hours  after  the  injury. 
The  autopsy  showed  fractures  of  (he  fourth  and  fifth  cervical  vertebrae  ;  cord  unhurt ; 
much  blood  effused  in  the  spinal  canal,  and  at  the  base  of  the  brain. 

(2)  Murney^  reports  the  case  of  a  laborer,  aged  22,  who  fell  from  a  scaffold  twenty- 
feet,  striking  his  back.  He  walked  to  a  neighboring  house.  In  two  hours  paralysis 
began  ;  priapism  with  retention  of  urine  and  feces  followed  ;  skin  hot.  Death  occurred 
in  lour  days.  The  autopsy  revealed  fractures  of  the  fifth,  sixth,  and  seventh  cervical, 
and  of  the  first  dorsal  vertebrae  ;  no  displacement ;  blood-clots  on  the  spinal  cord,  which 
also  was  softened.  (Ashhurst.)  In  this  case,  the  coming  on  of  paralysis  some  hours 
after  the  accident,  and  the  gradual  increment  of  the  symptoms,  kept  pace  with  the 
sanguinolent  effusion  in  the  spinal  canal. 

(3)  Hutton*  records  the  case  of  a  man,  aged  35,  thrown  from  a  cart  into  a  ditch. 
There  were  "  stunning,"  paralysis,  and  dyspnea  ;  and  death  ensued  in  four  days.  The 
autopsy  revealed  dislocation  of  the  fifth  from  the  sixth  cervical  vertebra,  with  shght 
fracture  ;  cord  softened  ;  and  extravasated  blood.  (Ashhurst.)  In  respect  to  symptoms 
and  spinal-cord  lesions,  this  case  strongly  resembles  the  last. 

(4)  A  very  great  extravasation  of  blood  occurred  within  the  theca  vertebralis  in 
a  case  under  the  care  of  Dr.  Stephen  Smith,  at  Bellevue  Hospital,  some  years  ago- 
The  patient  was  a  healthy,  temperate,  and  well-nourished  derrickman,  aged  41,  injured 
by  being  thrown  from  a  cart  and  striking  his  back  upon  the  pavement ;  he  was  not  ren- 
dered unconscious,  and  did  not  feel  hurt  until  some  one  attempted  to  raise  him  ;  then  he 
found  that  he  was  paralyzed,  and  that  motion  caused  him  intense  pain. 

On  October  12,  P.M.,  he  was  admitted  to  the  hospital,  two  hours  after  the  injury, 
in  a  state  of  collapse;  pulse  too  frequent  and  feeble  to  be  counted;  respiration  18. 
There  were  complete  sensory  and  voluntary-motor  paralysis  of  the  lower  extremities 
and  body  up  to  the  sixth  intercostal  space  ;  moderate  priapism  ;  normal  temperature. 
The  subjective  symptoms  were  severe  pain  in  the  back  of  the  neck,  and  pain,  numb- 
ness, and  tingling  in  the  arms.  Objectively,  nothing  abnormal  was  found  in  the  cervical 
region ;  but,  in  the  dorsal  region,  a  depression  was  discovered  between  two  spinous 


1  London  Hospital  Reports,  vol.  iii.  1866. 
•  Dublin  Medical  Journal,  vol.  xxiv. 


2  Op.  cit. 

*  Ibid.,  vol.  xvii. 


INJURIES  OF  THE  SPINAL  CORD  AND  SPINAL  NERVES. 


391 


processes  in  which  two  fingers  could  be  laid  ;  no  corresponding  abrasion  or  ecchymosis 
visible.  A  free  administration  of  stimulants,  with  an  anodyne  and  catherization,  were 
ordered. 

On  the  13th,  A.M.,  pulse  112;  respiration  26,  and  mainly  abdominal  ;  temperature 
of  trunk  and  lower  extremities  exalted.'  The  anaesthesia  had  progressed  upward,  having 
risen  to  the  fifth  rib.  The  pain  and  numbness  of  the  neck  and  arms  had  decidedly  in- 
creased. The  penis  was  not  erect,  but  it  was  easily  excited  on  irritating  the  spine. 
P.M.,  sloughs  had  commenced  upon  the  heel  and  upon  the  ball  of  the  great  toe  of  the 
left  foot,  and  over  the  external  malleolus  of  the  right  ankle.  A  consultation  was  held, 
and  resection  of  the  depressed  dorsal  lamina?  was  agreed  upon,  and  at  once  performed 
under  chloroform.  An  incision  six  inches  in  length,  made  in  the  line  of  the  spinous 
processes,  showed  a  depression  of  the  arch  upon  the  right  side  of  one  of  the  lower  dorsal 
vertebrse.  After  some  difficulty,  the  arch  was  divided  on  the  opposite  side,  and  then 
the  depressed  lamina3  were  pulled  out  by  a  duck-billed  forceps.  Through  the  opening 
thus  made,  from  six  to  twelve  ounces  of  dark-colored,  extravasated  blood  flowed  out  of 
the  spinal  canal.  No  benefit  resulted  from  the  operation,  and  death  occurred  soon 
afterward,  apparently  from  compression  of  the  spinal  cord. 

The  autopsy  revealed  fracture  of  the  body  of  the  tenth  dorsal  vertebra  upon  the  right 
side,  extending  from  the  base  of  the  transverse  process  half  way  to  the  mesial  line  an- 
teriorly, without  displacement ;  fracture  of  the  arch  of  this  vertebra  upon  the  right  side, 
with  depression  ;  extravasation  of  blood  within  the  theca  vertebralis  to  a  large  amount, 
and  extending  from  the  lower  cervical  vertebrae  to  the  sacrum.  From  the  increasing 
paralysis  it  was  inferred  that  this  extravasation  was  still  extending  upward  when  the 
patient  died.^ 

This  man's  accident  showed  so  many  things  clinically  and  experimentally,  that 
the  history  of  it  is  well  worth  the  space  consumed.  It  illustrated  compression  of 
the  spinal  cord,  with  ascending  paralysis  from  intra-vertebral  effusion  of  blood  ;  it 
proved  that  neuropathic  sphacelus  may  simultaneously  appear  at  several  different 
points  in  the  extremities  within  twenty-four  hours  after  the  injury  to  the  spinal  cord  ; 
it  illustrated  the  inutility  of  vertebral  resection;  and  it  proved  that  the  operation  of 
trephining  the  spine  will  not  relieve  the  cord  from  compression  arising  from  blood 
effused  upon  it. 

(5)  J.  Jardine  Murray^  reports  the  case  of  a  woman,  aged  62,  thrown  from  a  car- 
riage. There  were  paralysis  and  retention  of  urine,  and  next  day  coma  ;  in  twenty -four 
hours  death  occurred.  The  autopsy  showed  fractures  of  the  fifth  and  sixth  cervical 
vertebr£e  ;  spinal  canal  filled  with  clotted  blood ;  cord  unhurt.  (Ashhurst.) 

(6)  Ch.  D.  Doig^  relates  the  case  of  a  porter,  aged  37,  who  fell  into  the  hold  of  a 
steamboat,  and  hurt  his  neck.  There  were  pain,  paralysis,  dyspnoea  and  dysphagia, 
retention  of  urine  and  feces,  and  insomnia ;  in  four  days,  death  ensued.  The  autopsy 
revealed  fracture  and  dislocation  of  the  fifth  cervical  vertebra  ;  clotted  blood  effused  on 
the  spinal  cord;  cord  itself  unhurt.  (Ashhurst.) 

(7)  W.  T.  King*  reports  the  case  of  a  laborer,  aged  25,  thrown  from  a  cart  with  his 
neck  across  a  hamper.  There  were  par;j.lysis,  etc.  ;  death  occurred  in  fifty  hours.  The 
autopsy  showed  dislocation  forward  of  the  sixth  cervical  vertebra ;  no  fracture  ;  and 
blood  extravasated  around  the  spinal  cord.  (Ashhurst.) 

(8)  Holt^  records  the  case  of  a  man,  aged  45,  injured  by  a  horse  falling  upon  him. 
Paralysis  came  on  in  the  following  night ;  but  no  cerebral  symptoms.  In  seven  days 
death  ensued.  The  autopsy  revealed  fracture  of  the  fifth,  sixth*,  and"  seventh  cervical 
vertebrse ;  blood  effused  into  the  spinal  canal,  and  had  fallen  tP  the  bottom  of  it ;  spi- 
nal cord  uninjured  ;  a  tumor  in  the  cerebellum.  (Ashhurst.) 

(9)  Charles  Bell®  mentions  the  case  of  a  man  who  fell  from  a  barge  into  the  Thames, 
at  low  water.    His  head  stuck  in  the  mud,  and  he  died  instantly.    Subluxation  of  the 

1-  New  York  Journal  of  Medicine,  January,  1859,  pp.  87,  88o 
2  Edinburgh  Medical  Journal,  N.  S.,  vol.  vii. 
8  Ibid.,  vol.  ix. 

4  Lancet,  1849.  s  Ibid.  1850. 

6  Observations  on  Injuries  of  the  Spine  and  Thigh-bone 


392 


INJURIES  OF  THE  BACK. 


seventh  cervical  upon  the  first  dorsal  vertebra  was  found,  and  effusion  of  blood.  (Ash- 
hurst.) 

(10)  Malgaigne^  refers  to  the  case  of  a  carter,  injured  by  a  wheel  passing  over  his 
neck  and  shoulder.  There  were  pain,  paralysis,  etc.  In  thirty-one  hours  death  occurred. 
The  autopsy  showed  subluxation  of  the  sixth  cervical  vertebra,  with  slight  fracture. 
The  spinal  cord  was  stretched,  and  blood  effused. 

(11)  Sir  W.  Gull  relates  the  following  case  •?  A  man,  aged  40,  fell  backward  from  a 
moderate  height  with  a  plank  on  top  of  him,  and  was  at  once  brought  to  the  hospital 
(4  P.  M.,  July  7).  He  was  collapsed,  but  sensible,  and  partially  paralyzed  in  the. 
upper  as  well  as  in  the  lower  extremities.  No  injury  of  spine  discoverable.  As  reac- 
tion came  on,  and  he  grew  warm  again,  the  paralysis  wore  off.  At  10  P.  M.  he  said 
he  was  comfortable.  He  passed  a  restless  night.  At  8  A.  M.  (July  8)  he  was  en- 
tirely paraplegic  in  the  upper  as  well  as  in  the  lower  extremities  ;  sensation  lost  as  well 
as  motion  ;  priapism  ;  abdomen  tense  and  tympanitic  ;  the  breathing  was  wholly  dia- 
phragmatic ;  the  ribs  scarcely  moved  in  inspiration  ;  deglutition  difficult ;  temperature 
of  the  surface  increased  ;  during  the  day  the  skin  became  intensely  hot,  but  the  actual 
temperature  was  not  noted  ;  fifty-five  hours  after  the  accident  death  ensued.  Autopsy. 
— No  external  evidence  of  spinal  injury.  "Extravasation  of  blood  outside  the  theca 
vertebralis,  on  its  anterior  aspect.  The  effused  blood  compressed  the  cord,  which  other- 
wise was  uninjured.  After  careful  examination  there  were  not  found  any  signs  of 
bruising  of  its  tissue.  The  extravasation  apparently  arose  from  injury  to  the  lower  part 
of  the  body  of  the  fourth  cervical  vertebra,  which  had  been  fractured,  and  the  inter- 
vertebral substance  torn.  The  calibre  of  the  canal  was  slightly  encroached  upon  by 
the  displacement  of  the  fourth  vertebra,  but  not  so  as  to  press  on  the  cord.  The  extrava- 
sation, though  not  abundant  opposite  the  injury,  extended  downward  to  some  distance. 
The  membranes  of  the  cord  were  uninjured."  The  interspinous  and  capsular  ligaments 
between  the  fourth  and  fifth  cervical  vertebrae  were  torn  through,  and  the  articular  pro- 
cesses dislocated. 

It  is  worthy  of  remark  (1)  that  the  symptoms  of  paralysis  which  arose  from  the 
"  shock"  or  concussion  of  the  spinal  cord,  in  this  case,  passed  ofi'  in  a  few  hours  ;  (2) 
that  there  supervened  a  paralysis,  both  motor  and  sensory,  which  gradually  increased 
until  it  became  complete  and  extended  up  to  the  neck,  and  which  was  shown  by  necro- 
scopy to  have  resulted  from  the  effusion  of  blood  in  the  spinal  canal  between  the  theca 
and  the  bone ;  and  (3)  that  the  substance  of  the  cord  did  not  exhibit  any  appreciable 
lesion,  notwithstanding  the  compression  it  had  sustained  from  the  sanguinolent  effusion. 

Were  it  essential  to  a  correct  exhibit,  additional  examples  might  be  cited, 
but  these  eleven  cases,  together  with  some  twenty  others  which  have  already 
been  related  or  referred  to  above,  are  enough  to  prove  beyond  a  doubt  that 
compression  of  the  spinal  marrow  arising  from  hemorrhage  into  the  spi- 
nal canal  is  not  a  rare  occurrence,  as  asserted  by  Mr.  Hutchinson ;  and,  fur- 
thermore, that  any  surgeon,  however  large  his  practice  may  be  in  this  class 
of  injuries,  is  liable  to  fall  into  errors  of  belief  concerning  them,  when  he 
generalizes  solely  from  his  own  experience. 

The  diagnostic  symj)tom  of  cord-compression,  when  it  arises  from  the  extrava- 
sation of  blood  in  the  spinal  canal,  is  paralysis  of  sensation  and  voluntary 
motion,  commencing  in  the  legs  a  few  hours  after  the  accident,  and  gradu- 
ally extending  upward  to  the  chest  and  neck,  as  the  extravasation  progresses 
upward  in  the  spinal  canal,  and  joari  passu  with  the  same. 

M.  Brown-Sequard  states,  in  his  Dublin  Lectures,  that  hemorrhage  into  the 
substance  of  the  spinal  cord  may  be  distinguished  from  hemorrhage  around  it, 
by  the  sensibility  gradually  decreasing,  and  by  there  being  no  convulsions. 
When  the  hemorrhage  is  merely  around  the  cord,  and  compresses  the  roots 
of  the  spinal  nerves,  there  are-convulsions,  as  well  as  paralysis  of  voluntary 
motion.^ 

1  Traite  des  Fractures  et  des  Luxations,  t.  ii.  *  Guy's  Hospital  Reports,  1858,  p.  193. 

3  New  Sydenham  Soc.  Year-Book,  1859,  p.  41. 


INJURIES  OF  THE  SPINAL  CORD  AND  SPINAL  NERVES. 


393 


Compressions  of  the  spinal  marrow,  ai'ising 
from  the  displacements  of  dislocated  and  frac- 
tured vertebrae,  have  already  been  mentioned 
with  sufficient  particularity  while  presenting  il- 
lustrative examples  of  the  spinal  dislocations  and 
fractures  which  produce  them. 

Compression  of  the  spinal  cord  by  foreign 
bodies  which  have  entered  the  spinal  canal,  will 
be  sufficiently  illustrated  by  the  subjoined  ab- 
stract and  wood-cut  (Fig  878): — 

A  soldier,  aged  40,  wounded  May  8,  1864,  was  ad- 
mitted to  a  General  Hospital  on  the  IStli,  in  a  para- 
plegic condition,  and  died  a  few  hours  afterwards. 
Necroscopy. — A  conoidal  musket-ball  entered  over  the 
lower  ribs  on  the  left  side,  and,  penetrating  deeply,  had 
lodged  between  the  laminae  of  the  second  and  third  lum- 
bar vertebra?  and  partly  in  the  spinal  canal,  compress- 
ing and  bruising  the  cord.  (Fig.  878.)  The  bladder 
was  distended.^ 

Compression  of  the  spinal  marrow  by  the  products  of  inflammatory  action, 
as,  for  example,  by  serous  and  by  purulent  effusion,  will  presently  be  discussed 
under  the  heads  of  Traumatic  Spinal  Meningitis.,  and  Traumatic  Myelitis. 

Wounds  of  the  Spinal  Cord. — Incised  and  punctured  wounds  of  the  back, 
w^hich  penetrate  the  spinal  column,  as  well  of  those  made  by  gunshot  missiles, 
sometimes  involve  the  spinal  cord  also,  and  divide  it  either  partly  or  wholly. 
Three  cases,  in  which  incised  or  punctured  wounds  of  the  back  extended  into 
or  across  the  spinal  cord,  have  already  been  related.  (See  pp.  269,  270.)  In  all 
of  them  the  parts  supplied  by  the  cut  filaments  of  the  cord  were  paralyzed. 
Two  recovered  (one  completely,  the  other  partially)  and  one  died.  Inasmuch 
as  the  patient  who  recovered  completely,  had,  for  some  time  after  the  wound 
was  inflicted,  entire  loss  of  voluntary  motion  and  partial  loss  of  sensibility 
in  the  right  leg  and  thigh,  it  was  believed  that  the  divided  portion  of  the 
cord  had  grown  together  again,  or  united,  in  the  course  of  about  two  months, 
when  the  paralysis  ceased  in  toto,  and  the  cure  was  perfect.  Li  the  fatal  case 
there  was  complete  paraplegia,  both  motor  and  sensory,  from  the  moment  the 
vv^ound  was  inflicted.  Acute  bed-sores  (sphacelus)  soon  supervened,  and  caused 
•death  in  thirty-six  -days  after  the  injury.  The  cord  had  been  completely 
divided  by  the  knife,  and  there  was  no  attempt  at  reunion. 

Dr.  Eli  ITurd^  reports  a  remarkable  case  of  recovery  from  an  incised  wound 
of  the  spinal  cord : — 

In  jumping  from  a  wagon,  the  man's  feet  slipped,  and  he  fell  on  his  back.  In  at- 
tempting to  rise  he  found  his  lower  extremities  paralyzed.  Calling  for  help  he  stated 
that  a  chisel,  which  he  had  carried  in  his  coat-tail  pocket,  was  sticking  in  his  back  ; 
to  extract  it,  required  the  united  efforts  of  several  men.  It  measured  five  inches  in 
length  to  the  shoulders,  was  seven-eighths  of  an  inch  in  width,  and  from  one-fourth  of  an 
inch  at  the  shoulders  tapered  to  one-eighth  of  an  inch  in  thickness  at  the  cutting  end. 
It  had  entered  to  the  shoulders.  During  the  extraction,  the  patient  suffered  very 
little,  but  said  that  he  saw  apparently  vivid  fiashes  of  light,  which  were  followed  by  total 
darkness.  The  wound  was  opposite  the  spinous  processes  of  the  lower  dorsal  vertebra?. 
Total  loss  of  cutaneous  sensibility  below  the  wound,  with  total  loss  of  voluntary  motion 

1  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Volume,  p.  447. 
^  New  York  Journal  of  Medicine,  1845. 


Fig.  878. 


Showing  the  second  and  third  lumbar 
vertebrae,  with  a  conoidal  musket-ball 
lodged  between  their  laminae,  projecting 
into  the  spinal  canal,  and  compressing 
the  cord.    (Spec.  3523,  A.  M.  M.) 


394 


INJURIES  OF  THE  BACK. 


in  the  corresponding  parts,  and  paralysis  of  the  bladder  and  rectum,  were  the  imme- 
diate consequences.  The  patient  was  prostrated  for  forty  hours,  and  then  reaction  was 
followed  by  fever  for  several  days.  The  wound  healed  rapidly.  The  urine  was  with- 
drawn by  a  catheter  for  eight  days.  Cutaneous  sensibility  returned  on  the  fifth  day, 
and  imperfect  use  of  the  limbs  about  the  fifteenth.  After  five  years  he  still  walked 
with  crutches. 

Dr.  Hurd  fully  believed  that  the  spinal  marrow  was  divided  in  this  case, 
and  that  afterward  it  united  or  grew  together  again. 
Dr.  T.  Peniston  ^  relates  another  successful  case : — 

A  man,  aged  34,  received  a  stab-wound  from  a  dagger  between  the  eleventh  and 
twelfth  dorsal  vertebrae,  on  the  right  side.  It  was  attended  by  paralysis  of  the  right 
leg.  In  eight  months  he  recovered  so  far  that  he  walked  with  a  cane  or  crutch.  (Ash- 
hurst.) 

The  following  example  is  very  instructive  as  well  as  interesting : — 

M.  Vigues^  reports  the  case  of  a  man,  aged  28,  who  was  admitted  into  Professor 
Nelaton's  ward,  at  the  St.  Louis  Hospital,  on  February  4,  1850,  shortly  after  he  had 
been  wounded  in  the  back  with  a  sword  by  a  poHce-officer.  The  point  of  the  weapon, 
entering  three  centimetres  (one  inch)  from  the  line  of  the  spinous  processes  and  to  the 
right  thereof,  and  making  a  transverse  cut  one  centimetre  and  a  half  (half  an  inch)  in 
length,  passed  obliquely  toward  the  left  and  a  little  upward,  between  the  ninth  and 
tenth  dorsal  vertebrje,  into  the  spinal  canal,  and  wounded  the  spinal  cord.  There  were 
paralysis  of  the  lower  extremities,  with  retention  of  urine  and  feces,  and  marked  hyper- 
sesthesia  of  the  left  lower  limb  and  genital  organs.  On  February  20,  a  slough  was 
found  on  the  right  side  of  the  sacrum  ;  the  patient  had  not  felt  anything  there.  ^  In 
April,  voluntary  motion  had  returned  in  both  limbs,  but  sensibility  was  still  deficient 
in  the  right.  On  June  15,  the  patient  could  walk  with  the  help  of  a  cane ;  and  he 
left  the  hospital,  although  the  sensibility  was  not  yet  fully  restored  in  his  right  limb. 
Three  years  afterward  the  patient  was  again  seen ;  he  stated  that  he  was  quite  well, 
and  that  he  could  walk  without  difficulty  or  fatigue ;  but,  a  year  later,  having  walked 
a  distance  of  many  leagues,  he  found  a  large  eschar,  produced,  he  said,  by  the  friction 
of  his  pants  on  his  right  knee ;  he  had  felt  no  pain,  and  was  surprised  when  he  found 
this  sore.  Although  the  sensibiHty  was  still  deficient  in  this  hmb,  its  movements  were 
all  executed  freely  and  without  fatigue. 

Without  doubt  the  weapon,  in  this  man's  case,  gashed  the  spinal  cord  ex- 
tensively, and  the  severed  nerve-filaments  reunited  in  a  comparatively  brief 
time.  Here  is  still  another  successful  case  of  the  same  sort,  which  was 
recorded  by  Morgagni : — ^ 

A  young  man  was  struck  with  a  quadrangular  and  acute  poniard,  which  entered  his 
neck  below  the  left  ear,  and  passed  into  his  spinal  cord.  Immediately,  sensibility  and 
voluntary  motion  were  lost  in  all  the  parts  below  the  head.  The  respiration  was  en- 
entirely  diaphragmatic.  He  complained  of  being  cold  ;  and,  without  his  feeling  it,  the 
application  of  a  hot  metallic  vase  caused  burns  on  his  thighs,  legs,  and  feet.  On  the 
seventeenth  day,  he  began  to  recover  some  feehng  in  the  left  side  of  his  body  ;  and,  on 
the  twentieth,  he  began  to  move  the  toes  and  fingers  of  the  same  side  ;  these  faculties 
gradually  increased.  On  the  thirty-second  day,  there  was  a  return  of  some  feehng  in  the 
right  side  of  his  body ;  movement  also,  but  at  a  later  period,  returned  slowly  there.  On 
the  fortieth  day,  there  was  sensibility  and  movement  everywhere,  but  not  enough  to  allow 
the  patient  to  stand  up.  The  recovery  was  so  slow  that,  four  months  after  the  casualty, 
he  was  just  beginning  to  get  out  of  bed,  and  to  walk  as  a  child  learning  to  walk ;  and, 
even  then,  there  was  less  capacity  for  feeling  and  movement  in  the  right  than  in  the 
left  side  of  his  body. 

1  New  Orleans  Med.  and  Surg.  .Journal,  1851, 

2  Moniteiir  des  Hopitaux,  3  Septembre,  1855,  p.  838  ;  Brown-Sequard,  op.  cit.,  pp.  97-100. 

3  De  Sedibus  et  Causis  Morborum  ;  quoted  by  Brown-Sequard,  op.  cit.,  pp.  103,  104. 


INJURIES  OF  THE  SPINAL  CORD  AND  SPINAL  NERVES. 


395 


Tt  should  be  observed  that  the  complete  loss  of  sensibility  and  voluntary 
motion,  which  occurred  at  the  outset  of  this  case,  arose  from  the  intra-thecal 
extravasation  of  blood  and  consequent  compression  of  the  spinal  cord,  as  well 
as  from  the  section  of  certain  parts  of  the  cord  itself  by  the  poniard.  No 
doubt,  the  severed  nerve-fibres  reunited  in  this  case  also ;  and  the  clinical 
history  clearly  shows  how  very  slow  the  process  of  reunion  sometimes  is. 

But  incised  and  punctured  wounds  of  the  spinal  cord  may  give  rise  to 
inflammation  of  the  cord  and  its  membranes,  and  so  cause  death,  as  happened 
in  the  following  instance : — 

M.  Gama^  relates  the  case  of  a  soldier  who  received  a  bayonet  wound  between  the 
twelfth  dorsal  and  tirst  lumbar  vertebra?,  which  injured  the  spinal  cord.  On  the  seventh 
day  he  died,  without  having  had  any  paralysis.  There  was  at  the  outset  pain,  which 
dinriinished  after  several  venesections.  On  the  second  day,  however,  he  had  the  most 
excruciating  pains  and  violent  cramps  in  all  the  parts  below  tlie  wound,  and  they  con- 
tinued until  his  death.  There  was  also  extreme  hypersesthesia,  and  the  skin  on  the 
lower  part  of  his  trunk  and  inferior  extremities  was  so  sensitive  that  one  did  not  dare 
to  touch  him,  and  he  had  to  keep  himself  on  his  knees  and  hands.  Necroscopy  revealed 
a  wound  of  the  spinal  cord.  There  was  an  inflammation  of  the  spinal  cord  and  its 
membranes,  and  also  of  the  brain. 

The  pains  and  cramps  in  the  legs,  etc.,  arose  from  the  meningeal  inflam- 
mation involving  the  contiguous  spinal  nerves.  The  hyper?esthesia,  however^ 
arose  in  part  from  this  cause,  and  in  part  from  the  inflammatory  lesion  of  the 
spinal  cord,  but  mostly  from  the  latter.  Brown-Sequard  has  ascertained  by 
experiments  upon  animals,  that  a  wound  on  the  posterior  surface  of  the  cord 
is  followed  by  a  greater  hyper^esthesia,  in  the  lower  limbs,  when  made  at 
the  middle  of  the  enlargement  whence  the  spinal  nerves  proceed  to  these 
limbs,  than  when  it  is  made  higher. 

In  unilateral  injuries  of  the  spinal  cord,  there  is  often  observed  a  loss  of 
voluntary  motion  on  the  same  side  of  the  body,  with  a  loss  of  sensibility  on 
the  opposite  side.  This  point  is  an  important  one,  and  can  best  be  illustrated 
by  presenting  the  abstracts  of  a  few  cases  : — 

Dr.  F.  RiegeP  records  the  case  of  a  man,  aged  22,  who  was  stabbed  in  the  neck 
with  a  knife.  After  being  insensible  for  some  time,  he  presented  the  following  symp- 
toms :  On  the  left  side  of  the  body,  there  were  paralysis  of  all  tlie  muscles  excepting 
those  of  the  head  and  neck,  augmented  sensibility  to  touch,  changes  of  temperature, 
and  pain,  and  increase  of  reflex  irritability  ;  at  a  later  period,  there  was  atrophy  of  the 
paralyzed  muscles,  with  corresponding  thermometric  changes.  On  the  right  side  of  the 
body  there  was  almost  entire  anesthesia  as  regards  all  forms  of  sensation,  with  com- 
plete power  of  motion.  From  the  symptoms,  Riegel  concludes  that  the  left  half  of  the 
spinal  cord  was  divided  in  the  neck.  The  tremors  and  reflex  irritability  were  success- 
fully treated  with  hypodermic  injections  of  arsenious  acid.  M.  Bernhardt  gives  a  case 
of  the  same  kind.^ 

Boyer*  mentions  the  case  of  a  drummer  who  was  wounded  in  the  back  of  the  neck 
by  a  sword  thrown  at  him,  which  penetrated  the  upper  part  of  the  right  lateral  half  of 
the  neck.  An  incomplete  motor  paralysis  ensued  in  the  right  side  of  the  body ;  and,  it 
was  accidentally  discovered  some  time  afterward,  that  sensibility  was  lost  in  many  parts 
of  the  left  side.  After  twenty  days,  the  wound  was  cured  and  the  man  left  the  hos- 
pital, but  he  was  still  paralyzed. 

Dr.  J.  Hughlings  Jackson^  reports  a  stab-wound  of  the  cervical  region  involving  one 
side  of  the  spinal  cord.  There  were  loss  of  motion  and  ptosis  on  the  same  side  as  the 
lesion,  and  loss  of  sensation  on  the  opposite  side. 

^  Traite  des  Plaies  de  la  T6te  et  de  TEncephalite,  1830,  p.  318  ;  Brown-Sequard,  op.  cit.,  pp. 
60,  61. 

2  Berlin  klin.  Woch.,  1873.         s  New  Sydenham  Soc.  Biennial  Retrospect,  1873-74,  p.  123. 
*  Traite  des  Maladies  Chirurgicales,  t.  vii.  p.  9  ;  Brown-Sequard,  op.  cit.,  p.  101. 
5  London  Hospital  Reports,  vol.  1.  p  337. 


396 


INJURIES  OF  THE  BACK. 


Treatment. — Incised  and  punctured  wounds  of  the  spinal  marrow  should  be 
treated  by  closing  them  immediately  with  antiseptic  precautions,  and  with 
antiseptic  dressings  applied  on  the  outside,  in  order  to  get  union  of  the  external 
wo  and  by  "  the  lirst  intention,"  and  thus  stop  the  outflow  of  cerebro-spinal 
fluid  as  soon  as  possible.  To  promote  the  same  end,  the  injured  parts  should 
be  kept  in  a  state  of  rest,  as  nearly  perfect  as  possible.  By  employing  these 
means,  too,  the  occurrence  of  spinal  meningitis  or  myelitis  may  be  obviated. 
It  will  be  remembered  that,  in  a  case,  mentioned  above,  of  bayonet-wound  of 
the  spuial  cord,  traumatic  meningitis  supervened,  and  destroyed  the  patient.  , 
All  pains  that  arise  in  such  cases  should  be  subdued  by  administering  opium 
or  morphia. 

Gunshot  wounds  of  the  spinal  cord  are  of  frequent  occurrence.  In  nearly 
all  the  examples  of  gunshot  fracture  of  the  spinal  column,  which  have  been 
above  presented  to  the  reader,  traumatic  lesions  of  the  spinal  cord  also 
existed.  In  the  case  of  Soteldo  (p.  874),  the  missile  slightly  lacerated  the 
cord,  and  deposited  in  its  substance  a  spiculum  of  bone.  In  the  soldier's  case 
reported  by  M.  Hutin,  where  there  was  survival  of  the  injury  for  fourteen 
years,  death  resulting  from  Bright's  disease,  the  missile  divided  the  right 
half  of  the  cauda  equina,  displaced  the  left  half,  and  became  itself  firmly 
impacted  in  the  spinal  canal,  where  it  remained  innocuous  for  the  time 
specified.  In  several  instances  above  mentioned,  the  missile  completely 
divided  the  spinal  marrow. 

To  illustrate  the  phenomena  which  result  from  gunshot  wounds  of  the 
spinal  cord,  it  is  advisable  to  narrate  the  history  of  a  case  that  came  under 
my  own  observation : — 

Sergeant  A.  S.  Girt,  Co.  E,  4th  Pennsylvania  Cavalry,  aged  23,  was  wounded 
December  1st,  1864,  by  a  pistol-shot  which  entered  the  root  of  his  neck  about  an  inch 
above  the  inner  end  of  the  left  clavicle,  passed  backward,  downward,  and  inward  to  the 
spinal  column,  perforated  the  body  of  the  first  dorsal  vertebra,  wounded  the  theca  ver- 
tebrahs  and  the  spinal  cord,  fractured  the  laminae  of  the  second  dorsal  vertebra,  and 
lodged  on  the  right  side  of  its  spinous  process.     He  was  standing  at  the  time,  but 
instantly  fell  to  the  ground  in  a  helpless  condition  from  paraplegia.    The  wound  bled 
considerably  at  first,  but  the  bleeding  soon  ceased  spontaneously.    On  the  2d,  I  saw 
him  at  the  field-hospital  of  the  Cavalry  Division  in  front  of  Petersburg,  Va.  The 
orifice  of  the  wound  was  remarkably  small,  and  the  integuments  surrounding  it  were 
considerably  swelled  and  tender,  that  is,  inflamed.    There  was  complete  paralysis,  both 
sensory  and  motor,  of  the  lower  extremities,  and  of  the  abdomen  as  high  as  the  umbiU- 
cus.    He  had  no  power  of  voluntary  motion  whatever  in  those  parts.    Likewise,  I  failed 
to  excite  any  reflex  movement  whatever  by  tickling  the  soles  of  his  feet,  and  did  not 
produce  any  sensation  by  violently  pulUng  the  hairs  on  his  legs,  thighs,  etc.    The  urinary 
bladder  also  was  paralyzed,  and  catheterization  was  necessary.     He  had  priapism. 
There  was  faint  cutaneous  sensibility  just  above  the  umbilicus  ;  and,  proceeding  upward, 
this  gradually  increased  until  on  the  thorax  it  appeared  to  be  normal.    His  respiration 
was  superior-thoracic  and  diaphragmatic,  or  abdominal,  but  principally  the  latter.  The 
sensibility  of  the  upper  extremities  did  not  appear  to  be  impaired,  but  the  muscular 
power  was  considerably  diminished,  as  I  readily  ascertained  by  grasping  his  hands  and 
allowing  him  to  pull.    The  left  arm  was  weaker  than  the  right.    His  intellect  was  un- 
disturbed, and  he  did  not  complain  of  any  pain,  excepting  when  the  wound  and  its 
vicinage  were  manipulated.    On  the  5th,  I  again  saw  him.    He  was  smoking  his  pipe 
as  he  fay  in  bed  ;  countenance  cheerful,  and  free  from  any  sign  of  distress ;  he  said  his 
appetite  was  good,  and  that  he  swallowed  without  difliculty.    The  wound  was  scabbed 
over,  and  the  parts  were  less  swelled  and  inflamed.    His  bowels  acted  spontaneously  in 
the  bed,  and  he  had  no  control  over  them  whatever,  for  the  sphincter  ani  had  ceased  to 
act.    The  priapism  had  disappeared,  but  the  condition  of  the  bladder  and  other  parts, 
as  to  paralysis,  was  unchanged.    The  respiratory  function  was  quite  successfully  per- 
formed.  On  the  10th,  he  was  transferred  to  the  Depot  Field  Hospital  at  City  Point.  On 


INJURIES  OF  THE  SPINAL  CORD  AND  SPINAL  NERVES. 


397 


Fig.  879. 


wmi 


the  11th,  a  dusky  hue  of  the  countenance  was  observed,  as  if  the  blood  were  imper- 
fectly aerated.  On  the  12th,  the  breathing  became  labored  and  attended  with  moist 
rales.  The  dyspnoea  increased  ;  and,  on  the  13th,  he  died.  An  autopsy  was  made  by 
myself  on  the  15th.  The  missile  had  penetrated  the  root  of  the  neck  as  stated  above, 
g;one  through  the  sterno-mastoid  muscle,  and,  avoiding  the  great  vessels,  struck  tlie 
body  of  the  first  dorsal  vertebra  well  in  front  and  slightly  to  the  left  of  the  middle  line, 
bored  a  hole  through  the  body  of  this  vertebra  backward,  downward,  and  toward  the 
right,  penetrated  the  spinal  canal,  lacerated  the  theca  vertebralis  on  its  front  and  right 
sides  extensively,  cut  the  spinal  cord  partly  in  two,  fractured  by  its  impact  the  riglit 
lamina  of  the  second  dorsal  vertebra,  with  comminution  (it  had  also  fractured  indirectly 
the  left  lamina),  and  lodged  on  the  right  side  of  the  spinous  process  of  the  same  vertebra, 
having  passed  through  the  spinal  column  from  before  backward,  and  somewhat  obliquely 
from  left  to  right  and  from  above  downward.  The  fragments  were  small  and  did  not 
press  uDon  the  cord.  The  lungs  held  somewhat  more  blood  than  normal,  were  also 
moderately  oedematous,  and  the  air-passages  contained  a  quantity  of  frothy  unstained 
liquid.  Tliere  was  moderate  inflammatory  action,  adhesive  in  character,  in  the  theca 
vertebralis.  It  was  confined,  however,  to  the  immediate  neighborhood  of  the  wound. 
There  was  no  pus.  The  undivided  portion  of  the  cord  was  pulpefied  (contused),  and 
stained  with  blood,  but  it  did  not  appear  to  the  unaided  eye  to  be  inflamed. 

The  autopsy  of  this  patient  shows  that  gunshot  wounds 
of  the  spinal  cord  are  essentially  contused  and  lacerated  in 
their  nature,  while  his  clinical  history  exhibits  the  symp- 
toms of  concussion,  contusion,  and  laceration  of  the  cord, 
as  might  reasonably  be  expected.  The  loss  of  sensibility 
and  voluntary  motion  below  the  cord-lesion,  indicates  that 
the  functions  of  the  cord  as  a  conductor  of  impressions  to 
and  from  the  sensorium  were  entirely  destroyed  by  the 
wound,  and  the  loss  of  reflex  motor  action  shows  that  the 
functions  of  the  cord  as  a  nerve-centre  were  likewise  sup- 
pressed by  the  concussion. 

When  bronchial  eflusion  with  moist  rales  occurred  in 
this  case,  the  man  could  not  get  rid  of  it  by  coughing  and 
spitting ;  and,  therefore,  his  dyspnoea  rapidly  increased  until 
death  from  suffocation  took  place.  It  is  worthy  of  remark 
that,  when  complete  paraplegia  results  from  Injury  of  the 
spinal  cord  at  the  root  of  the  neck,  the  power  of  inspiration 
is  generally  preserved,  but  the  power  of  expiration,  as  needed 
particularly  for  coughing  and  shouting,  is  entirely  lost. 

The  traumatic  lesions  of  the  spinal  cord  that  result  from 
simple  fractures  and  dislocations  of  the  vertebrse,  consist  of 
contusion,  stretching,  laceration,  and  complete  division. 
Many  examples  have  already  been  presented.  In  Mr. 
Oline's  famous  case  of  resection  or  trephining  the  spinal 
column,  the  cord  was  found  to  be  three-fourths  torn 
through,  and  the  remaining  portion  was  bruised.  Occa- 
sionally, the  cord  is  found  to  be  lacerated  in  the  manner 
depicted  in  the  accompanying  wood-cut  (Fig,  879).  It 
represents  the  appearance  which  the  spinal  cord  and  mem- 
branes presented  in  the  case  of  a  soldier  whose  spinal 
column  was  fractured  by  the  limb  of  a  tree  falling  across  gj^^^^.^  laceration  of 
his  loins.  A  wood-cut  to  illustrate  the  vertebral  lesion  ""^^^^  ""mJmlnLL 
(transverse  simple  fracture  of  the  first  lumbar  vertebra)  and  cord  caused  by  sim. 
was  given  on  p.  351,  supra,  Fig.  862,  together  with  the  traosverse  fracture 
clinical  account  of  the  case.  Xecroscopy  showed  that  the  ""^[^l!^^  ^s^pel"  isotVecI' 
spinal  meninges  were  torn  entirely  across,  excepting  a  few    i,  a.  m.  m.j. 


398 


INJURIES  OF  THE  BACK. 


fibres  anteriorly  and  posteriorly,  and  were  congested  above  and  below  the 
rent.  Clots  of  blood  were  found  diffused  near  the  fracture.  The  lower  por- 
tion of  the  cord,  severely  lacerated,  was  drawn  up  into  a  bundle  at  the  seat  of 
injury,  entirely  deprived  of  the  membranes.  The  tubular  nerve  filaments 
were  seen  to  be  curiously  dissected  out  by  the  pus  in  which  the  cord  was 
bathed,  forming  a  leash  which  is  well  shown  by  the  preceding  wood-cut. 
Briefly  stated,  the  vertebral  lesion  consisted  of  a  transverse  fracture  extend- 
ing through  the  body  and  pedicles  of  the  first  lumbar  vertebra,  with  its  spin- 
ous and  left  transverse  processes  impinging  upon  the  cord.  The  latter  may 
have  been  driven  into  that  position  by  the  force  of  the  original  blow,  as  well 
as  by  injuries  sustained  in  transportation. ^  The  cause  of  death  apparently 
was  septicaemia  arising  from  gangrenous  bed-sores. 

Occasionally,  too,  the  cord  is  completely  severed  by  a  vertebral  dislocation 
or  fracture.    For  instance : — 

Malgaigne^  mentions  a  case  by  Melchiori,  in  which  a  mason  fell  from  a  height  upon 
his  back.  There  was  complete  forward  bilateral  dislocation  of  the  tenth  dorsal  vertebra. 
He  survived  the  injury  for  one  day  only.  The  autopsy  showed  that  there  was  no  frac- 
ture, but  that  the  spinal  cord  was  divided.  (Ashhurst.) 

Dr.  Parkman'  presented  to  the  Boston  Society  for  Medical  Improvement,  a  specimen 
in  which  the  third,  fourth,  and  fifth  dorsal  vertebrae  were  fractured ;  the  third  and 
fourth  were  also  displaced  or  projected  in  front  of  the  sixth  and  seventh,  and  were  co- 
ossified  in  that  position.  The  cord  was  completely  divided ;  still  the  patient  survived 
for  two  months. 

In  very  rare  instances,  a  splinter  from  a  fractured  vertebra  severs  the  spi- 
nal marrow,  as  happened  in  a  case  related  by  Abernethy,  already  mentioned, 
and  in  the  following : — 

Dr.  D.  S.  Conant*  reports  the  case,  already  mentioned  above,  of  a  man,  aged  55,  who 
was  blown  off  from  rigging  by  wind,  and  who  struck  on  his  shoulders.  There  were  frac- 
tures of  the  last  dorsal  and  first  lumbar  vertebrae,  paralysis,  chill,  and  dehrium. 
Blisters  formed  on  both  thighs,  before  death,  which  occurred  in  six  days.  The  autopsy 
showed  that  a  splinter  from  the  first  lumbar  vertebra  had  divided  the  cord.  (Ashhurst.) 

It  may  be  of  interest  to  state  that,  in  nearly  all  the  fatal  cases  of  disloca- 
tion or  fracture  of  the  spinal  column  collected  by  Mr.  Bryant  at  Guy's  Hospi- 
tal, the  vertebral  injury  was  complicated  with  some  structural  lesion  of  the 
spinal  cord ;  and  that,  in  at  least  three-fourtiis  of  these  fatal  cases,  the  cord 
was  irreparably  injured  by  the  mechanical  pressure  of  the  displaced  bones,  or 
by  the  effusion  of  blood  into  its  structure.^ 

It  is  believed,  however,  that,  under  favorable  circumstances,  the  nerve- 
fibres  when  divided  in  lacerations  (incomplete)  of  the  spinal  cord  from  simple 
fractures  and  dislocations,  as  well  as  in  incised  wounds,  may  unite  again,  pro- 
vided that  they  are  not  displaced  too  much,  just  as  the  filaments  unite  again  m 
the  nerves  of  the  face  and  extremities,  when  divided  by  accidental  wounds  or 
by  surgical  operations.  To  support  this  view,  the  condition  of  the  cord  which 
was  revealed  by  post-mortem  examination,  several  months  after  the  ongmal 
accident,  in  a  case  recorded  by  Dupuytren  of  vertebral  fracture  with  injury  of 
the  cord  and  paralysis,  where  recovery  had  taken  place,  may  here  be  cited  :— 

Charles  Millie,  aged  21,  was  admitted  to  the  Hotel-Dieu,  in  1825,  with  paralysis  of  the 
extremities  and  bladder,  caused  by  a  fall  upon  the  back  of  his  neck.  After  two  months 
and  a  half  of  entire  rest,  combined  with  venesection,  cupping,  and  leeching,  he  recovered, 

1  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Vol.,  pp.  426,  450. 
*  Traite  des  Fractures  et  des  Luxations,  t.  ii. 

3  American  Journal  of  the  Medical  Sciwces,  N.  S.,  vol.  xxv.  1853. 

4  American  Medical  Times,  1861.  ^  Lancet,  April  6,  1867. 


INJURIES  OF  THE  SPINAL  CORD  AND  SPINAL  NERVES. 


399 


and  left  the  liospital  with  only  slight  weakness  in  the  left  leg,  and  with  the  head  bowed 
slightly  forward. 

Subsequently  he  fell  and  broke  his  spine  again.  Thirty -four  days  after  that  he  died 
exhausted  from  bed-sores  and  colliquative  diarrhoea. 

The  autopsy  revealed  fractures  of  the  fourth  and  fifth  cervical  vertebrae,  which  had 
united ;  the  callus  had  been  broken  by  the  second  fall.  "  Opposite  the  point  of  com- 
pression, the  cord  exliibited  an  annular  constriction,  abrupt  and  well-marked,  and 
very  analogous  to  that  presented  by  the  inteshne  in  some  cases  of  strangulated  hernia. 
When  incised  longitudinally  at  this  spot,  the  color  and  consistence  of  the  cord  were 
found  altered  to  a  brownish  hue,  and  to  the  density  and  firmness  of  fibrous  tissue  ;  a 
small  circumscribed  spot,  about  a  line  in  extent,  was  especially  characterized  in  this 
way.  The  membranes  were  also  more  adherent  here  than  elsewhere."  It  was  inferred 
that  the  seat  of  this  peculiar  change  was  that  of  the  original  lesion  of  the  cord,  and  that 
the  morbid  appearance  constituted  a  true  cicatrix  of  the  spinal  marrow.^  Moreover,  this 
case  shows  that  the  process  of  re-uniting  the  filaments  of  the  spinal  cord,  when  lacerated 
by  vertebral  fractures  or  dislocations,  is  not  a  rapid  one,  and  that  certainly  several 
months,  and  possibly  several  years,  must  elapse  before  it  can  be  accomplished. 

M.  Brown-Sequard's  experiments  upon  animals  prove  that  in  them  reunion 
may  take  place  after  a  wound  of  the  spinal  cord,  so  that  its  lost  functions 
may  return.^  Furthermore,  this  eminent  observer  has  sometimes  seen  a  nota- 
ble return  of  lost  functions  (rachidian)  in  animals,  when  their  spinal  columns 
had  been  fractured  and  their  spinal  cords  crushed.^  The  investigations  of  MM. 
Masius  and  Van  Lair,"*  in  regard  to  the  regeneration  of  the  spinal  marrow, 
show  how  great  the  reparative  power  of  this  organ  really  is.  These  experi- 
menters divided  the  spinal  marrow  in  frogs,  and  at  the  end  of  from  two  to 
four  months  obtained  undoubted  evidence  that  these  frogs  had  regained  sensi- 
bility and  voluntary  motility  in  their  hind  legs.  In  other  frogs,  histologi- 
cal examination  showed  a  more  or  less  complete  regeneration  of  the  spinal 
marrow. 

The  fact  that  cases  of  long-standing  infantile  spinal  paralysis  are  cured — 
cases  in  which  there  can  be  no  doubt  of  the  existence  of  the  spinal  lesion 
(atrophy  of  the  anterior  cornua) — is  of  itself  sufficient  evidence  to  prove  that 
the  reparative  power  of  the  spinal  cord  is  very  great.  (Hammond.)  Like- 
wise, it  will  be  remembered  that  four  examples  of  reunion  of  the  spinal  cord 
in  the  human  subject,  when  it  had  been  gashed  by  cutting  instruments,  were 
presented  on  pages  393,  394  (supra).  There  can  therefore,  be  no  doubt, 
that  the  nerve-lilaments  of  the  spinal  cord  may  reunite  when  they  have  been 
severed  by  simple  fractures  and  dislocations  of  the  spinal  column. 

The  treatment  which  such  wounds  of  the  spinal  cord  require,  has  already 
been  laid  down  while  discussing  the  simple  fractures  and  dislocations  of  the 
spinal  column  that  cause  them.  Briefly  stated,  it  consists,  (1)  in  withdrawing 
the  vulnerating  body  from  the  cord-wound  by  reducing  the  fracture  or  dis- 
location ;  (2)  in  placing  the  severed  cord-filaments  in  the  condition  most 
favorable  for  reunion  by  maintaining  perfect  rest  of  body  ;  and  (3)  in  turning 
aside  any  phlogosis  which  would  retard  or  prevent  their  reunion,  by  leeching 
or  cupping,  cold  applications,  and  counter-irritants,  lised  externally,  and  by 
opium  or  morphia,  potassium  iodide,  and  ergot,  given  internally,  according 
to  the  indications  for  their  employment. 

Injuries  of  the  Spinal  ^^'erves.^— In  fractures  and  dislocations  of  the 
vertebrae,  whether  simple  or  compound,  the  roots  of  the  spinal  nerves  are 

1  Op.  cit.,  pp.  358,  359. 

2  Experimental  Researches  applied  to  Physiology  and  Pathology,  p.  17.    New  York,  1853. 

3  Lectures  on  the  Physiology  and  Pathology  of  the  Central  Nervous  System  delivered  before 
the  Royal  College  of  Surgeons  of  England,  p.  250.    Appendix.    Philadelphia,  1860. 

^  Archives  de  Physiologic,  t.  iv.  p.  268.  5  gee  Figure  877.  p.  382. 


400 


INJURIES  OF  THE  BACK. 


liable  to  sufter  injury  during  their  passage  through  the  intervertebral  fora- 
mina." Such  lesions  were  undoubtedly  present  in  many  examples  of  these 
fractures  and  dislocations  which  have  been  mentioned  in  the  foregoing  pages; 
but  there  is  special  ground  for  believing  that  such  lesions  were  present  in 
those  cases  of  spinal  fracture  or  dislocation  where  great  pain  was  experienced 
by  patients  in  the  regions  of  body  supplied  by  the  spinal  nerves  which  leave 
the  spinal  column  at  the  seat  of  the  displacement  {e.g.,  in  the  walls  of  the 
abdomen  at  the  pit  of  the  stomach,  when  the  sixth  or  seventh  dorsal  vertebra 
is  broken  or  displaced,  etc.) ;  for  when  the  peripheral  nerves  in  general  are 
mechanically  irritated  in  any  part  of  their  course,  painful  sensations  or  in- 
creased sensibility  (hypersesthesia)  are  usually  produced  in  the  parts  where 
they  terminate,  and,  when  they  are  divided,  these  parts  immediately  become 
paralyzed,  and  their  paralysis  lasts  until  the  severed  nerves  have  grown  to- 
gether again. 

The  traumatic  lesions  which  the  spinal  nerves  most  frequently  sustam  at 
the  intervertebral  foramina,  are  such  prickings  and  scratchings  of  their  com- 
ponent threads  as  cause  pains  (often  severe),  or  increased  sensibility,  in  the 
integuments  and  muscles  of  the  back,  where  the  posterior  branches  of  the 
injured  nerves  are  distributed,  as  well  as  in  the  integuments  and  muscles 
which  are  supplied  by  the  anterior  branches  of  the  injured  nerves.  Some- 
times cramp  and  other  signs  of  convulsive  action  are  experienced  in  the  parts 
supplied  by  the  injured  nerves.  Occasionally  the  spinal  nerves  are  severed 
by  the  displaced  bones  in  cases  of  vertebral  fracture  or  luxation,  and  then  the 
parts  supplied  by  them  are  at  once  deprived  of  all  sensation,  as  well  as  of  all 
power  of  both  voluntary  and  reflex  motion. 

Stromeyer  mentions  an  interesting  case  in  which  the  phrenic  nerve  must  have  been 
contused  by  a  bullet,  for  during  eight  days  great  dyspncea  was  present,  and  the  patient 
was  obhged  to  remain  in  a  sitting  posture  ;  it  was  at  first  supposed  that  the  lung  had 
been  injured,  but  there  were  no  physical  changes  on  the  corresponding  side  of  the 
chest.^ 

This  matter  of  severe  pain  being  felt  in  the  peripheral  extremities  of  the 
spinal  nerves,  when  they  are  injured  by  fractures  or  dislocations  of  the  spinal 
column,  is  beautifully  illustrated  by  the  case  of  a  colored  soldier  of  our  army, 
who  received  from  the  conoidal  ball  of  a  Colt's  navy  revolver,  January  28, 
1866,  fractures  of  the  spinous  processes  of  the  sixth  and  seventh  dorsal  ver- 
tebrae, laying  open  the  spinal  canal  between  these  processes,  and  lacerating 
the  cord ;  for  he  had  great  pain  in  the  epigastric  region,  as  well  as  complete 
paralysis  below  the  seventh  dorsal  vertebra.^ 

Traumatic  Inflammation  of  the  Membranes  and  Substance  of  the  Spinal 

Cord. 

There  are  at  least  two  considerable  errors  which  have  been  long  and  widely 
taus^ht  by  surgeons  in  En2:lish-speaking  countries,  as  well  as  in  others,  namely  : 
(1)  that  when  the  verteb'i^se  are  displaced  in  luxations  and  fractures  of  the 
spinal  column,  no  effort  should  be  made  to  restore  them  to  a  normal  position, 
that  is,  that  a  dislocated  or  broken  spine  should  not  be  "  set;"  (2)  that  when 
the  spinal  membranes  and  spinal  cord,  whether  separately  or  collectively,  are 
injured,  they  are  by  no  means  liable  to  take  on  inflammatory  action,  that  is, 
that  traumatic  inflammation  of  the  spinal  cord-substance,  and  traumatic 

>  stromeyer,  Gunshot  Fractures  etc.  :  translated  by  S.  F.  Statham,  p.  37.    Am.  ed. 
«  Circular  No.  3,  S.  (I.  O.,  August  17,  1871,  p.  38. 


TRAUMATIC  SPINAL  MENINGITIS. 


401 


inflammation  of  the  spinal  meninges,  occur  so  veiy  rarely  in  cases  of  verte- 
bral injury,  that  no  special  thought  nor  pains  need  be  taken  to  avert  them 
while  conducting  the  treatment  of  such  cases.  The  first-mentioned  error 
has  already  been  sufliciently  refuted  in  the  foregoing  pages.  It  is  now  our 
duty  to  inquire  into  the  second.  In  the  first  place,  it  should  be  said  that 
the  last-named  mistake  can  have  arisen  only  from  the  comparatively  great 
infrequency  with  which  the  precise  condition  of  the  spinal  cord  antl  spinal 
membranes  is  exactly  ascertained  by  a  thorough  examinatiou  of  these  struc- 
tures, after  death,  in  fatal  cases  of  spinal  fracture  or  dislocation.  Indeed, 
it  often  is  no  easy  matter  to  make  such  an  examination,  or  even  to  get  per- 
mission to  make  it,  especially  in  private  practice.  But,  as  the  membranes 
and  substance  of  the  brain  are  liable  to  become  inflamed  when  they  are 
wounded  in  any  manner,  so  the  membranes  and  substance  of  the  spinal  mar- 
row, when  similarly  injured,  are  liable  to  become  inflamed,  (1)  because  the 
anatomical  formation  of  these  structures  is  identical  in  both  ;  (2)  because 
they  extend  continuously  from  one  region  to  the  other,  the  continuity  of  each 
structure  being  preserved  intact  throughout;  and  (3)  because  those  inflamma- 
tions which  are  essentially  dift'usive,  spread  readily  from  one  region  to  the 
other,  from  the  spinal  canal  to  the  cranial  cavity,  and  vice  versa.  Cases  of 
traumatic  spinal  meningitis  and  traumatic  myelitis  have  been  recorded  much 
less  frequently  than  cases  of  traumatic  cerebral  meningitis  and  traumatic 
cerebritis,  it  may  be  because  post-mortem  examinations  have  much  less  fre- 
quently been  made  in  traumatic  lesions  of  spinal  column  than  in  traumatic 
lesions  of  the  head. 

The  following  account  of  traumatic  spinal  meningitis  and  traumatic  mye- 
litis is  largely  drawn  up  from  the  examples  reported  by  our  military  sur- 
geons during  and  since  the  late  civil  war,  as  well  as  from  other  reliable 
observations.  In  practice,  it  has  been  found  that  both  diseases  often  occur 
together ;  but  even  then,  either  the  one  or  the  other  usually  predominates, 
and,  therefore,  the  phenomena  presented  by  individual  cases  will  vary  not 
only  in  accordance  with  the  severity  of  the  attack,  but  also  in  accordance 
with  the  disease  which  predominates,  or  the  anatomical  seat  of  the  inflamma- 
tory lesion. 

Traumatic  Spinal  Meningitis. — A  considerable  number  of  cases  in  which 
this  lesion  caused  death  have  alread}^  been  mentioned  in  the  foregoing 
pages. 

Symptoms. — This  disorder,  when  acute,  is  often,  but  not  always,  ushered  in 
by  rigors  or  chilliness ;  pyrexia  generally  ensues,  and  the  pulse  rises  as  w^ell 
as  the  body  heat.  There  are  pain  more  or  less  severe  in  the  aflfected  part  of 
the  spinal  column  (rachialgia),  which  is  increased  by  motion ;  tenderness  of 
the  same  part  under  pressure,  with  increase  of  temperature  above  that  of  the 
unaflected  parts  of  the  organism ;  and  restlessness,  sometimes  great,  with 
general  cutaneous  hyperaesthesia,  the  patient  feeling  "  sore  all  over."  i^ot 
unfrequently,  pain  with  cutaneous  hypersestbesia  exists  in  one  or  more  of  the 
extremities ;  occasionally,  when  paraplegia  is  present,  the  hyperpesthesia  of 
the  integuments  occupies  a  band-like  space,  extendhig  around  the  body  just 
above  the  line  of  paralysis ;  in  some  rare  instances,  where  the  sensory  filaments 
of  the  spinal  nerves  are  greatly  irritated  by  the  inflammatory  process  in  the 
adjacent  membranes,  the  hyper?esthesia  becomes  very  severe,  and  so  distress- 
ing that  w^ords  cannot  describe  the  suft'ering;  at  the  same  time,  the  eflfects  of 
this  inflammatory  irritation  upon  the  motor  filaments  of  the  spinal  nerves 
are  manifested  by  stiflfness  and  contraction  of  the  posterior  cervical  and  dorsal 
muscles,  whereby  the  patient's  head  becomes  drawn  backward  or  recurved, 
so  as  to  deeply  indent  the  pillow ;  the  patient  may  feel  "  stifl',"  as  well  as 
VOL.  IV. — 26 


402  INJURIES  OF  THE  BACK. 


"sore  all  over."  When  the  motor  filaments  are  greatly  irritated  in  this  man- 
ner all  the  muscles  supplied  by  these  filaments  are  aftected  with  tonic  or 
tetanic  spasms,  and  the  case  may  be  mistaken  for  one  of  tetanus  •  when  the 
disease  spreads  to  the  cranial  membranes,  there  is  marked  headache  with 
other  signs  of  cranial  meningitis ;  as  the  case  progresses  from  bad  to  worse, 
delirium  followed  by  coma  supervenes,  and  usually  death  soon  ensues;  but, 
occasionally,  the  tetanic  spasms  are  so  severe  and  extensive  as  to  entirely  stop 
the  resi)iratory  movements,  thus  causing  death  by  sudden  as^jhyxia,  and  then 
the  mind  may  remain  clear  until  the  last  moment.  The  examples  of  this  dis- 
order are,  by  their  symptoms,  clinically  separable  into  three  distinct  groups : 
(1)  the  foudroyanU  embracing  those  in  which  life  is  destroyed  a  few  hours 
after  the  attack,  as  it  were  by  a  thunder-stroke ;  (2)  the  tetanic,  embracing 
those  in  which  tonic  spasms  of  the  muscles  constitute  the  most  striking  part 
of  the  phenomena ;  and  (3)  the  group  embracing  those  in  which  hyperesthesia 
is  the  predominating  symptom.  ^ 

It  should  be  remarked,  however,  that  the  sign  which  is  most  characteristic 
of  this  disorder,  is  recurvation  of  the  head  and  neck  from  tonic  contraction 
(spasm)  of  the  posterior  cervical  muscles.  ^ 

The  phenomena  of  each  of  the  three  clinical  groups  just  mentioned  will  be 
exemplified  by  presenting,  as  briefly  as  may  be  consistent  with  clearness,  some 
abstracts  of  appropriate  cases.  .      .    ,  • 

The  following  abstract  of  a  foudroyant  case  of  traumatic  spinal  meningitis 
and  myelitis  is  very  instructive,  as  well  as  interesting : — 

A  cavalry  soldier  was  wounded,  October  14,  1868,  in  an  affray,  by  a  pistol-ball, 
which  entered  the  right  side  of  his  neck,  half  an  inch  above,  and  somewhat  external 
to  the  crreater  cornu  of  the  hyoid  bone,  lodged,  and  was  not  extracted.  On  the  18th  he 
entered  the  post  hospital  at  Atlanta,  Ga.  There  were  complete  motor  and  sensory  para- 
lysis of  the  lower  extremities  and  the  right  arm,  and  partial  paralysis  of  the  left  arm, 
with  spasmodic  movement  when  used  ;  intercostal  muscles  paralyzed  ;  respiration  abdo- 
minal, and  slow;  pulse  slow  and  regular;  bowels  partially,  and  bladder  completely 
paralyzed ;  sensation  lost  throughout  the  abdominal  region,  but  normal  on  the  upper 
part  of  the  chest  and  the  face;  intellect  clear;  patient  complained  of  coldness  of  the 
surface,  although  the  skin  and  extremities  were  hot  to  the  touch.  The  track  of  the 
ball  could  not  be  ascertained,  as  the  wound  had  nearly  healed ;  but  injury  of  the  spinal 

cord  was  surmised.  ,     t  •  • 

Durino-  the  first  week  in  hospital,  mucus  constantly  accumulated  in  the  air-passages, 
threatening  suffocation,  which  was  averted  by  the  use  of  stimulating  expectorants  The 
bowels  were  relieved  by  injections  and  purgatives,  and  the  bladder  by  the  catheter 
There  was"  no  perceptible  improvement  in  the  paralysis.    A  large  bed-sore  xormed 

over  the  sacrum.  n       •      •  •  u..  u„4- 

Durino-  the  second  week,  there  was  partial  recovery  of  motion  m  the  right  arm,  but 
none  of  sensation.  The  patient  could,  by  an  effort,  draw  this  arm  across  his  breast. 
CEdema  of  the  left  leg  appeared,  and  was  treated  by  bandaging.  ' 

During  the  third  week  there  was  no  improvement.  ■  ,    .  ,  .       .  , 

DurinS  the  fourth  week,  on  the  suggestion  of  Dr.  A.  K.  Smith,  potassium  iodide, 
and  afterward  tincture  of  ergot,  were  given  with  perceptible  benefit.  The  mucus 
diminished  in  quantity,  expectoration  became  easy,  and  the  patient  s  appetite  increa,se^. 

During  the  first  part  of  the  fifth  week,  the  improvement  was  very  encouraging.  The 
respiration  became  more  normal  (that  is,  ceased  to  be  diaphragmatic),  the  bowels  acted 
readily,  the  appetite  remained  good,  and  the  bed-sores  looked  healthy. 

On  November  20,  the  patient  complained  of  stiff  neck,  headache  [backache],  and 
extreme  coldness,  and,  toward  night,  had  slight  fever.  On  the  21st  tlie  fever  had  sub- 
sided, but  he  still  complained  of  headache  [backache]  and  coldness,  and  suppuration  was 
diaixnosticated.  On  the  morning  of  the  22d  he  was  comatose,  with  the  left  pupil  dilated, 
and  the  right  pupil  contracted.  A  blister  was  applied  to  the  nape  of  the  neck  purga- 
tives, etc.,  were  given,  but  to  no  purpose  ;  he  died  at  11.15  P.  M.  Autopsy,  15  hours 
after  death  .—The  missile  had  passed  from  the  point  of  entrance  mentioned  above,  toward 


TRAUMATIC  SPINAL  MENINGITIS. 


403 


the  spinal  column,  crossing  the  carotid  sheath  externally,  and  just  missino-  it.  It 
appeared  to  have  penetrated  the  spinal  canal  through  the  third  intervertebral  foramen, 
but  it  oould  not  be  found.  The  membranes  of  the  cord  and  left  hemisphere  of  the  brain 
were  extensively  disorganized  from  inflammation.  Plastic  lympli,  forming  a  continu- 
ous layer,  was  found  effused  on  the  inner  surface  of  the  theca  vertebralis,  throughout 
the  entire  length  of  the  spinal  cord.  The  subarachnoid  space  was  distended  with  a 
pyoid  serum,  by  which  the  cord  was  compressed  and  softened  opposite  the  third  and 
fourth  cervical  vertebnB.  Here  the  theca  vertebralis  was  ecchymosed  and  separated 
from  the  bone  (by  the  missile).  The  layer  of  plastic  exudation  extended  through  the 
foramen  magnum,  and  along  the  base  of  the  brain  as  far  forward  as  the  optic  commis- 
sure. In  the  anterior  lobe  of  the  left  cerebral  hemisphere,  circumscribed  softening-  was 
found,  presenting  the  appearance  of  an  abscess.  The  gray  substance  of  this  lobe  was 
changed  in  color  and  consistence,  in  consequence  of  the  inflammatory  process;  the 
medullary  substance  was  injected  ;  the  lateral  ventricles  were  marked  by  radiatino- 
bloodvessels  ;  the  corpora  striata  and  optic  thalami  were  injected.' 

This  soldier  died  very  suddenly  from  traumatic  inflammation  of  the  spinal 
and  cranial  meninges,  the  symptoms  of  which  first  appeared  on  ^s'ovember 
20,  death  by  coma  following  on  the  22d.  The  symptoms  were  rigors, 
pyrexia,  headache,  backache,  stifihess  of  the  posterior  cervical  muscles,  and 
€oma,  death  resulting  from  compression  of  the  brain  as  well  as  from  com- 
pression of  the  spinal  cord,  efi:ected  by  the  products  of  a  meningeal  inflam- 
mation wdiich  extended  over  the  whole  length  of  the  spinal  cord,  and  over 
the  base  of  the  brain  up  to  the  optic  commissure.  It  is  probable  that  hyper- 
iesthesia  of  the  integuments  and  rachidian  tenderness  under  pressure  in  the 
neck  were  also  present  at  the  outset.  The  anatomical  changes  wrought  by 
meningeal  inflammation  are  well  described.  There  was  a  continuous  layer 
of  plastic  lymph  found  on  the  inner  surface  of  the  dura  mater,  extending 
unbroken  from  the  lower  end  of  the  spinal  cord  up  to  the  optic  commissure 
at  the  base  of  the  brain.  The  meshes  of  the  pia  mater  were  also  distended 
by  a  pyoid  serum  which  lifted  up  the  arachnoid.  It  is  not  improbable  that 
this  inflammatory  attack  was  directly  incited  by  the  autumnal  vicissitudes 
of  atmospheric  temperature,  resulting  from  what  is  popularly  called  "  catch- 
ing cold." 

But  the  history  of  the  first  four  weeks  of  this  man's  case  is  of  equal,  if 
not  greater,  interest  to  the  thoughtful  surgeon.  The  impact  of  the  missile 
caused  ecchymosis  of  the  theca  vertebralis,  and  separated  it  from  the  bone. 
It  also  bruised  the  spinal  cord,  from  which  lesion  a  very  extensive  paraplegia 
immediately  resulted.  Moreover,  the  bruising  of  the  cord  was  followed  by 
inflammation  of  the  cord-substance,  the  symptoms  of  which  were  exaggerated 
reflex  motion,  particularly  noted  in  the  partially  paralyzed  left  arm  (for  it 
exhibited  spasmodic  movements  whenever  he  tried  to  use  it),  the  sensation  of 
cutaneous  coldness  without  any  apparent  cause,  the  formation  of  a  large  gan- 
grenous eschar  over  the  sacrum,  and  the  threat  of  death  from  sufibcation.  JSText, 
there  occurred  a  most  interesting  feature  of  the  case,  namely,  the  great  benefit 
which  was  derived  from  potassium  iodide  and  ergot.  Under  these  remedies 
the  myelitis  rapidly  subsided,  the  respiration  ceased  to  be  diaphragmatic,  the 
appetite  and  digestion  improved,  the  bowels,  etc.,  acted  readily,  the  bed-sores 
became  clean  and  appeared  healthy,  and  the  case  began  to  look  quite  encour- 
aging ;  the  existence  of  the  nerve-lesions  was  proved,  after  death,  by  the  soft- 
ened state  of  the  cord-substance  which  was  found  opposite  the  seat  of  the 
original  injury. 

The  next  abstract  presents  a  brief  record  of  a  very  instructive  case  in  which 
hypercesthesia  was  the  most  prominent  symptom  : — 

1  Circular  No.  3,  S.  G.  0.,  August  17,  1871,  pp.  23,  24o 


404  INJURIES  OF  THE  BACK. 

A  cavalry  soldier,  aged  28,  was  accidentally  wounded  March  26,  1866,  by  a  pistol- 
shot  (conoidal,  calibre,  36)  which  entered  his  loins  near  the  posterior  superior  process 
^  .  of  the  right  ilium,  some  two  inches  from  the  spine, 

■p'     ggQ  passed  inward,  forward,  and  upward,  struck  the 

spinal  column,  and  finally  lodged  in  the  spinal  canal 
opposite  the  fourth  lumbar  vertebra  (Fig.  880).  He 
instantly  fell  to  the  ground  ;  the  lower  limbs  were 
paralyzed,  and  over  the  entire  posterior  part  of  the 
pelvis  there  was  also  complete  loss  of  sensation.  On 
the  second  day,  he  complained  of  much  pain  across 
the  sacral  region  and  in  the  thighs  ;  could  not  change 
the  position  of  the  lower  part  of  his  body,  and  all 
attempts  by  others  to  move  him  gave  great  pain, 
especially  across  the  lower  part  of  his  back  ;  bowels 
torpid.  He  could  micturate,  but  lacked  expulsive 
Showing  a  pistol-ball  lodged  in  the  spinal      ^^^^  readily.    Afterward,  he  slowly  im- 

foran^en  (canal)  of  the  fourth  lumbar  ver-     P  ^  ^^^^ 

tebra,  and  causing  meningitis.    (Spec.  683,      piuveu.      ^uu  /  v^^ot  l.r.cv.Ual 

Sect.  I,  A.  M.  M.)  in  an  army -wagon,  sixty  miles,  to  the  post-hospital 

at  Austin,  Texas,  which  he  entered  on  April  18.  He 
then  looked  emaciated  and  anxious,  and  was  much  exhausted  by  his  journey.    He  com- 
plained of  pain,  especially  in  the  right  side  of  the  sacrum,  and  of  severe  pam  in  the  pos- 
terior muscles  of  his  legs,  aggravated  by  pressure.    He  could  not  stand  without  support, 
and  made  no  attempt  to  walk.    When  lying  on  his  side,  he  was  able  to  slowly  flex 
and  extend  his  legs,  but  could  not  separate  them  ;  bowels  extremely  torpid ;  urination 
frequent  and  very  difficult ;  considerable  thirst ;  but  little  appetite  ;  upper  extremities 
not  affected.    Under  dry  cupping  of  the  sacral  region,  enemata  and  laxatives,  tonics, 
nutrients,  and  alcoholic  stimulants,  he  improved  somewhat,  but  made  no  attempt  to 
walk     Under  the  use  of  strychnia,  early  in  May,  his  bowels  moved  spontaneously,  and 
the  ability  to  move  his  legs  was  somewhat  increased.    This  medicine,  however,  was 
soon  discontinued,  because  it  readily  exhibited  an  unduly  stimulating  action,  characterized 
by  the  production  of  diminished  sensibility  from  the  haunches  downward,  with  severe 
pain  in  the  posterior  muscles  of  the  legs  ;  appetite  decreasing,  and  debihty  gradually  in- 
creasing   Durincx  the  second  week  in  May  and  forepart  of  the  third,  the  patient  s  general 
tone  diminished'greatly ;  sensibility  became  lost  almost  entirely  below  the  knees,  but 
limited  motor  power  still  remained.    The  power  to  urinate  was  nearly  lost ;  urine  passed 
in  drops,  with  continued  painful  desire  to  pass  more  (vesical  hypersesthesia)  ;  introducing 
the  catheter  gave  temporary  relief,  but  he  could  not  retain  the  instrument  longer  than 
a  few  minutes  [in  consequence  of  the  urethral  hyperaesthesia].  From  this  symptom,  bel- 
ladonna (<-r.  i)  would,  for  a  considerable  period,  give  most  decided  rehef.    The  patient 
lay  chiefly  on  his  back,  with  the  knees  drawn  up  ;  stools  passed  involuntarily,    ihe  pain 
in  the  le<^s  and  in  the  sacral  region  was  increased  ;  wet  cups  were  applied  over  the  lower 
part  of  the  spine,  daily,  for  four  days,  but  without  any  benefit  whatever  ;  he  was  catheter- 
ized  twice  daily,  and  this  was  continued  until  the  end.    On  May  24,  he  rejected  all  food. 
On  the  25th,  there  was  active  delirium.   On  the  27th,  the  delirium  still  continued  ;  pulse 
120  •  respiration  40,  and  performed  almost  entirely  by  the  diaphragm ;  no  sensation  in 
leo-s,'exceptincr  under  hard  pressure,  but  he  kept  them  flexed  upon  the  thighs,  and  the 
thi-hs  upon  the  pelvis;  complained  of  intense  pain  in  the  back  part  of  the  pelvis,  abdo- 
men, and  thorax,  extending  along  the  spine  upward,  making  it  difficult  to  rest  his  neck 
upon  the  pillow  ;  he  described  the  pain  as  that  of  lying  upon  hot  embers  ;  he  continued 
to  cry  out  in  pain  until  a  few  moments  before  death,  which  occurred  on  the  following 
mornincr  (May  28).  Autopsy,  twenty-one  hours  after  death—The  missile  had  grazed  the 
ricrht  tninsverse  process  of  the  fifth  lumbar  vertebra,  imbedding  some  particles  of  lead 
therein  ;  then,  glancing  upward,  had  struck  the  spinous  process  of  the  third  lumbar  ver- 
tebra (its  lower  border),  and  had  been  deflected  through  the  laminae  into  the  spinal  canal. 
Here  it  had  been  deflected  downward  by  the  elastic  action  of  the  ligamenta  subflava  to 
wliich  the  upper  border  of  the  broken  laminae  remained  attaclied,  and  had  lodged  (point 
downward)  within  the  spinal  foramen  of  the  fourth  lumbar  vertebra.    The  missile 
rested  within  the  leash  of  nerves  forming  the  cauda  equina,  near  the  left  angle  of  the 
spinal  foramen  (canal),  its  point  reaching  downward  to  the  lower  border  of  the  fourth 


TRAUMATIC  SPINAL  MENINGITIS. 


405 


lumbar  vertebra.  The  spinal  membranes  surrounding  the  point  of  the  missile  were 
lacerated,  injected,  and  of"  light  venous  color.  The  nerve-tissue  within  the  spinal  mem- 
branes  was  also  injured  ;  it  was  reduced  nearly  to  a  pultaceous  consistence  ;  white  soft- 
ening. The  fourth  and  part  of  the  tiiird  lumbar  vertebra,  with  the  missile  attached, 
was  contributed  to  the  Army  Medical  Museum.  This  specimen  is  represented  by  the 
accompanying  wood-cut  (Fig.  880)/ 

The  intense  agony  which  was  engendered  by  the  hyperoesthesia  in  this  case  is  some- 
thing too  liorrible  to  be  contemplated  without  emotions  of  pity. 

It  is  worthy  of  remark  that  strychnia  did  harm  to  this  patient,  and  that  its  use  was 
suspended  for  this  cause.  It  is  also  worthy  of  remark  that  the  vesical  and  urethral 
hyperaisthesia  was  notably  lessened  by  giving  belladonna,  and  that  the  application  of 
dry  cups  was  apparently  useful  on  another  occasion. 

The  next  example  occurred  in  the  Crimean  war.  Intense  hypercBSthesia 
appeared,  and  fowlroyant  symptoms.  Death  from  coma  (that  is,  from  com- 
pression of  the  brain  and  spinal  cord)  resulted  in  five  days. 

Private  S.  L.,  aged  21,  was  wounded  in  the  trenches,  August  23,  1855.  A  Minie 
ball  passed  through  his  right  cheek,  fractured  the  right  alveolar  processes  and  ascend- 
ing ramus  of  the  lower  jaw,  with  comminution,  and  lodged  near  the  base  of  the  skull. 
There  was  not  much  hemorrhage.  The  ball  could  not  be  discovered,  and  every  attempt 
to  find  it  caused  very  acute  agony.  There  was  no  paralysis.  But  deglutition  was  diffi- 
cult, and  every  movement  of  his  neck  aroused  intense  pain,  so  much  so  as  to  cause  him 
to  scream  violently.  Delirium,  stertor,  and  coma  set  in  ;  death  ensued  on  the  28th, 
five  days  after  the  casualty.  Necroscopy  showed  both  jaws  to  be  fractured,  and  the 
lower  comminuted.  The  missile  had  lodged  just  below  the  basilar  process,  having  broken 
off  and  almost  detached  a  large  piece  of  the  atlas,  and  thus  uncovered  the  spinal  mem- 
branes. They  did  not  appear  to  have  been  injured  primarily;  "but  they,  as  well  as 
the  membranes  of  the  brain,  showed  marks  of  acute  inflammation  having  been  set  up."^ 

On  the  same  page,  Staff-Surgeon  T.  P.  Matthew,  the  surgical  historio- 
grapher of  the  Crimean  War,  remarks :  "  Even  where  the  spinal  cord,  appa- 
rently, was  not  primarily  injured,  inflammation  of  it  or  its  membranes  was 
sometimes  set  up,  and  quickly  proved  fatal." 

The  following  example  of  traumatic  spinal  meningitis  and  myelitis  was 
characterized  by  the  occurrence  of  tetanic  spasms  of  the  muscles  in  the 
extremities : — 

On  the  first  of  August,  says  Stromeyer,  I  extracted  a  bullet,  which  had  entered  on 
the  6th  of  July,  between  the  laminae  of  the  third  and  fourth  lumbar  vertebra?,  and 
there  had  become  fixed.  At  first  there  Avere  no  severe  symptoms  ;  suddenly  there 
occurred  violent  pains,  with  cramp  in  the  extremities  having  similarity  to  tetanus,  and 
accompanied  by  delirium.  The  operation  was  easily  performed  by  the  help  of  an  ele- 
vator, after  dilating  the  outer  wound.  On  removing  the  bullet,  a  finger  could  be  put 
into  the  spinal  canal.  The  patient  sank  rapidly,  and  the  autopsy  showed  inflammation 
of  the  spinal  cord  and  its  membranes.^ 

Tetanic  spasms  of  the  muscles  were  likewise  observed  in  the  next  instance, 
which  occurred  in  our  civil  war : — 

An  artillery  soldier,  aged  28,  was  wounded  at  Gettysburg,  July  1,  1863,  by  a 
conoidal  ball,  which  entered  below  the  spine  of  the  left  scapula,  struck  the  spinous  pro- 
cess of  the  eighth  dorsal  vertebra,  fractured  it,  but  without  displacement,  and  lodged  in 
the  angle  between  the  spinous  and  transverse  processes.  He  walked  to  the  field  hos- 
pital without  assistance,  and  was  able  to  move  about  and  help  himself  until  the  6th, 
when  tonic  spasms  of  the  abdominal  muscles  and  diaphragm  set  in.  They  steadily 
increased  in  severity  ;  anaesthetics  were  administered,  and  the  urine  was  drawn  off  by 

1  Medical  and  Sargical  History  of  the  War  of  the  Rebellion,  First  Surgical  Volume  p.  448. 

2  Medical  and  Surgical  History  of  the  British  Army  in  the  Crimean  War  vol.  ii.  p.  337. 

3  Op.  cit.,  p.  38.  ,      .    .  y.  > 


406 


INJURIES  OF  THE  BACK. 


a  catheter.  On  the  eveninoj  of  the  7th,  he  fell  into  a  sleep  ;  but,  upon  awakening,  the 
spasms  returned  and  continued  until  11  P.M.,  when  death  occurred.^  Though  the 
track  of  the  missile  was  traced  in  this  case,  and  its  place  of  lodgment  discovered  by  a 
post-mortem  examination,  it  does  not  appear  that  the  spinal  canal  was  laid  open,  and 
that  the  spinal  meninges  and  cord  were  submitted  to  inspection.  Had  such  an  exami- 
nation been  made,  the  evidences  of  traumatic  spinal  meningitis  would  doubtless  have 
been  revealed;  for  it  should  be  observed  that  the  tetanic  spasm  first  appeared  in  the 
muscles  (of  the  abdomen)  that  were  supplied  by  spinal  nerves  (the  seventh  and  eighth 
dorsal)  which  issued  from  the  spinal  column  at  the  place  of  injury  (the  eighth  dorsal 
vertebra),  and  consequently  from  the  focus  of  traumatic  inflammation,  whereas  true 
tetanus  usually  begins  with  trismus  or  lock-jaw.  There  is,  then,  little  room  for  doubt 
that  the  tetanic  spasms  of  the  abdominal  muscles,  etc.,  which  appeared  in  this  case, 
were  merely  symptoms  or  phenomena  that  resulted  from  the  inflammatory  lesions  of  the 
spinal  membranes  and  spinal  cord. 

Moreover,  tetanic  spasms  characterized  an  example  presented  on  page  376, 
toa;et*her  with  a  wood-cut  to  illustrate  it,  that  bears  a  strong  resemblance 
to^Stromeyer's  case  as  briefly  related  above.  In  both,  a  small-arm  missile 
struck  the  spinal  cohmm,  and  became  impacted  between  the  laminae  of  two 
lumbar  vertebrse.  In  both  instances,  severe  pain  in  the  spine  and  tetanic 
spasms  in  the  muscles  of  the  extremities  ensued.  In  both  instances  the  mis- 
siles were  extracted,  and  both  patients  died.  The  autopsy  of  Stromeyer's 
patient  revealed  traumatic  inflammation  of  the  spinal  membranes  and  cord. 
But  the  autopsy  of  the  other  patient  does  not  appear  to  have  been  carried 
far  enough  to  expose  the  spinal  membranes  and  spinal  cord  to  view.  Never- 
theless, the  symptoms  which  characterized  this  case,  e.  g.,  the  intense  rachi- 
diap  pain,  the  extreme  degree  of  restlessness  or  general  hypersesthesia,  and 
the  tetanic  spasms,  constitute  a  group  of  symptoms  often  seen  in  cases  of 
epidemic  cerebro-spinal  meningitis  when  the  spinal  symptoms  predominate; 
and,  without  doubt,  these  symptoms  arose  in  this  instance  also  from  an  acute 
inflammation  of  the  spinal  membranes,  but  having  a  traumatic,  instead  of  an 
epidemic  origin,  just  as  they  did  in  Stromeyer's  case. 

Epileptiform  convulsions,  as  well  as  tetanic  spasms,  are  sometimes  observed 
in  cases  of  traumatic  spinal  meningitis.  Charles  BelP  reports  an  example  in 
which  a  subluxation  of  the  last  cervical  upon  the  flrst  dorsal  vertebra  was 
followed,  on  the  eighth  day,  by  general  convulsive  movements,  accompanied 
by  signs  of  inflammation  of  the  spinal  membranes.  The  patient  died  twelve 
days'afterward  of  exhaustion,  not  having  been  completely  paraplegic  at  any 
time.  The  autopsy  showed  a  little  subarachnoidean  eflusion  of  serum  in  the 
cranium,  and  an  abundant  deposit  of  pus  within  the  theca  vetebralis,  lying 
between  it  and  the  spinal  cord.  This  case  has  already  been  mentioned  (page 
332) 

^  Pathological  Anatomy  of  Traumatic  Spinal  Meningitis.— spinal  mem- 
branes, like  the  cranial,  are  not  much  disposed  when  injured  to  exhibit 
inflammatory  changes  of  a  destrucfive  character.  Still,  when  their  vulnera- 
tion  is  attended  or  followed  by  influences  adverse  to  healing,  they,  like  the 
cranial  membranes,  are  liable  to  take  on  inflammatory  action  which  may 
cause  death.  Having  thoroughly  discussed  the  symptoms  of  traumatic  spinal 
meningitis,  it  is  next  in  order  to  consider  the  structural  lesions  which  it 
engenders.  They  consist  in  the  exudation  of  serum,  the  formation  of  plastic 
lymph  and  purulent  matter,  and  the  perforation,  etc.,  of  the  membranes  them- 
selves by  ulceration.  The  following  abstract  and  wood-cut  (Fig.  881)  will  serve 
to  illustrate  at  least  some  of  these  lesions. 

>  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Vol.,  p.  452. 
*  Surgical  Observations,  p.  145. 


TRAUMATIC  SPINAL  3IENINGITIS. 


407 


A  soldier,  aged  37,  received  a  gunshot  wound  of  the  back,  Fig.  881. 

at  the  Wilderness,  May  6,  1864  ;  the  ball  entered  over  the 
transverse  process  of  a  dorsal  vertebra,  and  lodged  in  the 
bone.  He  was  sent  to  Washington  ;  and,  on  tlie  next  day, 
he  was  admitted  to  Mount  Pleasant  Hospital.  On  the  loth, 
he  was  transferred  to  Jarvis  Hospital,  Baltimore,  where  he 
died  on  July  20,  seventy-five  days  after  the  casualty,  from 
spinal  meningitis.  Necroscopy — It  was  found  that  the  ball 
had  struck  the  body,  and  fractured  the  transverse  process,  of 
a  dorsal  vertebra.  The  injured  bone  was  necrosed.  The 
spinal  membranes  showed  ulceration  and  unequivocal  marks 
of  intense  inflammation,  for  two  inches  above  and  below  the 
fracture.  Tiie  spinal  cord,  opposite,  was  partially  disor- 
ganized. The  inflammatory  lesions  of  the  meninges  are 
represented  in  the  adjoining  wood-cut  (Fig.  881).^ 

It  does  not  appear  that  the  spinal  cord  and  mem- 
branes, in  this  man's  case,  received  any  direct  injury 
from  the  blow  struck  by  the  missile  upon  his  spinal 
column.  Subsequently,  however,  the  vitality  of  the 
bruised  vertebra  was  destroyed  by  necrosis,  and  the 
inflammatory  process  spread  therefrom  to  the  contig- 
uous membranes  and  cord,  when  the  traumatic  spinal 
meningitis,  thus  excited,  caused  his  death  seventy-five 
days  after  infliction  of  the  wound. 

The  inflammatory  process,  when  it  is  excited  in  the 
spinal  membranes  by  traumatic  causes,  may  be  either 
diffuse  or  circumscribed  in  character.  In  several  in- 
stances, related  above,  it  was  very  difl:use,  and  not 
only  involved  the  entire  extent  almost  of  the  spinal 
membranes,  but  passed  upward  through  the  foramen 
magnum  and  attacked  those  of  the  cranium.  In  the 
last  example,  however,  it  was  not  difl'use,  but  con- 
fined to  a  space  extending  two  inches  above  and 

below  the  place  of  injury.  In  the  next  case  the  meningeal  inflammation  was 
also  circumscribed  and  restricted  to  comparatively  narrow  limits : — 

Capt.  Thomas  H.,  67tl)  Regt.  Indiana  Vols.,  was  wounded  by  a  pistol-ball  in  the 
back,  November  3,  1863,  and  entered  a  general  hospital  on  the  9tli.  There  was  partial 
paralysis  of  the  left  thigh  and  extremity.  The  missile  had  entered  about  four  inches 
to  the  right  of  the  fourth  dorsal  vertebra,  but  its  course  could  not  be  traced.  The 
tract  of  the  spinal  column,  both  above  and  below  the  wound,  was  equally  sensitive.  The 
paralysis,  in  the  first  week,  invaded  the  right  leg,  tlie  bladder,  and  the  rectum  ;  and,  by 
the  end  of  the  tliird  week,  sensibility  and  voluntary  motion  had  disappeared  (that  is, 
there  was  complete  paraplegia)  in  all  parts  below^  the  wound.  The  only  noticeable 
instance  of  excito-motor  action  which  remained  was  the  peculiarity  that  tickling  the 
glans  penis  produced  a  partial  evacuation  of  the  bladder;  and  this  feature  continued 
until  the  patient's  death,  which  resulted  from  acute  pneumonia  on  December  19. 
Necroscopy  showed  that  the  ball  had  passed  downward  and  inward,  slightly  wounding 
the  costal  pleura  ;  had  fractured  the  right  transverse  process  of  the  seventh  dorsal  ver- 
tebra ;  and  had  lodged  in  the  body  thereof,  producing  a  slight  exfoliation  from  the  inner 
side  of  the  body  into  the  spinal  canal,  which  had  caused  inflammation  of  the  spinal 
membranes  and  cord.  Pus  was  found  in  the  theca,  that  is,  in  the  spinal  pia  mater. 
The  right  lung  was  far  advanced  in  suppuration.^ 

This  case  is  strictly  analogous  to  those  instances  of  traumatic  meningitis 
and  cerebritis  which  arise  from  exfoliations  from  the  inner  table  of  the  skull, 


Showing  the  efiFects  of  trau- 
matic spinal  meningitis  and 
myelitis,  in  the  dorsal  region. 
The  membranes  have  been 
perforated  by  ulceration,  and 
exhibit  other  inflammatory 
changes  ;  cord  partially  disor- 
ganized. (Spec.  3190,  Sect.  I,  A. 
M.  M.) 


1  Med.  and  Surg.  Hist,  of  the  War  of  the  Rebellion,  First  Surg.  Vol.,  p.  439. 

2  Ibid.,  p.  438. 


408  INJURIES  OF  THE  BACK. 


in  consequence  of  cranial  Injury,  and  winch  produce  subdural  or  intra- 
menino-eal  abscesses,  attended  by  corresponding  palsies  of  the  cerebral  func- 
tions.''in  this  officer's  case,  the  pressure  exerted  by  the  products  of  the 
meningeal  inflammation  (purulent  matter  and  serum)  upon  the  spinal  cord,  as 
well  as  the  inflammatory  changes  which  occurred  in  the  cord-substance  itself, 
caused  complete  paralysis  of  all  the  parts  of  his  body  which  were  situated 

below  the  spinal  lesion.  ,  ,    ■   i  i  •    i  r 

A  few  words  should  also  be  said  concerning  the  pathological  histology  ot 
traumatic  spinal  meningitis.    This  disorder  usually  consists  of  acute  hyper- 
8em.ia  and  suppurative  inflammation  of  the  pia  mater.    There  is  a  tolerably 
wxU-marked"  congestion  of  all  the  vessels  in  the  pia  mater,  together  with 
purulent  infiltration  of  the  subarachnoid  lymphatic  spaces.    The  most  strik- 
ing point  in  connection  with  it  is  the  strict  way  in  which  the  purulent  for- 
mation is  limited  to  the  parenchyma  of  the  pia  mater  ;  it  never  transgresses 
-  (when  diftuse)  the  arachnoid  lamella  which  forms  its  outer  boundary.  In 
the  first  foudroyant  example  related  above,  the  meshes  of  the  pia  mater  were 
seen  to  be  distended  by  purulent  serum  which  lifted  up  the  arachnoid.  The 
comparison  of  the  arachnoid  to  a  serous  sac,  formerly  so  popular,  has  ceased 
to  be  entertainable  ever  since  Luschka's  investigations  proved  that  the  so- 
called  parietal  layer  of  the  arachnoid  was  merely  the  epithelium  of  the  dura 
mater.    The  very  striking  deviation  from  the  superficial  character  of  serous 
inflammations  in  general,  just  mentioned,  completes  the  demonstration  that 
the  arachnoid  is  not  a  serous  membrane  in  the  same  sense  as  the  pleura  or 
the  pericardium.     It  seems  to  me,"  says  Rindfleisch,  "  as  though  this  devia- 
tion were  simply  due  to  the  presence  of  very  distensible  spaces  immediately 
around  the  vessels.    Here,  if  any  where,  we  may  apply  Cohnheim's  theory 
of  inflammatory  exudation.    Even  the  naked  eye  can  show  us  that  the  pus 
everywhere  originates  along  the  course  of  the  vessels.    Like  a  double-streak 
of  a  yellowish-white  color,  narrow  at  first  and  growing  steadily  wider,  the 
pus  follows  the  edges  of  the  vessels,  especially  of  the  large  and  small  venous 
trunks.    The  longer  the  process  lasts,  the  nearer  do  the  purulent  streaks 
accompanying  the  vessels  approach  one  another,  till  they  finally  coalesce  ;  the 
pia  mater  swells  up  as  a  whole ;  it  often  acquires  a  peculiar  stifthess,  owing 
to  the  stretching  of  its  fibrous  bands,  perhaps  also  to  the  coagulation  of  some 
lymphatic  constituents  of  the  exudation."^  It  may  then  be  stripped  ofl  from 
the  compressed  and  bloodless,  rarely  softened,  surface  of  the  cord,  together 
with  the  prolongations  which  it  sends  into  the  sulci,  forming  a  solid  mould 
of  the  rachidian  irregularities.    The  morbid  process  generally  begins  with 
hypersemia  (active  congestion)  of  all  the  inter-meningeal  vessels  at  the  place 
of  injury,  followed  by  the  appearance  of  serum  and  flakes  of  lymph  ;  and 
it  terminates,  as  just  stated,  in  subarachnoid  suppuration. 

rrm^me7?i.-- Traumatic  spinal  meningitis,  whether  difl'use  or  circum- 
scribed, is  an  exceedingly  dangerous  disorder;  and,  to  treat  it  with  success, 
it  is  indispensable  that  vigorous  measures  should  be  promptly  employed  Ihe 
preventive  measures  {prophylaxis)  consist  m  removing  all  foreign  bodies 
from  gunshot  wounds  of  the  spine,  and  applying  antiseptic  dressmgs  ;  m 
reducing  simple  as  well  as  compound  dislocations  and  fractures  of  the  ver- 
tebra, thereby  lessening  the  meningeal  irritation ;  in  maintaining  afterward 
'  absolute  quietude  of  all  the  injured  parts  ;  and  in  promptly  abating  any  in- 
flammation which  may  arise  in  the  circumjacent  structures. 

Meningeal  congestion  should  be  combated  by  administering  ergot  m  large 
doses  at  short  intervals  (from  30  to  60  minims  of  the  fluid  extract  every  four 


1  Manual  of  Patliological  Histology,  vol.  ii.  p.  309.    New  Sydenham  Society's  translation. 


TRAUMATIC  MYELITIS. 


409 


hours  until  the  indication  is  fulfilled),  and  by  giving  opium  or  morphia  in 
such  doses  and  at  such  intervals  as  will  suppress  the  rachidian  pain. 

The  inflammatory  process  is  to  be  combated  by  exhibiting  one  or  two 
purgative  doses  of  calomel  at  the  outset,  by  abstracting  blood  locally  with 
leeclies  or  cups,  by  applying  cold  to  the  overheated  back,  and  by  administer- 
ino-  saline  drinks  of  a  cooling,  laxative,  and  diuretic  nature.  At  a  later 
statue,  potassium  iodide  in  full  doses,  and  counter-irritation  by  vesicants  or  by 
the^  actual  cautery  should  be  employed.  The  remedy,  however,  which  is 
most  efficacious  to  remove  meningeal  congestion  is  ergot,  provided  it  be 
given  in  sufficiently  large  doses ;  while  that  which  is  most  etiectual  to  pre- 
vent the  exudation  of  serum  and  the  formation  of  plastic  lymph  (and  thus 
to  save  the  spinal  cord  from  undue  pressure),  is  opium,  or  morphia,  also 
given  in  adequate  doses. 

attempt  should  be  made  to  relax  the  tetanic  spasms  by  administering 
chloroform  or  any  other  anaesthetic ;  such  medication  did  no  good  what- 
ever in  two  cases  which  are  mentioned  above,  and  it  probably  hastened  the 
end  in  each.  But  morphia  combined  with  the  bromides  of  calcium,  sodium, 
potassium,  or  ammonium,  and  chloral  hydrate,  may  be  used  for  this  purpose. 

In  treating  the  paralysis  attending  the  chronic  forms  of  the  disease, 
the  bichloride  of  mercury,  in  doses  of  gr.  y'^  every  eight  hours,  often  does 
good.  Strychnia  is  not  admissible,  and  it  clearly  did  harm  in  one  case  above 
related. 

Traumatic  Myelitis. — As  cerebriti^  is  true  inflammation  of  the  hrain-suh- 
stance,  so  myelitis  is  true  inflammation  of  the  cord-substance,  and  as  cerebritis 
presents  a  marked  contrast  to  cerebral  meningitis  (or  what  is  popularly 
known  as  "inflammation  of  the  brain")  in  respect  to  extent,  acuity,  and 
phenomena,  so  true  inflammation  of  the  cord-substance  difl:ers  widely  in  the 
same  particulars  from  spinal  meningitis  (or  what  is  sometimes  known  as 
"  inflammation  of  the  spinal  cord"),  which  has  just  been  described. 

Both  cerebritis  and  myelitis  are  always  caused  by  a  wound  or  an  injury  in 
the  widest  sense  of  the  term — that  is,  by  some  local  irritation  of  extra- 
cerebral or  extra-rachidian  origin.  The  skull  or  the  spinal  column  may  have 
been  struck  or  concussed ;  it  may  have  been  penetrated  by  a  cut,  a  stab,  or 
a  fracture,  which  has  directly  damaged  the  brain-substance  or  the  cord-sub- 
stance ;  or  a  focus  of  inflammation  and  suppuration,  originating  in  the 
neighborhood  of  the  brain  or  the  spinal  cord,  may  have  been  propagated  to 
its  tissues  at  the  point  of  contact ;  or,  finally,  the  plugging  of  a  vessel  by  an 
embolon,  or  a  thrombus,  or  the  rupture  of  its  coats  from  atheromatous  disease, 
etc.,  may  have  caused  a  circumscribed,  punctiform  hemorrhage,  followed  by 
inflammation  as  a  secondary  consequence. 

In  myelitis,  and  in  cerebritis,  the  behavior  of  the  parenchyma  proper  of 
the  spinal  cord  and  brain  is  the  main  point  to  be  attended  to;  this  is  usually 
said  to  undergo  purulent  liquefaction  ;  and  the  statement  is  so  far  true  that 
a  deposit  of  pus  is  usually  found  to  occupy  the  place  of  the  rachidian  or  the 
cerebral  substance. 

"The  phenomena  of  acute  myelitis  leading  to  abscess  are  exactly  similar 
to  those  of  encephalitis  [or  cerebritis].  The  form  of  the  aft'ected  part  varies 
with  the  [nature  of  the]  injury.  Fractures  of  the  spine  usually  crush  the 
cord  ;  inflammation  and  suppuration  take  place  around  the  crushed  part,  and 
isolate  it  from  the  healthy  tissue."^  ^lany  examples  of  traumatic  myelitis 
have  already  been  mentioned  in  this  article. 

Symptoms. — The  acute  form  of  the  disease  is  often  ushered  in  with  a  dis- 


1  Rindfleisch,  op.  cit..  vol.  ii.  pp.  324-330. 


410 


INJURIES  OF  THE  BACK. 


tinct  chill ;  pyrexia  follows,  with  thirst  and  increased  frequency  of  pulse,, 
and  the  body  temperature  may  rise  to  103°  Fahr.  The  alfected  part  is 
generally  the  seat  of  a  dull  pain  or  ache  (quite  distinct,  however,  from  the 
intense  pain  of  meningitis),  which  is  increased  by  bending  and  by  percussing 
the  diseased  part,  and  by  applying  a  hot  sponge  over  it.  The  functions  of 
the  spinal  cord  are  immediately  disturbed,  and  notable  derangements  of  the 
cutaneous  sensibility  at  once  ensue.  They  often  take  the  form  of  "pins  and 
needles,"  of  a  sensation  as  if  Vv^ater  were  trickling  over  the  cutaneous  sur- 
face, as  if  the  limbs  Avere  asleep,  or  as  if  the  cutaneous  surface  were  very 
cold,  while  in  reality  it  is  very  hot,  and  vice  versa.  It  will  be  remembered 
that  coldness  of  the  surface  without  any  apparent  cause  was  complained  of 
in  the  first  foudroyant  case  of  spinal  meningitis  above  related.  But  anses- 
thesia  is  the  general  condition  of  the  skin  that  is  most  common  in  this 
disease.  It  is,  however,  attended  not  unfrequently  by  cutaneous  pain  or 
hypersesthesia ;  indeed,  spontaneous  and  severe  pains  are  often  felt  in  the 
skin,  when  the  cutaneous  sensibility  is  already  much  impaired.  Complete 
analgesia  soon  follows. 

The  voluntary  motility  is  destroyed  at  an  early  period  in  this  disease.  At 
first  the  refi.ex  excitability  may  be  exaggerated,  but  it  likewise  soon  disap- 
pears. Then  the  sphincter  ani  and  sphincter  vesicae  entirely  cease  to  act, 
and  the  feces  and  urine  fl.ow  out  into  the  bed  without  any  restraint  whatever. 
The  urine  becomes  alkaline,  and  oftentimes  is  thick  Avith  mucus.^  Simul- 
taneously, sacral  eschars,  or  so-called  acute  bed-sores,  are  very  liable  to  be 
formed.  These  eschars  are  due  less  to  the  patient's  position  than  to  the 
lesion  of  the  spinal  cord.  In  twenty-four  hours  these  bed-sores  sometimes 
appear,  and  in  such  cases  the  febrile  movement  caused  by  the  myelitis  is  often 
mistakenly  ascribed  to  the  eschars  themselves. 

In  the  subacute  and  circumscribed  forms  of  the  disease,  the  aberrations  of 
sensibility  are  less  strongly  marked,  and  they  succeed  each  other  less  rapidly 
on  account  of  the  slower  progress  or  the  more  restricted  range  of  the  morbid 
process.  The  sensation  of  a  band  drawn  tightly  around  the  body  is  generally, 
but  not  always,  present  in  such  cases,  and  its  seat  marks  the  upper  limit  of 
the  rachidian  inflammation.  The  destruction  of  voluntary  motility  and  of 
reflex  excitability  usually  travels  upward,  joari  passu^  with  that  of  sensibility. 

The  inflammatory  process  in  traumatic  myelitis  generally  exhibits  a  re- 
markable tendency  to  spread  upward  in  the  rachidian  substance.  This  pecu- 
liarity was  long  ago  specially  noted  by  Dupuytren,  in  cases  where  inflam- 
mation of  the  cord  had  arisen  from  dislocation  or  fracture  of  the  spine. 
The  most  frequent  mode  in  which  traumatic  myelitis  destroys  life  is  by  par- 
alyzing the  respiratory  muscles  in  consequence  of  its  upward  spread,  and 
thus  causing  fatal  asphyxia.  The  following  example  illustrates  this  point,  as 
well  as  several  others  in  the  natural  history  of  the  disease : — 

A  cavalry  soldier  at  Fort  Gibson,  Cherokee  Nation,  received  a  shot-wound  in  the 
neck,  in  a  brawl,  on  November  19,  1868,  and  was  taken  into  hospital  shortly  afterward. 
There  was  complete  paralysis  of  both  upper  extremities  ;  respiration  gasping  and  fre- 
quent ;  pulse  about  100,  of  fair  volume  and  strength  ;  mind  clear  ;  he  complained  of  some 
pain  in  the  hands.  The  missile  had  penetrated  the  neck,  on  its  left  side,  at  the  anterior 

1  Dr.  C.  B.  Radcliffe,  however,  has  recorded  a  case  (Lancet,  December  3,  1864)  in  which  the 
urine  remained  acid  throughout.  The  myelitis  was  acute  and  very  extensive,  and  in  ten  or 
twelve  days  death  ensued.  There  were  retention  of  urine  and  marked  priapism.  The  motor  and 
sensory  paralysis  extended  up  to  a  line  drawn  round  the  body  four  inches  below  the  ensiform 
cartilage  ;  reflex  movements  absent.  Autopsy. — Spinal  membranes,  normal  ;  substance  of  cord, 
yellowish-red  in  color  and  softened  to  the  consistence  of  cream,  from  its  brachial  enlargement  to 
its  inferior  extremity  ;  it  here  consisted  of  tlie  debris  of  its  normal  structure  mixed  with  blood- 
oorpuscles,  exudation  granules,  and  some  pus-corpuscles. 


TRAUMATIC  MYELITIS. 


411 


border  of  the  trapezius  muscle,  and  about  two  iiiclies  below  the  mastoid  process  ;  passed 
downward  and  to  the  right;  fractured  one  or  more  of  the  vertebrae;  and  lodged  beyond 
the  reach  of  the  bullet-probe.  A  few  loose  fragments  of  bone  were  removed.  He  was 
placed  on  a  water-bed.  Anodynes  were  given  to  procure  sleep  and  relieve  pain.  The 
bladder  was  relieved  by  the  catheter.  The  paralysis  of  the  abdominal  muscles  allowed 
gases  to  ccUect  in  the  intestines  to  such  an  extent  as  greatly  to  augment  the  pre-existino- 
difficulty  of  breathing.  Vent  was  given  to  these  gases,  from  time  to  time,  by  inserting 
an  elastic  tube,  per  anum^  and  compressing  the  belly  externally.  The  paralysis  from 
day  tc  day  became  more  profound  ;  the  respiration  more  difficult;  asphyxia  slowly  ap- 
peared, with  delirium  followed  by  coma,  and  on  the  28th  deatii  ensued,  about  nine  days 
alter  the  casualty.  The  autopsy  revealed  (1)  fracture  of  the  spinous  process  of  the  last 
cervical  vertebra;  (2)  fracture  of  the  lamina?  of  the  first  dorsal  vertebra  at  the  point 
where  tjiey  unite  to  form  the  spinous  process  ;  this  fracture  opened  the  spinal  canal  and 
ruptured  the  theca  vertebralis  ;  (3)  several  small  fragments  of  bone,  embedded  in  the 
substance  of  the  spinal  cord,  which  was  softened  and  bathed  in  pus.  The  bullet  had 
also  fractured  the  first  rib  with  the  coracoid  process  of  the  scapula,  and  had  lodo-ed 
in  the  right  axilla,  where  it  was  found.  The  lungs  were  deeply  congested,  as  was  the 
mucous  coat  of  the  bronchi ;  and  the  bronchi  themselves  were  filled  with  a  tenacious 
mucus. ^ 

The  injury  of  the  spinal  cord  in  this  case  was  followed  by  suppurative 
inflammation  of  its  substance,  which  not  only  involved  the  whole  thickness 
of  the  cord,  but  spread  upward  also.  Simultaneously  the  paralysis  became 
more  profound,  and  rose  to  higher  points,  from  day  to  day,  until  the  man 
breathed  by  the  diaphragm  alone.  Then  the  occurrence  of  tympanites  greatly 
increased  the  dyspnoea  by  opposing  the  descent  of  the  diaphragm ;  tenacious 
mucus  formed  in  the  air  passages,  and  accumulated  therein, "because  there 
was  no  power  to  expel  it  by  coughing ;  mucous  rales  (bronchial)  soon  super- 
vened, and  death  from  suffocation  ensued,  ere  the  disintegrating  process  had 
ascended  the  cord  high  enough  to  paralyze  the  phrenic  nerves.  This  man 
died  of  ascending  myelitis  in  nine  days.  But,  on  page  343,  I  have  presented 
the  case  of  another  soldier  who  died' of  ascending  myelitis  in  about  forty- 
eight  hours  aftei'  sustaining  simple  fractare  of  the  fourth  cervical  vertebra,  in 
consequence  of  falling  from  a  second  story.  On  another  pag-e,  I  have  men- 
tioned the  case  of  a  man,  aged  40,  who  died  of  ascending  myelitis  on  the 
eleventh  day  after  sustaining  simple  fracture  and  dislocation  of  the  eleventh 
dorsal  vertebra,  with  contusion  of  the  cord.  I  have  likewise  referred  to 
many  other  cases  of  spinal  injury,  in  'which  ascending  myelitis  supervened 
with  fatal  effect,  as  was  shown  by  necroscopy. 

In  the  next  example,  the  patient  died  of  haemoptysis  before  the  inflammatory 
process  in  the  spinal  cord  had  reached  the  stage  of  suppuration  :— 

A  cavalryman,  aged  35,  entered  a  general  hospital,  October  28,  1864,  for  a  wound  from 
a  pistol-shot  which  had  penetrated  to  the  left  side  of  the  spine,  and  had  fractured  the 
twelfth  dorsal  vertebra.  All  below  a  line  drawn  from  the  wound  to  the  pubis  was  para- 
plegic. There  was  much  depression  ;  pulse  about  130  ;  much  pain  over  abdomen  and 
right  side  ;  constipation  ;  incontinence  of  urine  from  overflow^  of  bladder.  A  catheter 
was  introduced  and  three  pints  of  very  thick,  dark-colored  urine  were  withdrawn. 
Stimulants,  tonics,  and  a  cathartic  were  given,  with  an  anodyne  at  night.  The  patient 
improved  and  did  well  until  November  lo,  when  a  bad  cough  set  in.  He  died  suddenly 
on  the  18th  from  hasmoptysis.  Necroscopy — The  spinal  canal  ^vas  laid  open  posteriorly 
from  the  second  dorsal  vertebra  to  the  sacrum.  Upon  removing  the  spinal  cord,  the 
theca  was  found  congested  and  firmly  adherent  to  the  vertebra?.  The  substance  of  the 
cord  looked  very  red.  The  ball  had  passed  between  the  arches  of  the  twelfth  dorsal  and 
first  lumbar  vertebra?,  and  then  through  the  body  of  the  twelfth  dorsal,  outside  of  the 
spinal  meninges;  but  its  track  could  not  be  further  traced.    The  right  pleural  cavity 


1  Circular  No.  3,  S.  G.  0.,  August,  17,  1871,  pp.  21,  22. 


412 


INJURIES  OF  THE  BACK. 


contained  three  pints  of  dark,  bloody,  stinking  fluid.  The  muscular  tissue  in  the  lumbar 
reo-ion  was  very  dark  and  softened,  but  contained  no  a-bscesses  nor  infiltrated  pus.^ 
Death  occurred  three  weeks  after  the  infliction  of  the  wound. 

The  membranes  and  substance  of  the  spinal  eord,  in  this  caise,  exhibited 
the  signs  of  convalescence  from  in^ammation,  and  that  process  must  have 
riin  pretty  high  at  one  time,  for  the  theca  vertebralis  had  become  strongly 
adherent  to  the  spinal  column.  The  spinal  membranes  were  still  congested, 
and  the  cord-substance  looked  very  red,  when  exposed  to  view  at  the  autopsy. 

Pathological  Anatoiny. — This  reddened  hue  of  the  rachidian  parenchyma  is 
accounted  for  by  the  peculiar  manner  in  which  the  vascular  apparatus  is 
involved.  The  intense  hypersemia  which  ushers  in  the  morbid  changes 
invariably  gives  rise  to  a  large  number  of  minute  ecchymoses ;  these,  of 
course,  are  equally  numerous  when  the  hemorrhage  is  the  primary  and  the 
inflanmiation  the  secondary  phenomenon.  Should  the  affected  part  undergo 
softening  and  purulent  liquefaction,  the  extravasated  blood  mingles  with  the 
pulp,  and  imparts  to  it  a  more  or  less  intensely  red  color.  Hence,  the  term 
red  softening  is  generally  applied  to  parts  aftected  by  encephalitis  (cerebritis), 
or  by  myelitis  r  but  this  term  is  equally  applicable  to  other  cases  in  which 
similar  effects  are  produced  by  very  different  causes.  The  presence  of  pus  is 
characteristic  of  the  inflammatory  form  of  red  softening ;  so,  too,  is  the  pre- 
sence of  an  areola,  from  one  to  two  lines  in  width,  in  which  the  parenchyma 
is  studded  wdth  numerous  bloody  points,  and  swollen  by  a  commencing  puru- 
lent hifiltration.  (Rindfleisch.)  But  purulent  softening  had  not  yet  appeared 
in  the  example  just  related;  or,  rather,  the  hypersemia  of  the  rachidian 
parenchyma,  which  was  very  intense  and  accompanied  by  a  great  multitude 
of  minute  extravasations  of  blood,  seems  to  have  been  passing  away,  that  is, 
undergoing  resolution  or  cure,  the  intensely  red  hue  arising  therefrom  alone 
remaining.  I  have  dwelt  somewhat  upon  this  case,  because  it  affords  sure 
ground  for  the  hope  of  obtaining  a  cure  by  timely  medication  in  analogous 
cases  of  traumatic  inflammation  of  the  membranes  and  substance  of  the 
spinal  cord. 

But  when,  on  the  other  hand,  resolution  of  acute  hypersemia  of  the  cord 
does  not  occur,  either  spontaneously  or  in  consequence  of  treatment,  purulent 
infiltration  of  the  reddened  tissue  will  ensue,  and  purulent  matter  will  take 
the  place  of  the  rachidian  substance.  Concerning  the  manner  in  which  the 
liquefaction  occurs,  no  unquestionable  theory  can  be  advanced  in  the  present 
anarchical  state  of  our  doctrines  concerning  suppuration.  "We  can  but 
express  suppositions,  keeping  a  firm  hold  on  individual  facts  of  unquestioned 
certainty  to  serve  as  guides.  Among  these  I  include,"  Eindfleisch  justly 
observes,  "  the  passive  behavior  of  the  nervous  elements  in  the  suppurative 
process,  and  the  intense  activity  of  the  vascular  system  in  every  stage  of  the 
disease.  The  nerve-fibres  within  the  affected  area  are  partly  suspended  m 
the  pus  as  disconnected  fragments,  partly  protruded  from  the  walls  of  the 
cavity  in  a  state  of  advancing  maceration  and  decay.  I  have  not  been  able  to 
detect  any  traces  either  of  fatty  or  of  granular  degeneration  in  them;  drops 
of  myelin  separate  from  their  surface ;  the  axis-cylinders  grow  thmner  by 
degrees,  and  finally  disajjpear.  The  ganglion-cells  of  the  affected  part  become 
darkly  granular,  and  break  up  into  splinters ;  I  have  often  recognized  well- 
marked  fragments  of  them  in  the  pulp."^  From  what  source  comes  the 
purulent  matter  in  such  cases  ?  The  same  indefatigable  observer  remarks  :— 
"  My  own  investigations  have  taught  me  that  the  pus  first  collects  around 
those  vessels  from  which  extravasation  [of  blood]  has  occurred.    In  trans- 

1  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  First  Surgical  Volume,  p.  441. 
«  Op.  cit.,  vol  ii.  p.  325. 


TRAUMATIC  MYELITIS. 


418 


verse  sections  of  the  encephalitic  foci  (red  softening),  hardened  in  preservative 
fluids,  we  find  these  vessels  girdled  by  a  relatively  wide  areola  of  pus-cells ; 
and  by  dint  of  careful  management,  we  may  even  pull  vessels  coated  with 

pus  furnished  with  regular"  sheaths  of  pus-corpuscles — out  of  the  recent 

specimen.  Finally,  we  may  also  see  in  the  transverse  sections  that  the  pus 
has  actually  juished  the  extravasated,  but  still  fluid,  blood  away  from  the 
vessels,  the  blood-corpuscles  forming  a  ring  around  the  pus,  instead  of  a 
2:lobular  drop.  This  would  lead  us  to  infer  that  the  pus  was  generated  by 
the  adventitia,  or  furnished  by  the  emigration  of  leucocytes.  Nevertheless, 
I  am  loth  to  refuse  the  power  of  generating  pus  to  the  neuroglia ;  I  am 
quite  sure  that  it  is  capable  of  producing  corpuscular  elements  (solitary 
tubercles,  gliomata);  and,  although  I  regard  the  results  of  my  inquiries,  just 
given,  as  trustworthy  so  far  as  they  go,  yet  I  do  not  consider  them  exhaus- 
tive." ^  The  purulent  matter,  then,  in  such  cases,  (1)  arises  from  the  emi- 
gration of  leucocytes;  (2)  is  generated  by  the  adventitia;  and  (3)  is  probably 
produced  also  by  the  neurog'lia ;  but,  whatever  be  its  origin,  it  destroys  and 
takes  the  place  of  the  inflamed  substance  of  the  cord.  Thus  suppurative 
inflammation  of  its  substance  may  demolish  the  structure  of  the  spinal  cord, 
not  only  through  and  through,  but  upw^ard  as  well  as  downward  for  a  con- 
siderable distance  in  its  continuity.  Thus  come  to  pass  the  disorganized 
and  liquefied  conditions  of  the  spinal  cord  revealed  by  necroscopy  in  cases  of 
vertebral  fracture  or  dislocation,  where  death  has  occurred  some  clays  or 
wxeks  after  the  accident,  many  examples  of  which  have  been  mentioned  in 
the  foreo;oing  pages. 

To  emphasize  this  important  point,  a  few  brief  abstracts  will  here  be 
added: — 

(1)  Zambaco^  mentions  the  case  of  a  man  having  fracture  and  luxation  of  the  third 
dorsal  vertebra.  The  compression  of  the  spinal  cord  was  not  constant ;  it  could  be 
reHeved  by  pressure.  However,  death  ensued  eighteen  days  after  the  injury,  through 
the  lungs  ;  that  is,  from  asphyxia.  (Ashhurst.)  No  doubt,  the  injury  of  the  cord  in 
this  case  caused  ascending  myelitis  which  disorganized  the  cord  in  the  upper  dorsal 
and  lower  cervical  regions,  paralyzed  the  respiratory  nerves  and  muscles  thereby,  and 
thus  completely  arrested  the  resph-atory  movements. 

(2)  Luke^  reports  the  case  of  a  man  who  had  fracture  of  the  seventh  dorsal  vertebra. 
The  displacement  was  corrected  by  making  extension,  and  reduction  was  accompanied 
by  an  audible  sound.  Death  from  erysipelas  supervened  seven  days  after  the  accident. 
On  autopsy,  the  spinal  cord  was  found  to  be  softened  and  disorganized,  and  to  contain 
purulent  matter.  (Ashhurst.) 

(3)  Dupuytren*  mentions  the  case  of  a  man  injured  by  jumping  from  a  third  story. 
There  was  deformity  of  the  spinal  column  in  the  lumbar  region,  with  great  mobility ; 
paralysis,  at  first  partial,  but  afterwards  complete ;  and  bed-sores.  Death  resulted. 
The  autopsy  revealed  fracture  of  the  second  dorsal  vertebra ;  the  spinal  cord  was  lique- 
fied ;  and  a  purulent  cyst  was  found  by  the  tenth  dorsal  vertebra.  (Ashhurst.) 

(4)  Adams  ^  relates  the  case  of  a  woman,  aged  28,  who  fell  ten  feet,  striking  the 
head.  "  Grating  in  the  neck"  was  felt ;  there  was  a  protuberance  in  the  pharynx  and 
a  depression  in  the  back  of  the  neck  ;  paralysis ;  pain ;  dyspnoea ;  retention  of 
urine;  insomnia;  involuntary  evacuation  of  the  bowels;  bed-sores;  and  convulsions.  In 
twelve  days  death  ensued.  The  autopsy  revealed  dislocation  of  the  fifth  from  the  sixth 
cervical  vertebra ;  also  fracture  of  the  sixth  dorsal  vertebra.  Opposite  the  latter  point 
the  spinal  cord  was  divided,  and  above  it  the  cord  was  softened.  (Ashhurst.)  Here 
again  was  shown  the  remarkable  propensity  to  travel  upward,  which  characterizes  trau- 
matic myelitis. 


'  Ibid.,  p.  326. 
3  Lancet,  1850. 

5  Dublin  Med.  Journal,  vol.  vi. 


«  Rec.  des  Trav.  de  la  Soc.  Med.  d'Obs.,  t.  i. 
^  Diseases  and  Injuries  of  Bones. 


414 


INJURIES  OF  THE  BACK. 


Moreover,  in  occasional,  perhaps  in  frequent  instances  of  traumatic  myelitis, 
the  inflammatory  process  does  not  involve  the  whole  thickness  of  the  cord  ; 
it  may  be  restricted  to  the  central  gray  matter ;  and,  possibly,  to  one  of  the 
columns.    An  instance  in  point  is  given  by  Anstie  :— ^ 

A  woman,  aged  38,  fell  thirty  feet  from  a  window,  and  came  under  Mr.  Holt's  care. 
There  was  a  scalp  wound,  with  concussion  paralysis  and  delirium.  In  eight  days 
death  supervened.  The  autopsy  showed  fractures  of  the  sixth  cervical  vertebra  and 
skull ;  red  softening  of  the  central  gray  matter  of  the  cord  ;  antero-lateral  columns 
healthy.  (Ashhurst.) 

Another  instance  in  point  is  given  by  Genest : — ^ 

A  woman,  aged  40,  received  a  blow  on  her  back.  Six  weeks  afterwards  she  felt  pain 
starting  from  the  right  foot.  Gradually  the  pain  extended  to  various  parts  of  the  limb  ; 
and,  after  a  month,  it  was  accompanied  by  spasmodic  contractions,  and  by  diminished 
voluntary  motion.  She  walked  with  great  difficulty,  even  with  the  help  of  a  stick. 
There  was  no  alteration  in  the  temperature  of  this  limb.  The  convulsions  extended  to 
the  other  limbs  and  to  the  head,  and  the  patient  died.  Autopsy — Brain  normal ; 
cerebellum  a  little  softened ;  no  meningitis  ;  spinal  cord  healthy,  excepting  at  the  swell- 
ing for  the  lower  limbs,  which,  for  an  extent  of  eighteen  lines  and  a  depth  of  one  line, 
on  its  posterior  aspect,  was  softened,  and  looked  like  cream,  somewhat  rose-colored. 
The  softening  in  this  case  was  obviously  inflammatory,  and  was  restricted  to  the  poste- 
rior columns.  This  circumstance  is  also  instructive  as  well  as  interesting,  because  the 
morbid  action  was  engendered  by  concussion  (contusion)  of  the  cord  substance. 

To  briefly  enumerate  the  morbid  appearances  which  result  from  traumatic 
myelitis  :  they  are  (1)  red  softening  ;  (2)  purulent  infiltration  of  the  reddened 
and  softened  rachidian  substance ;  (3)  collections  of  purulent  matter  (abscesses) 
surrounded  by  areolae  of  red  softening,  one  or  two  lines  thick,  in  the  rachidian 
substance ;  (4)  more  or  less  complete  liquefaction  of  the  cord,  but  without 
well-defined  margins.  The  morbid  appearances  usually  extend  through  the 
whole  thickness  of  the  cord,  and  some  considerable  distance  in  a  longitudinal 
direction,  but  mostly  upward ;  occasionally,  however,  they  are  restricted  to 
the  central  gray  matter,  or  to  the  columns. 

Etiology. — Traumatic  inflammation  of  the  spinal  cord  may  arise  from  any 
wound  which  penetrates  the  spinal  canal.  It  is  often  caused  by  simple  frac- 
tures and  dislocations  of  the  spinal  column,  as  well  as  by  those  that  are  com- 
pound. It  is  not  unfrequently  produced  by  concussions  of  the  spinal  cord, 
especially  those  that  are  attended  by  ecchymosis  of  the  cord-substance  ;  in  such 
cases,  the  inflammatory  process  is  apt  to  be  subacute  and  to  pursue  a  chronic 
course. 

Dr.  Nairne,^  however,  has  recorded  an  acute  case  occurring  in  a  lad,  aged  17,  in  whom 
it  was  caused  by  severe  jolting  in  a  cart.  Next  day  he  was  unable  to  walk,  from  para- 
lysis ;  he  rapidly  grew  worse  ;  and,  after  ten  days,  he  died.  On  autopsy,  the  spinal 
veins  were  found  to  be  greatly  congested ;  and  a  portion  of  the  spinal  marrow  opposite 
the  third  and  fourth  dorsal  vertebra?,  at  least  one  inch  in  length,  was  thoroughly  disor- 
ganized and  reduced  to  a  semi-fluid  state. 

Occasionally,  traumatic  myelitis  results  from  violent  strains  of  the  spinal 
column,  although  the  bones  and  ligaments  are  apparently  uninjured. 

Sir  W.  Gull*  relates  the  case  of  a  man,  aged  25,  employed  as  a  laborer  in  the  com- 
mercial dock,  who  felt  a  sudden  pain  in  tlje  back  after  lifting  some  deals,  on  November 
22.    He  walked  to  his  home  (about  a  mile  and  a  half)  ;  was  apparently  well  on  the 

'  Trans.  Lond.  Patlx.  Society,  vol.  x. 

2  Brown-Sequard,  op.  cit.,  p.  72  ;  quoted  from  Gazette  Medicale  de  Paris,  1831,  p.  34. 
'  Medico-Chirurgical  Transactions,  vol.  xxxiv.  p.  37. 
4  Guy's  Hospital  Reports,  18r)8,  pp.  189,  190. 


TRAUMATIC  iMYELITlS. 


415 


following  day.  Next  morning  (November  24),  on  waking,  the  legs  were  paralyzed. 
On  the  26th,  he  entered  the  hospital.  There  was  complete  paraplegia,  a  bed-sore  had 
already  begun  to  form  over  the  sacrum,  and  ammoniacal  urine  dribbled  from  the  blad- 
der.   He  died  exhausted,  on  January  2,  forty-one  days  after  the  strain. 

Autopsy. — A  large  bed-sore  exposed  the  sacrum  in  its  whole  length.  The  bones  and 
ligaments  of  the  spine  exhibited  no  trace  of  injury.  The  cord  was  softened,  oi)posite 
the  fifth  and  sixth  dorsal  vertebrae,  through  all  its  columns,  into  a  thick,  greenish,  muco- 
puritbrm  Huid,  with  a  brown  tinge.  Lumbar  and  cervical  portions  of  tlie  cord  normal. 
Commencing  suppuration  in  the  cortical  substance  of  the  kidneys.  Mucous  membrane 
of  tlie  pelves  greenish,  with  patches  of  greenish  fibrinous  exudation.  Mucous  membrane 
of  the  ureters  and  bladder  in  the  same  condition  ;  the  bladder  contained  a  quantity  of 
muco-purulent  fluid.  The  microscope  showed  the  softened  part  of  the  cord  to  consist 
of  disintegrated  nerve-tissue,  with  a  few  irregular  collections  of  granules. 

Prognosis. — The  outlook  in  cases  of  traumatic  myelitis  is  always  gloomy. 
From  inflammatory  disintegration  of  the  spinal  cord,  gangrenous  bed-sores 
often  arise ;  and  they  prove  fatal,  not  unfrequently,  by  inducing  septicaemia 
or  pygemia,  as  happened  in  the  following  instance : — 

A  soldier  was  wounded  at  Antietam,  September  17,  1862,  in  the  lumbar  spine, 
and  lay  on  the  field  until  the  20th,  when  he  was  taken  to  general  hospital.  At  that 
time  he  could  walk,  but  paralysis  soon  supervened.  Retention  of  urine  lasted  two  days  ; 
no  difficulty  afterw^ard  ;  no  derangement  of  the  alimentary  canal  ;  pulse  small  and  weak  ; 
face  flushed.  The  patient  suffered  greatly  from  bed-sores.  On  October  6  he  suf- 
fered great  pain  in  the  legs  ;  they  were  without  feeling,  but  warm.  On  the  10th,  pro- 
fuse sweats  occurred;  he  sank  rapidly,  and  died  on  the  11th,  apparently  of  septicaemia 
arising  from  the  bed-sores.  A  conoidal  ball  was  found  to  have  passed  through  the  spinal 
column  and  cauda  equina  at  the  third  lumbar  vertebra,  and  to  have  lodged  at  the  left 
intervertebral  foramen  ;  condition  of  cord  and  membranes  not  reported.^ 

Again,  traumatic  myelitis  may  destroy  life  by  causing  vesical  and  renal 
inflammation,  as  well  as  an  alkaline  state  of  the  urine.  But  the  discussion 
of  this  point  is  reserved  for  the  section  on  Disorders  of  the  Urinary  Ora;ans 
arising  from  Lesions  of  the  Spinal  Cord. 

Most  frequently,  however,  traumatic  myelitis  ends  in  death  by  asce*nding 
the  spinal  cord  until  it  involves  the  origins  of  the  spinal  nerves  upon  which 
the  respiratory  movements  depend,  when  paralysis  of  the  respiratory  muscles 
and  death  from  asphyxia  (apnoea)  ensue.  Stromeyer  mentions  a  case  in  which 
the  posterior  parts  of  the  fifth  and  sixth  cervical  vertebrae  were  torn  away  by 
a  bullet,  and  which  ended  fatally  on  the  fifth  day  from  this  cause.  Paralysis  of 
the  lower  extremities  occurred  on  the  first  day  ;  afterward,  complete  paralysis 
of  the  arms,  etc.,  was  superadded.^  I  have  already  presented  many  examples 
in  Avhich  death  resulted  in  the  same  way,  that  is,  by  paralysis  of  the  respira- 
tory muscles  in  consequence  of  ascending  myelitis.  In  the  following  example, 
where  the  cauda  equina  was  injured,  death  appears  to  have  been  caused  in 
the  same  manner  : — 

A  corporal,  aged  26,  was  wounded  by  a  conoidal  musket-ball,  July  9,  1864,  in  the 
lumbar  region,  and  on  the  next  day  entered  general  hospital.  Three  days  after  that, 
incomplete  paraplegia  set  in.  He  suffered  at  times  from  excruciating  pains  at  the  seat 
of  the  wound  and  in  the  lower  extremities.  Anodynes  were  freely  given.  Sphincter 
ani  muscle  paralyzed  ;  patient  delirious  at  times  ;  pulse  slightly  accelerated.  Death 
resulted  on  the  18th.  Necroscopy — The  missile  had  entered  at  a  point  midway  be- 
tween the  anterior  and  posterior  spinous  processes  (upper)  of  the  ilium,  one  inch  below 
the  crest,  passed  inward  and  backward,  chipped  the  sacrum  at  its  posterior  superior 
angle,  fractured  the  fourth  lumbar  vertebra,  and  lodged  in  the  spinal  canal ;  condition 
of  the  Cauda  equina  and  membranes  not  reported.^     The  symptoms  clearly  indicate 

1  Medical  and  Surgical  Historj  of  the  War  of  the  Rebellion,  First  Suro-ical  Vol.  p.  446. 

2  Op.  cit.,  p.  37. 

3  Med.  and  Surg.  History  of  the  War  of  the  Rebellion,  First  Surgical  Vol.,  p.  447. 


416 


INJURIES  OF  THE  BACK. 


that  this  also  was  a  case  of  ascending  myelitis.  Paraplegia  beginning  some  days  after 
the  injury  was  inflicted,  and  then  gradually  extending  upward,  with  incontinence  of 
feces  and  urine,  delirium,  and  diaphragmatic  breathing,  are  signs  quite  characteristic  of 
this  affection  when  it  spreads  from  the  lumbar,  upward  to  the  cervical  region. 

In  respect  to  disordered  sensations,  it  should  be  observed  that  the  excru- 
ciating pains  in  the  wound  and  lower  extremities  which  this  patient  endured, 
arose  from  the  sphial  meningitis  which  attended  the  inflammation  of  the 
cord-substance.  But  patients  having  acute  traumatic  myelitis  often  make  no 
complaint  of  pain  whatever  during  the  whole  course  of  the  disease.  A  case  in 
point  is  related  on  page  371,  in  which  the  cord  was  severed  by  the  missile 
(Fig.  870) ;  and  although  the  upper  portion  of  the  cord  was  much  softened 
by  the  inflammatory  process,  there  was  i^o  complaint  of  pain.  Sir  W.  Gull's 
case  of  acute  myelitis,  arising  from  a  strain  of  the  back  (related  above),  like- 
wise shows  that  the  spinal  cord  may  be  completely  destroyed  for  a  consider- 
able distance  by  the  inflammatory  process  without  causing  much  if  any  pain  ; 
for,  in  that  case,  no  pain  wbg^tever  was  complained  of,  excepting  the  pain 
which  attended  the  strain  itself. 

Among  the  symptoms  which  are  particularly  bad  as  prognostics  in  cases  of 
traumatic  myelitis,  we  may  mention  gangrenous  eschars  over  the  sacrum 
that  are  rapidly  enlarging,  inflammations  of  the  kidneys  or  bladder  that  are 
rapidly  extending,  ascending  paraplegia— paralysis  of  the  upper  extremities 
appearing  some  days  after  that  of  the  lower  extremities,  etc.,  has  occurred — 
and  diaphragmatic  breathing,  especially  when  the  latter  is  attended  by  dys- 
pnoea and  bronchial  rales,  for  then  the  end  may  be  quite  near. 

But,  although  the  prognosis  of  traumatic  myelitis  is  generally  unfavorable, 
we  are  still  not  entirely  without  hope  during  the  first  stage  of  the  disease  ; 
for,  in  the  case  of  the  cavalryman,  aged  35,  whose  death  suddenly  resulted 
from  hseraoptysis  the  case  is  related  on  page  411),  the  disease  was  shown  by 
the  necroscopy  to  be  undergoing  resolution ;  and  in  the  foudroyant  case  of 
traumatic  spinal  meningitis  related  on  page  402,  potassium  iodide  and  ergot 
were  •ad  ministered  with  a  notably  good  eflect  upon  the  inflammation  (acute 
hypenemia)  which  attended  the  injury  of  the  cord-substance,  and  preceded 
the  inflammation  of  the  spinal  membranes. 

Treatment— ^trome J er  says:  "In  a  case  where  a  bullet,  entering  laterally, 
bruised  the  third  and  fourth  cervical  vertebrae  severely,  and  was  not  extracted, 
death  resulted  from  the  advance  of  inflammation  of  the  spinal  cord  and  brain; 
there  was  at  first  paralysis  of  the  arm  belonging  to  the  injured  side  ;  it  was 
followed  by  incomplete  paralysis  of  all  the  limbs,  ending  in  coma.  Anti- 
phlogistic treatment  had  been  entirely  neglected."  ^  The  patient  afflicted 
with  acute  traumatic  myelitis  should  always  be  placed  on  a  water  bed.  In 
other  respects  the  prophylaxis  and  treatment  of  this  disease  are  the  same  as 
for  traumatic  spinal  meningitis  (see  page  408). 

For  an  account  of  the  prophylaxis  and  treatment  of  sacral  eschars  (so- 
called  bed-sores),  and  of  vesical  and  renal  inflammations  which  result  from 
myelitis,  the  reader  should  consult  the  sections  specially  devoted  to  those 
topics.  . 

In  regard  to  the  treatment  of  chronic  myelitis  with  paraplegia,  I  will 
briefly  mention  a  case  which  was  successfully  managed  by  Dr.  C.  Taylor.^ 
The  disease  had  lasted  eleven  months  before  the  treatment  was  comnaenced. 
This  consisted  in  the  administration  of  ergot  and  belladonna,  potassium  iodide, 
and  cod-liver  oil,  with  alternated  cold  and  hot  flapping  of  the  back,  twice 
daily,  and  a  cold  douche  followed  by  violent  rubbing  with  niustard  every 
morning.    Complete  recovery,  excepting  some  slight  want  of  ability  to  guide 

1  Op.  cit.,  p.  38.  ^  British  Med.  Journal,  May  24,  1862. 


SACRO-GLUTEAL  ESCHAKS. 


417 


the  legs,  was  obtained  The  symptoms  were  very  well  marked;  the  treat- 
ment was,  therefore  founded  on  an  accurate  diagnosis.  It  will  also  be 
remembered  that  belladonna  (per  orem)  gave  notafie  relief  to  vesical  and 
urethral  hypersesthesia  m  one  of  the  cases  related  above.  In  at  least  three 
mstmices  belonging  to  the  same  category  as  Dr.  Taylor's  patient,  I  have  seen 
much  benefit  derived  from  the  fluid  extract  of  ergot  and  potassium  iodkle 
In  one  case  where  there  probably  was  constitutional  (tertiar\  )  sv)>hilis  cor 
rosive  sublimate  (gr.  ^  thrice  daily)  did  good.  Concerning  bellidouna,  E row, : 
Sequard  justly  remarks  that  no  other  medicine  known  has  so  much  l  ower  to 
diminish  the  reflex  faculty  of  the  spinal  cord.'  Ifux  vomica  and  strychnia 
are  never  admissible  in  the  treatment  of  this  disease,  because  they  increase 
the  amount  of  blood  in  the  cord.  •'^  "iciedse 


Sacro-Gluteal  Eschars,  and  other  so-called  Bed-Sores,  arising  from 
Lesions  of  the  Spinal  Cord  and  Spinal  Nerves. 

These  affections  so  often  present  themselves  in  cases  of  spinal  iniury 

t  to'™  {f'"'  f  *°  both  surgeons  and  attendants,  as''weli 

as  to  patients  whenever  they  do  appear;  and  finally,  they  prove  so  fre^ 
quently  to  be  the  proximate  cause  of  death  in  fatal  cls'es  of  sS  injury 
that  a  special  consideration  of  them  is  demanded  in  this  place    There  are 
two  important  varieties  of  these  eschars  or  sores  which  are  met  with  iii  cases 
where  the  spine  is  injured ;  and  they  differ  very  widely  in  respec   to  thei? 
causation,  the  gravity  of  the  r  prognosis,  and  the  remedial  measure  that  a^e 
necessary  _  These  distinct  kinds  or  varieties  of  bed-sores  are :  (1)  the  cammn 
or  that  which  IB  often  met  with  in  cases  where  there  is  no  spinil  fnjury  nor 
spinal  disease  as  well  as  in  cases  where  the  spinal  column  is  injured  ■  IId7>) 
he  neurotroplue  ov  neMropathie  or  that  which  arises  from  somi  morbid  exci^ 
tation  or  disease  of  the  spinal  cord  or  spinal  nerves.    The  former  has  hnl 
been  known  ;  the  latter  w-as  first  describid  by  M.  Brown-Sequaixl!  = 
(1)  The  common  kind  of  bed-sore  is  liable  to  occur  in  all  injuries  or  dis- 
eases which  are  attended  with  inability  on  the  part  of  patients lo  move 
themselves  or  change  their  positions  in  bed ;  for  instance,  in  cei  ta  n  fLTurls 
of  the  femur  and  in  certain  forms  of  disease  or  injury  of  the  hip  oi^in  etc 
as  well  as  m  fractures  and  dislocations  of  the  spind  c^olun  n    Siuch  cases 
the  patients,  unless  properly  cared  for  by  others,  ^vill  continue  to  lie  in  one 
set  led  or  unchanged  position  all  day,  and  all  nic^ht,  perhaps  for  several  davs 
and  nights  together.    Hence,  the  whole  weight  °of  heir  h  4  will  press  Sh 
concentrated  energy  upon  the  integuments  which  cover  thf^  Cjecti^^ 
points  of  their  pelves    The  skin  and  fascia  overlying  the  Zerhml  co  f 
vex,  and  irregular  surface  of  the  sacrum  sustain  the  priifciml  pS'e  That" 
compression  interrupts  the  circulation;  the  blood  which^oui  t  to  ^^^te^^  he 
compressed  tissues  is  prevented  from  doino-  so  •  the  blood  nWn.l,,  +i  • 
squeezed  out;  the  vessels  are  tenantless.    An  add  tlndevif  rrnvfin, 
almost  impossible,  with  even  the  o-reatest  care  to  nrevp^^^^^^        lemains;  it  is 
but  ver^^  little,  from  trickling  intS  ^^H^^^Zj^Z^^l^:^^ 
rurthermore  in  spite  of  every  attention,  the  fecal  discharge  lodge  d  oi  the 

ment's  of^r    ■  T       '^'i!"''  '^"'^  ^ets  mixed  with  the  i^rine.  "  t1^  integu- 
ments of  the  nates  may  become  macerated  in  tliis  stinkino-  mixture  and 
then  Its  liquid  portion  will  act  on  the  sodden  tissues  like  ahs?harot?c' sub 
stance.    It  is,  therefore,  not  surprising  that  the  intec^uments  coveri^r  he 
sacrum,  etc.,  when  subjected  to  the  destructive  influenc%  Jpres  ure"oTcon! 


»  Op.  cit.,  pp.  175,  176. 

VOL.  IV. — 27 


418  INJURIES  OF  THE  BACK. 

stant  or  long  continued,  combined  with  that  of  decomposing  urine  and  feces, 
should  soon  become  converted  into  an  eschar,  a  slough,  or  a  bed-sore,  .bor  a 
further  account  of  the  common  variety  of  bed-sore— of  its  symptoms  and 
treatment— the  reader  is  referred  to  Prof.  Moore's  Article  m  the  J^irst  Vol- 
ume of  this  Work,  pp.  800-802. 

(2)  The  neurotrophic  or  neuropathic  variety  of  bed-sore  appears  to  have 
been  clearly  understood  for  the  first  time  by  M.  Brown-Sequard,  as  already 
intimated,  for  he  first  demonstrated  by  experiments  on  animals  the  peculiar 
nature,  as  well  as  the  causal  relations  and  causal  indications  for  treatment,  of 
this  important  lesion.  The  celebrated  Dr.  Bright,  however,  had  already 
been  so  much  struck  by  its  chief  clinical  features  that  he  caused  drawings 
and  models  in  wax  illustrating  them  to  be  prepared  ;  and  he,  likewise,  related 
four  examples  in  point  in  his  "  Reports  of  Medical  Cases."^  But  M.  Brown- 
Sequard,  after  prolonged  research  and  reflection,  and  after  making  numerous 
experiments  on  animals,  to  elucidate  this  lesion,  remarked  concerning  it,  in 
1858,  as  follows : —  .  V  ^ 

"The  production  of  sloughs  on  the  sacrum  cannot  be  considered  as  an 
eftect  of  prolonged  pressure  [from  the  decubitus]  upon  the  parts  of  the  skin 
where  they  appear,  [inasmuch]  as  they  sometimes  are  produced  m  a  few  days 
and  even  in  a  few  hours  after  the  fracture.  They  result  from  a  morbid  excita- 
tion of  the  spinal  cord,  and  not  from  the  loss  of  action  [paralysis]  of  that 
nervous  centre  owing  to  its  partial  or  complete  section,  as  I  have  proved  by 
experiments  [on  animals]  showing  that  they  never  occur  after  [simple]  section 
of  the  cord.  The  proof  that  pressure  upon  the  sacrum  has  but  a  slight 
influence  in  their  production,  is  clearly  given  in  the  case  of  animals  on  which, 
after  fractures  of  the  spine,  I  have  seen  sloughs  occurring  m  parts  that  were 
not  subjected  to  pressure.  Besides,  it  is  known  that  men  who  are  confined 
to  bed  by  other  causes  than  a  nervous  complaint,  may  bear  pressure  upon 
the  same  part  of  the  body  for  a  long  time  without  producing  sloughs.  Pressure 
upon  the  sacrum  is,  therefore,  only  an  additional  cause  of  sloughs,  i  or  the 
mode  of  action  of  the  nervous  system  in  producing  alterations  of  nutrition, 
I  will  refer  to  my  lecture  on  the  influence  of  the  nervous  system  upon  nutri- 
tion,2  and  I  will  only  say  here  that  an  irritation,  and  not  a  paralysis,  is  the 
cause  of  these  morbid  changes."^  ,  .     ^  n 

Among  the  points  established  in  the  lecture  to  which  he  refers,  are  the 

following: —  .         ^  ^  , 

(1)  The  phenomena  of  reflex  action,  that  is,  pains  and  muscular  contrac- 
tions in  the  peripheral  parts,  can  also  be  produced  by  directly  irritating  either 
the  spinal  cord  as  a  compound  nervous  centre  (that  is,  a  series  ot  nervous 
centres  arranged  one  above  another),  or  the  spinal  nerves  which  issue  trom  it. 

(2)  "  The  phenomena  of  this  direct  irritation  have  very  often  been  mistaken 
for  consequences  of  the  absence  of  action  in  the  nervous  centres.  I  will 
merely  point  out  here  the  rapid  sloughs  that  are  observed  after  fractures  or 
luxations  of  the  vertebral  column,  and  the  rapid  change  of  the  urinary  secre- 
tion in  similar  cases."*  ^.i       •  i 

(3)  "  I  will  only  add,  as  reo;ards  the  influence  of  the  pressure  on  the  spinal 
cord  producing  sloughs  on  the  nates  and  other  morbid  changes,  that  it  is 

1  Op.  cit.,  vol.  ii.  pp.  383,  423,  Diseases  of  the  Brain  and  Nervous  System.    London,  1831. 

2  For  more  details  on  the  capital  point  that  it  is  chiefly  owing  to  a  morbid  ^f^^^^^he  nervous 
system  that  alterations  of  nutrition  take  place  in  diseases  of  that  system,  and  not,  genera  ^ 
supposed,  to  a  paralysis,  that  is,  to  a  cessation  of  the  action  ot  that  system,  see  Journal  de  Physi- 

"^'3^  Brown^FquaM's  Lectures  on  the  Physiology  and  Pathology  of  the  Central  Nervous  System, 
etc.,  pp.  248,  249. 
4  Ibid.,  p.  176. 


SACRO-GLUTEAL  ESCHARS.  419 


chiefly  in  exciting  a  persistent  contraction  of  the  bloodvessels  in  the  parts 
where  nutrition  or  secretion  is  morbidly  altered,  that  the  pressure  on  the  cord 
acts.  As  it  often  happens  that  death,  after  a  fracture  or  a  luxation  of  the 
spine,  is  due  to  the  slough  formed  on  the  nates,  I  think  I  must  remark  that 
^  a  very  good  means  of  dilating  the  bloodvessels  consists  in  exhaustino-  their 
irritability  by  applications  of  powerful  galvanic  currents."^  ^ 

"  To  complete  the  demonstration  of  the  proposition  that  death  after  frac- 
ture of  the  spine  is  usually  due  to  the  effects  of  the  excitation  of  the  spinal 
cord  by  pieces  of  broken  bone  [by  ecchymosis  from  contusion  of  its  sub- 
stance, and  by  inflammation  of  its  substance],  and  not  to  the  results  [merely] 
of  a  partial  or  complete  section  of  this  nervous  centre,  we  will  only  say  that 
there  are  many  cases  on  record  showing  that  a  section  or  even  a  crushins;  of 
the  spinal  cord  has  not  proved  fatal  [in  man],  and  that  in  animals  death  is 
rarely  caused  by  a  partial  or  complete  section  of  the  cord  in  the  dorsal  region 
while  they  die  as  quickly  and  as  often  as  men  after  a  fracture  of  the  spine,  if 
.the  broken  pieces  be  not  removed  [and  if  myelitis,  etc.,  be  not  prevented].'"^ 
There  is  no  doubt,  then,  that  the  eschars  in  question  result  not  from  mere 
division  of  the  cord-substance,  whether  partial  or  complete,  but  from  morbid 
excitation  of  that  substance  arising  either  from  the  irritation  that  is  caused 
by  the  contact  of  foreign  bodies,  e.  g.,  splinters  of  bone  and  extravasations  of 
blood,  or  from  the  inflammatory  process  acting  upon  its  histological  ele- 
ments, when  it  is  aroused  by  the  injury. 

This  remarkable  affection  of  the  parts  situated  at  the  peripheral  extremi- 
ties of  the  spinal  nerves,  which  results  mainly  from  central  causes,  Samuel 
has  proposed  to  characterize  by  naming  it  Decubitus  Acutus,  and  Charcot  has 
accepted  the  appellation. ^  ^Nevertheless,  this  term  is  far  from  being  satis- 
tactory, first,  because  the  term  ''decubitus"  is  commonly  applied  to  the  pos- 
ture ot  the  patient  in  bed,  which  has  generally  but  a  small  share  in  the 
production  ot  the  disease ;  and,  secondly,  because  in  some  strondy  marked 
exan]ples  on  record,  the  "  decubitus"  has  had  nothing  whatever  to  do  in  causino- 
the  peripheral  gangrene,  as,  for  instance,  in  the  following  highly  instructive 
case,  which  has  already  been  several  times  referred  to  :— 

The  late  Dr  D.  S.  Conant^  presented  to  the  New  York  Pathological  Society,  together 
with  the  osteological  specimen,  an  account  of  an  interesting  case,  in  which  the  last 
dorsal  and  the  first  lumbar  vertebra  were  fractured,  and  the  spinal  cord  severed  by  an 
osseous  splinter  from  the  laminae  of  the  first  lumbar.  Within  six  days  after  the  casu- 
alty, an  immense,  gangrenous  blister  formed  on  the  inner  side  of  each  thio-h  without 
any  apparent  cause.  ° 

A  stout  man  aged  55,  was  blown  off  from  the  rigging  of  a  ship  on  which  he  was  at 
work,  by  a  high  wmd  on  a  certain  Monday.  He  hit  something  in  his  descent  and 
turned  over,  but  finally  struck  heavily  upon  his  shoulders.  When  taken  up  by  his 
comiacks,  he  was  completely  paralyzed  in  both  lower  extremities.  Three  days  after- 
ward  Dr.  Conant  saw  him  in  consultation,  and  found  that  there  was  complete  loss  of 
sensibility  and  moUon  below  a  certain  well-defined  line  extending  around  his  body 
Ihere  was  also  noticed  a  posterior  angular  deformity  of  the  spine  at  the  dorso-lumbar 
junction  and  Dr.  Conant  diagnosticated  fracture  with  crushing  of  the  body  of  the 
Uvelfth  dorsal  vertebra,  and  with  fragments  of  bone  impinging  upon  the  spinal  cord. 
The  patient  went  on  very  well  until  the  Saturday  following  the  injury  his  mind 
remaining  perfectly  clear.  On  Sunday  morning  his  physician  noticed  a  large  blister 
on  he  inner  side  of  each  thigh,  and  extending  nearly  tlie  whole  length  thereof,  uncon- 
nected with  any  previous  local  irritation.  At  four  o'clock  he  had  a  chill,  his  mind  till 
then  having  remained  clear.    But  soon  after  be  became  delirious,  and  quietly  died 

!  Ibid.  p  Ibid.,  p.  250. 

Philarelph7a,T879^'  translated  by  Dr.  G.  Sigerson,  p.  57. 

*  American  Medical  Times,  June  1,  1861,  pp.  359,  360. 


420  INJURIES  OF  THE  BACK.  , 

without  any  convulsions  at  seven  o'clock  the  same  evening,  six  days  and  some  hours 
after  the  accident,  apparently  in  consequence  of  septicaemia.  ,     .  -,  p 

Autopsy  There  was  a  considerable  quantity  of  extravasated  blood  on  each  side  ot 

the  spinal  column,  in  the  vicinity  of  the  last  rib.  The  body  of  the  last  dorsal  vertebra 
was  found  crushed,  and  a  little  piece  of  bone  from  the  laminae  of  the  first  lumbar  ver- 
tebra had  cut  the  spinal  cord  entirely  off.  The  blisters  on  the  inner  sides  of  the  thighs 
were  found  to  be  the  results  of  mortification.  The  internal  organs  were  all  healthy. 
No  statement  is  reported  as  to  the  presence  of  a  sacro-gluteal  eschar,  but  without 
doubt  there  was  a  large  one  formed  by  Saturday,  when  it  was  noted  that  the  patient 
was  not  doing  so  well.  It  is  mentioned  that  there  was  but  little  disturbance  of  the 
pulse,  notwithstanding  that  mortification  was  occurring  in  the  lower  extremities.  The 
textural  condition  of  the  spinal  cord,  aside  from  its  complete  division  by  a  fracture- 
splinter,  is  not  described.  The  gangrenous  inflammation  'of  the  thighs  was  thought 
to  be  due  to  "  injury  of  the  sympathetic  ganglia  situated  at  the  angles  of  the  last  two 
ribs."  But,  inasmuch  as  in  other  cases  belonging  to  the  same  category,  similar  eschars 
have  appeared  when  vaso-motor  paralysis  has  been  completely  wanting,  it  is  only  fair 
to  infer  that  in  this  case  the  gangrenous  lesions  of  the  thighs  arose  from  morbid  excita- 
tion of  the  spinal  cord,  which  is  merely  another  name  for  traumatic  myelitis,  at  least 
in  this  particular  instance. 

Again,  in  the  following  example  of  chronic  myelitis  arising  from  concussion 
of  the  spinal  corcl,  at  the  lower  part  thoreof,  where  the  resultant  paraplegia 
was  very  far  short  of  being  complete,  an  ulcer  or  slough  of  large  size  pre- 
sented itself  in  the  integuments  over  the  sacrum,  although  there  had  been 
no  absolute  confinement  to  bed  at  any  time 

Professor  Wm.  A.  Hammond  ^  relates  the  case  of  an  originally  healthy  married  wo- 
man, ao-ed  22,  admitted  into  the  Baltimore  Infirmary,  on  March  14,  with  chronic 
myelitis,  the  result  of  an  injury.  She  was  a  sober,  intelligent  young  woman,  by  occu- 
pation a  weaver,  four  years  married,  and  the  mother  of  a  child  then  three  years  old. 
She  had  always  been  healthy  until  her  present  illness,  excepting  that  in  girlhood  she 
had  been  affected  to  some  extent  with  rheumatism  and  occasional  epistaxis. 

Eleven  months  before  admission,  whilst  in  a  somnambulistic  state,  she  fell  from  a 
second-story  window,  and  struck  the  hand-rail  of  a  porch  in  her  descent,  injuring  her 
back  about  the  junction  of  the  lumbar  vertebrae  with  the  sacrum.  The  immediate 
consequences  were  pain  in  that  region,  soreness  across  the  abdomen,  and  the  passage 
of  bloody  urine.  For  seven  months  catheterization  was  necessary,  after  which  time 
the  bladder  in  a  measure  recovered  its  contractility,  but  soon  lost  it  again,  the  sphinc- 
ter also  becoming  paralyzed.  Severe  cough  likewise  ensued;  and  the  catamenia, 
heretofore  quite  regular,  entirely  ceased.  There  was  slight  paralysis  of  the  lower  ex- 
tremities from  the  time  of  the  accident,  which  gradually  increased  until  considerable 
difficulty  was  experienced  in  walking,  or  even  in  standing.  There  was  also  deficient 
sensibility  in  both  lower  extremities,  and  likewise  over  the  sacral  region.  Soon  after 
the  accident,  the  sphincter  ani  lost  its  power.  From  the  first,  she  experienced  more  or 
less  numbness  and  spasm  in  her  lower  extremities.  She  had  been  treated  by  cupping 
the  lumbar  and  sacral  regions,  and  by  strychnia. 

At  the  time  of  admission,  there  was  complete  paralysis  of  the  sphincters  ot  the 
bladder  and  rectum.  Her  urine  was  constantly  flowing  from  her,  and  the  moment 
her  feces  entered  the  rectum  it  was  evacuated.  Upon  introducing  a  finger  into  the 
bowel,  it  was  found  to  be  entirely  relaxed  ;  and,  in  fact,  three  or  four  fingers  could  be 
inserted  with  ease.  Her  lower  extremities  were  partially  paralyzed.  Although  she 
could  still  walk,  she  did  so  with  difficulty.  Frequent  cramps  and  almost  constant 
formication  were  present,  and  there  were  occasional  startings  of  the  limbs  without  her 
being  aware  of  them.  There  was  a  good  deal  of  pain  in  the  sacral  region  ;  and,  as  is 
usual  in  such  cases,  a  large  ulcer  existed  in  the  same  locality. 

On  applying  the  sesthesiometer  to  the  anterior  surface  of  her  legs  and  thighs,  to  those 
parts  which  are  supplied  by  branches  of  the  lumbar  plexus  of  nerves,  there  was  no 
diminution  of  sensibility  found.    She  appreciated  the  two  points  when  separated  only 


1  American  Medical  Times,  June  15,  1861,  pp.  379-381. 


SACRO-GLUTEAL  ESCHARS.  421 

to  .the  extent  of  half  an  inch.  But,  on  applying  tlie  instrument  to  the  posterior  surface 
of  her  legs  and  thighs,  to  the  parts  which  are  supplied  by  the  sacral  plexus,  sl)e  was 
conscious  o  but  one  impression.  Even  when  the  points  were  separated  to  the  extent 
ot  five  inches,  but  one  impression  was  perceived  ;  and,  over  the  gluteal  and  sacral 
.  regions,  she  could  not  feel  them  ^it  all.  It  was  therefore  evident  that  the  disease 
affected  the  portion  of  the  spinal  cord  from  which  the  sacral  plexus  arose— namely 
the  lower  portion.  In  addition,  it  was  found  tiiat  the  sphincters  of  the  bladder  and 
rectum,  which  likewise  derive  their  nerve-filaments  from  the  same  plexus,  had  lost 
their  contracti  e  power.  Tliere  was  a  sense  of  constriction  also  present,  and  the  urine 
was  strongly  alkaline. 

The  diagnosis  of  chronic  myelitis  was  founded  on  the  fact  that  for  a  Ion-  time  the  i>a. 
tient  had  experienced  constant  pain  at  the  point  where  the  healthy  and  diseased  portions  of 
the  cord  united ;  that  there  was  a  sense  of  constriction  also  present  there ;  that  there  was 
a  feeling  of  numbness  almost  constantly  present  in  the  paralyzed  portions  of  her  body  • 
and,  frequently,  other  morbid  sensations,  such  as  coldness,  burning,  formication,  etc  ' 
that  there  were  oftentimes  reflex-motor  spasms  in  the  lower  extremities  ;  that  there  was 
well-marked  anaesthesia  in  the  portions  of  cutaneous  surface  supplied  by  nerves  issuin- 
from  the  diseased  part  of  the  spinal  cord ;  that  the  sphincters  of  the  anus  and  bladder 
were  paralyzed  ;  that  the  normal  movements  of  the  lower  extremities  were  consider- 
ably impaired ;  that  there  was  a  large  slough  over  the  sacrum ;  and  that  the  urine  was 
strongly  alkaline. 

The  treatme7it  consisted  in  administering  ergot  in  moderate  doses  by  the  mouth,  and 
belladonna  by  the  skm,  by  applying  thereto  a  large  plaster  made  of  that  remedy ;  fresh 
air,  moderate  exercise,  and  a  good,  nutritious,  diet  were  also  enjoined.  The  sacral 
slough  was  treated  by  the  method  recommended  by  M.  Brown-S^quard  (which  will 
presently  be  described),  and  by  applying  galvanism. 

May  16.   The  patient  has  recovered  full  control  over  the  bladder,  the  rectum,  and 
the  extremities  ;  her  ability  to  walk  is  also  very  much  improved.    The  slouo-h  over  the 
sacrum  has  been  entirely  cured.    The  pain  has  almost  entirely  departed  from  the  cord 
and  she  IS  no  longer  troubled  with  cramps  or  numbness  in  the  lower  extremities.  This 
highly  beneficial  plan  of  treatment  is  to  be  continued  until  the  cure  is  comolete 

I  he  history  of  this  exceedingly  instructive  case  I  have  presented  as  brieflV  as  seemed 
consistent  with  elucidating  in  a  satisfactory  manner  the  symptoms,  the  diagnosis,  and 
the  therapeusis  of  this  sometimes  obscure  and  often  very  troublesome  disorder  of  the 
spinal  cord  ;  and  by  so  doing  I  have  really  saved  the  use  of  many  words  and  even  para- 
graphs  in  the  way  of  abstract  description,  which  ultimately  would  have  been  required. 

T  ^  ^^^'^  presented  two  important  examples  in  which  the  patient's  "  decu- 

bitii.  had  no  part  whatever  in  the  production  of  the  eschars  in  question,  and 
mthQ  latter  ot  them  the  eschar  was  not  even  "  acute."  It  is,  therefore  ouite 
evident  that  the  term  "  decubitus  acutus"  is  not  at  all  appropriate  for  such 
mstances,  as  well  as  not  particularly  appropriate  for  any  instance  of  the  lesion 
under  consideration ;  and  with  a  view  to  indicate  at  the  fii-st  o-lance  the  ner- 
vous origin  ot  the^e  sloughs,  I  have  ventured  to  call  them  imiropaihic  eschars, 
that  IS,  eschars  which  arise  mainlv  in  consequence  of  morbid  excitation  or 
disease  of  the  spinal  cord  itself,  or  of  the  spinal  nerves  that  supply  the  parts 
on  which  the  eschars  are  formed.  ^ 

Symptoms  of  Neitropathic  Eschar s.~ThQ)^v^t  sign  of  this  disorder  is  an  ery- 
thematous  patch  on  which  vesiculc^  and  bullae  are  rapidly  developed;  morti- 
'^wf"  ^,y^i^,.P^^t^,^^     ^lie  skm  and  subjacent  tissues  very  often  ensues. 

VVlien  this  disorder  appears  in  consequence  of  a  lesion  of  the  spinal  cord 
It  usually  presents  itself  in  the  sacral  region.  Here  it  is  bisected  vertically 
by  the  median  line ;  and  it  extends  itself  symmetrically,  on  either  side,  into 
the  adjacent  integuments.  (Fig.  882.)  But  it  may  likewise  appear  on  almost 
any  part  of  the  truidv  or  the  members  that  may  be  subjected,  by  posture,  to 
a  somewhat  continuous  pressure.  In  certain  cases,  a  very  slight  and  a  very 
short  pressure  suffices  to  determine  its  appearance.    Finally,  there  are  some 


422 


INJURIES  OF  THE  BACK. 


Fig.  882. 


cases,  the  number  of  which  is  probably  not  very  great,  wherein  it  seems  to  be 
produced  without  the  intervention  even  of  the  least  degree  of  pressure,  or  of 

any  other  cause  of  a  similar  kind.  I 
have  just  presented  two  very  instruc- 
tive examples  belonging  to  this  cate- 
gory. 

This  disorder  is  quite  distinct  from 
the  various  cutaneous  eruptions  which 
are  seen  not  unfrequently  in  the  sacral 
region  of  patients  condemned  by  dif- 
ferent aifections  to  long  maintain  a 
recumbent  posture  in  bed.  These 
eruptions,  which  sometimes  are  ery- 
thematous and  lichenoid,  sometimes 
pustular  and  ulcerous,  sometimes  pap- 
ular, and  having  a  deceptive  resem- 
blance to  syphilitic  sores  [plaques  mu- 
qiieuses),  are  generally  caused  by  re- 
peated and  prolonged  contact  with 
irritating  substances,  such  as  decom- 
posing urine  and  fecal  matter.  They, 
as  well  as  the  neuropathic  erythema 
and  blebs,  may  become  the  starting 
points  of  genuine  eschars,  as  already 
stated  above.  But  the  neuropathic 
eschar  is  often  distinguishable,  clinic- 
ally, from  that  of  the  former,  by  certain 
important  characteristics,  namely  :  (1) 
By  appearing  shortly  after  the  pri- 
mary disorder  of  the  nerve-tissue,  or  by  following  upon  a  sudden  exacerbation 
of  that  disorder  ;  and  (2)  By  exhibiting  a  very  rapid  evolution.  (Charcot.) 

Some  days,  or,  it  may  be,  onl}^  some  hours,  after  the  causative  affection  of  the 
spinal  cord  has  manifested  itself  in  such  cases,  there  appear  on  certain  portions 
of  the  skin,  already  mentioned,  one  or  several  erythematous  patches,  variable 
in  extent  and  irregular  in  shape.  The  skin  hei^e  has  a  rosy  hue  ;  sometimes, 
however,  it  is  dark-red,  and  even  violet,  but  still  the  color  disappears  mo- 
mentarily on  making  pressure  with  a  finger.  M.  Charcot  has  ascertained 
that  in  such  cases  the  derma  is,  anatomically,  infiltrated  with  leucocytes,  as 
happens  in  erysipelas.^  Occasionally,  but,  for  the  most  part,  in  examples  of 
myelitis,  there-appears  besides  an  apparently  phlegmonous  tumefaction,  involv- 
ing the  derma  and  subjacent  tissues,  which  may  be  attended  by  acute  pain^ 
if  the  affected  part  have  not  been  previously  stricken  with  anaesthesia. 

In  a  day  or  two,  but  sometimes  sooner,  vesicles  or  bullae  make  their  ap- 
j)earance  about  the  middle  of  the  erythematous  patch  ;  they  contain  a  liquid 
substance  or  serosity,  which  is  sometimes  colorless  and  perfectly  transparent^ 
and  sometimes  more  or  less  opaque,  reddish,  or  of  a  brownish  hue. 

If  the  causative  affections  of  the  spinal  cord  or  spinal  nerves  now  abate, 
the  vesicles  and  blebs  soon  wither,  dry  up,  and  disappear.  Sometimes,  how- 
ever, the  blistered  epidermis  becomes  torn,  drops  off*  in  pieces,  and  lays  bare 
a  bright-red  surface  strewn  with  violet  points  or  patches,  corresponding  with 
a  sanguinolent  infiltration  of  the  cutis  vera.  In  such  cases,  the  subcutaneous 
connective  tissue,  and  sometimes  even  the  subjacent  muscles,  are  likewise 
invaded  by  the  sanguinolent  infiltration.  This  fact  M.  Charcot  has  repeat- 
edly  verified  by  post-mortem  examination.^ 


Showing  a  sacro-gluteal  eschar  of  neuropathic  origin, 
which  was  formed  in  a  case  of  myelitis  involying  the 
dorsal  portion  of  the  spinal  cord:  1.  The  mortified 
part    2.  The  erythematous  zone.  (Charcot.) 


Op.  cit.,  p.  TjS,  foot-note. 


2  Ibid. 


58. 


SACR0-13LUTEAL  ESCHARS,. 


423 


These  violet-colored  points  or  patches  of  saiiguinoleiit  infiltration  rapidly 
widen,  and  soon  their  edges  run  together  or  coalesce.  Thus,  in  a  short  time, 
there  supervenes  in  the  affected  part  a  mortification  of  the  cutis  vera,  which 
is  at  first  superficial,  but  soon  becomes  profound,  and  may  involve  not  only 
^  the  subcutaneous  connective  tissue,  but  likewise  the  subjacent  muscles,  and 
even  the  subjacent  bones.  Thus  the  eschar  is  constituted  in  the  neuropathic 
cases  under  consideration.  If  there  be  some  chance  for  a  favorable  issue  still 
remaining,  the  work  of  reaction  against,  and  elimination  of,  the  mortified  tis- 
sues at  once  begins  ;  and,  should  the  prospect  become  more  favorable,  a  period 
of  reparation  w^ill  follow,  which,  however,  is  liable  to  exhibit  many  fluctua- 
tions in  its  course. 

It  should  have  been  stated  that  in  cases  of  typhus  and  typhoid  fever,  a  cuta- 
neous afi^ection  of  the  sacro-gluteal  region,  etc.,  not  unfrequently  occurs,  which 
bears  a  strong  resemblance  to  the  neuropathic  bed-sore  now  under  considera- 
tion, and  which,  perhaps,  arises  in  part  from  analogous  conditions.  This  cuta- 
neous afi:ection  of  the  buttocks,  in  typhus  and  typhoid  fevers,  has  been 
minutely  described  by  Piorry,  in  France,  and  by  Pfeiifer,  in  Germany. 

In  the  production  of  neuropathic  bed-sores,  the  patient's  posture  in  bed 
often  plays  an  important  part.  For  instance,  it  is  not  unusual  in  cases  where 
the  patient  is  so  placed  as  to  repose  on  his  side,  during  part  of  the  day,  to 
find,  in  addition  to  the  sacral  eschar,  large  necrotic  ulcerations  occurring  over 
the  great  trochanters.  It  is  also  quite  common  to  see  in  cases  of  spinal  injury 
attended  with  paralysis,  that  the  difi:erent  parts  of  the  paralyzed  limbs  which 
are  exposed  to  only  slight  and  brief  pressure,  such  as  the  ankles,  heels,  and 
inner  surfaces  of  the  knees,  present  lesions  characteristic  of  neuropathic  bed- 
sores. On  page  269  [supra)^  I  have  presented,  with  a  wood-cut  (Fig.  852), 
an  abstract  of  the  case  of  a  soldier  whose  spinal  cord  was  severed  by  a  knife 
opposite  the  fifth  cervical  vertebra ;  neuropathic  sjDhacelus  soon  followed, 
attacking  all  the  projecting  points  on  the  lower  part  of  his  body,  and  pro- 
ceeding rapidly  until  it  almost  bared  the  sacrum.  In  some  rare  instances,  I 
have  also  seen  neuropathic  eschars  present  themselves  over  the  scapulae  and 
over  the  olecranon  process. 

Clinical  Relations. — In  the  foregoing  pages  I  have  mentioned  or  referred  to 
a  great  many  cases  in  which  neuropathic  eschars  appeared  in  connection  with 
fractures  or  dislocations  of  the  vertebrae,  and  consequent  injury  of  the  spinal 
cord.  In  regard  to  the  time  wdien  the  symptoms  of  neuropathic  eschars  are 
most  likely  to  present  themselves  in  cases  where  the  spinal  column  is  injured, 
Dr.  E.  Grurlt,  whose  opinion  on  this  subject  is  based  on  the  study  of  a  very 
large  number  of  cases,  holds  that  the  first  symptoms  of  this  afi:ection  usually 
appear  from  the  fourth  to  the  fifth  day  after  the  accident.  But  the  initial 
erythema  and  bullee  may  appear  very  much  earlier  than  that ;  for,  on  page 
315  {supra)^  I  have  presented,  with  a  wood-cut  (Fig.  859)  illustrating  the  ver- 
tebral lesion,  the  case  of  a  soldier  who  dislocated  the  fourth  cervical  ver- 
tebra with  much  displacement  and  much  damage  to  the  spinal  cord,  in  a 
vain  attempt  to  turn  a  somersault,  and  who  survived  the  accident  only  forty- 
four  hours ;  nevertheless,  it  was  found  at  the  autopsy  that  "  ulceration  over  the 
sacrum  had  already  commenced  ;"  that  is,  a  w^ell-marked  bed-sore  was  already 
formed.  In  this  case,  then,  the  initial  erythema  and  vesicles  or  blebs  must 
have  presented  themselves  within  a  few  hours  after  the  accident. 

The  initial  symptoms  of  a  neuropathic  eschar  on  the  breech  appeared  in 
less  than  thirty-six  hours  after  the  injury,  in  a  case  under  the  late  Dr.  James 
E.  Wood's  care,  at  Bellevue  Hospital : — 

The  patient  was  a  stableman,  aged  30,  who  fractured  the  seventh  cervical  vertebra 
by  falling  down  stairs,  at  7  P.  M.,  on  June  13.    He  was  insensible  for  the  moment. 


424 


INJURIES  OF  THE  BACK. 


On  the  14th,  at  6  P.  M.,  he  was  admitted  to  the  hospital,  with  complete  motor  and 
sensory  paralysis  of  the  entire  body,  below  the  third  rib  in  front  and  the  fourth  rib 
behind.  The  decubitus  was  dorsal,  with  head  and  neck  thrust  forward.  The  respira- 
tion was  purely  abdominal  (diaphragmatic).  The  penis  was  strongly  erected.  Neither 
urine  nor  feces  had  been  passed  since  the  accident. 

On  the  15th,  A.  M.,  a  red  spot,  nearly  two  hands'  size,  was  observed  upon  the  left 
nates,  and  vesication  in  the  fissure  near  the  extremity  of  the  coccyx.  In  the  evening, 
marked  increase  of  temperature  all  over  the  surface  of  the  body  was  found,  and  a  pur- 
plish spot,  the  commencement  of  a  slough,  low  down  in  the  cleft  of  the  nates. 

On  the  16th,  A.  M.  A  purple  spot  commencing  over  the  third  or  fourth  lumbar 
vertebra  ;  some  haematuria  ;  and  conside^-able  tympanites.  7^  P.  M.  Great  dyspnoea  ; 
bronchial  tubes  and  trachea  filled  with  secretion. 

On  the  17th.  The  incipient  bed-sores  no  further  developed  ;  patient  delirious  at  times 
through  the  day.  7  P.  M.  Entire  anaesthesia  and  paralysis  of  both  arms — they  were 
not  paralyzed  early  in  the  afternoon  ;  great  tympanites  ;  urine  high-colored  ;  priapism 
always  induced  by  passing  the  catheter  ;  was  conscious  and  sane.  9  P.  M.  Comatose  and 
insensible  ;  eyes  suffused  ;  convulsive  movement  of  lower  jaw  ;  body  still  hot ;  pulse  full 
and  strong.    11|  P.  M.  Died  quietly,  comatose,  and  without  general  convulsions,  four 

days  plus  four  and  three-fourth  hours  after  the  accident.    Autopsy  Body  of  seventh 

cervical  vertebra  fractured  transversely  and  completely ;  ligamenta  subflava  completely 
disrupted ;  the  vertebra  dislocated ;  spinal  cord  not  lacerated  ;  brain  moderately  con- 
gested. Pathological  condition  of  the  cord  not  described.^  The  ascending  and  deep- 
ening character  of  the  paralysis,  however,  denotes,  under  the  circumstances,  that  there 
was  ascending  myelitis. 

In  a  case  related  on  page  390  (supra)  the  initial  symptoms  of  neuropathic 
sphacelus  simultaneously  occurred  at  several  different  points  in  the  lower 
extremities,  in  less  than  twenty-four  hours  after  the  spinal  lesion : — 

The  patient  was  a  derrick-man,  aged  41,  admitted  to  Bellevue  Hospital,  in  Dr. 
Stephen  Smith's  service,  two  hours  after  he  had  sustained  a  fracture  of  the  tenth  dorsal 
vertebra,  with  complete  paraplegia,  in  consequence  of  being  thrown  from  a  cart  and 
striking  his  back  upon  the  stony  street.  Next  .morning  it  was  observed  that  sloughs 
had  commenced  to  form  upon  the  heel  and  upon  the  ball  of  the  great  toe  of  his  left  foot, 
and  over  the  external  malleolus  of  his  right  ankle,  without  any  apparent  cause  ;  several 
hours  afterwards,  death  ensued  in  consequence  of  compression  of  the  spinal  cord  by 
extravasated  blood. 

In  a  case  recorded  by  Dr.  L.  Buchner,  of  Darmstadt,  in  which  a  man,  aged  46,  liad 
sustained  complete  diastasis  of  the  sixth  and  seventh  cervical  vertebra  by  falling  from 
a  height,  and  in  which  death  supervened  sixty  hours  after  the  accident,  a  well-marked 
bed-sore  of  spinal  origin  was  already  visible.  (Gurlt.) 

It  has  been  claimed  by  many  that  ancesthesia  is  an  essential  factor  in  the 
causation  of  bed-sores  having  a  spinal  origin.  This  view,  however,  is  nega- 
tived by  the  case  of  a  young  woman,  aged  22,  related  by  Professor  Hammond, 
which  I  have  presented  on  page  420  ;  for,  in  that  case,  a  large  sacral  eschar 
appeared,  although  the  patient  had  never  been  confined  wholly  to  bed,  and 
had  never  been  entirely  unable  to  walk ;  and,  therefore,  of  course,  had  never 
had  complete  paraplegia,  nor  anything  like  profound  ansesthesia. 

This  view  is  also  negatived  by  an  example  of  vertebral  fracture  reported 
by  Jeffreys : — ^ 

The  patient  was  a  man,  who  was  injured  by  a  fall  of  twenty-five  feet  from  a  ladder. 
There  was  much  shock,  with  a  cold  skin,  and  a  barely  perceptible  pulse.    All  the 
parts  below  the  fracture  were  deprived  of  sensibility  and  voluntary  motion.    Next  day 
there  was  persistent  priapism ;  "  then  supervened  phlyctenae  in  the  region  of  the  sacrum 
and,  on  the  same  day,  "  the  patient  recovered  his  sensibility."     Death,  however, 

'  New  York  Journal  of  Medicine,  January,  1859,  pp.  85-87. 
2  London  Medical  Journal,  July,  1826. 


SACRO-GLUTEAL  ESCHARS. 


425 


ensued ;  and,  on  post-mortem  examination,  it  was  found  that  the  bodies  of  the  seventli 
and  eighth  dorsal  vertebrae  were  broken  into  several  pieces,  which  were  much  displaced. 

In  a  case  where  neuropathic  eschars  appear,  priapism,  strong  alkalinity  of 
the  urine,  hsematuria,  inllamniation  of  the  urinary  bladder  or  kidneys,  hyper- 
^  sesthesia,  vaso-motor  exaltations  or  depressions  of  the  body-heat,  clonic  con- 
vulsions of  the  paralyzed  members,  tonic  (that  is,  tetanoid)  spasms  occurring 
in  paroxysms,  in  brief,  all  those  symptoms  which  usually  reveal  an  excited 
state  of  the  spinal  cord  and  spinal  membranes,  often  precede,  accompany,  or 
closely  follow  the  formation  of  these  eschars. 

When  the  injuries  (traumatisms)  or  the  secondary  lesions  which  excite  the 
spinal  cord  in  cases  where  neuropathic  eschars  ensue,  afiect  the  cord  symme- 
trically, the  eschars  themselves,  as  a  rule,  are  symmetrically  developed,  as 
shown  by  Fig.  882 ;  as  also  happened  in  Dr.  Conant's  case,  where  a  laro;e 
gangrenous  eschar,  of  an  equal  size,  presented  itself  on  the  inner  side  of  each 
thigh  ;  and^  as  in  Dr.  Stephen  Smitli's  case,  referred  to  above,  where  sloughs 
of  similar  size  and  appearance  simultaneously  formed  on  each  foot  and  ankle, 
in  consequence  of  spinal  injury.  But,  when  the  traumatism  affects  one  f^ide 
only  of  the  spinal  cord,  then  the  neuropathic  eschars  which  arise  therefrom 
are  not  symmetrically  developed  ;  they  are  found  only  on  the  side  of  the 
i)ody  opposite  the  side  of  the  cord  which  is  injured  or  diseased.  For  ex- 
ample, in  the  case  of  a  man  admitted  into  Professor  ^^'elaton's  ward  at  the 
St.  Louis  Hospital,  for  a  sword-wound  of  the  back  dividing  the  left  half  of 
the  spinal  cord  (I  have  already  presented  a  pretty  full  account  of  this  case  on 
page  394),  ''a  slough  formed  on  the  right  side  of  the  sacrum,  although  the 
patient  had  not  felt  anything  there.''  The  man,  however,  recovered.  The 
same  peculiarity  has  been  observed  in  several  analogous  cases ;  and,  accord- 
ins^  to  M.  Brown-Sequard's  experiments,  it  is  a  constant  fact  in  the  case  of 
animals. 

The  information  derived  from  M.  Brown-Sequard's  experiments  in  this 
regard,  is  capable  of  giving  so  ninch  practical  aid  or  useful  help  to  surgeons 
m  diagnosticating  spinal  lesions  and  spinal  disorders,  that  I  will  briefly  refer 
to  them  in  this  place.  We  learn  first  from  these  experiments,  that  after 
wounds  dividing  one  lateral  half  of  the  spinal  cord,  there  supervenes  in  animals 
motor  paralysis  of  the  lower  extremity  on  the  same  side  as  the  lesion  of 
the  cord.  This  limb  also  presents  exaltation  of  tactile  sensibility  (hyper^es- 
thesia)  in  a  more  or  less  marked  degree,  and  it  likewise  exhibits  a  notable 
elevation  of  temperature  correlated  with  vaso-motor  paralysis.  But  the 
opposite  limb,  on  the  contrary,  retains  the  normal  temperature  and  the  normal 
power  of  motion,  whilst  its  tactile  sensibility  is  much  lessened,  or  may  even 
be  extinct ;  that  is,  it  exhibits  ansesthesia  and  sensory  paralysis.  All  these 
phenomena  or  symptoms  are  exactly  reproduced  in  man  under  analoo-ous 
circumstances.  In  his  case,  as  in  that  of  animals,  we  may  also  find  various 
trophic  derangements  rapidly  supervening  in  the  peripheral  parts  of  the 
body,  which  manifestly  arise  from  the  sq^inal  lesion.  Among  the  conse- 
quences of  these  trophic  derangements  I  have  already  mentioned  bed-sores, 
occurring  not  on  the  injured  side,  where  the  voluntary  motor  and  vaso-motor 
paralysis  is  to  be  found,  together  with  exaltation  of  temperature  and  hyper- 
pesthesia,  but  on  the  opposite  side  of  the  body,  particularly  on  the  opposite 
side  of  the  sacral  region,  that  is,  on  the  side  where  the  motor  functions,  both 
voluntary  and  vasal,  are  unimpaired,  and  where  there  exists  only  a  deadening 
of  the  sensibility,  or  aneesthesia.  This  circumstance  clearly  shows  that  neuro- 
pathic bed-sores  do  not  arise  from  vaso-motor  paralysis,  as  some  persons  have 
vainly  imagined. 

In  man,  other  nutritive  lesions  of  a  similar  character  have  been  observed. 


426 


INJURIES  OF  THE  BACK. 


I  shall  here  take  space  to  mention  only  two  of  them,  namely :  (1)  Rapid 
diminution  of  the  faradic  contractility  of  the  muscles,  soon  followed  by  an 
equably  rapid  atrophy  of  the  muscles  themselves,  or  acute  muscular  atrophy  ; 
and  (2)  A  peculiar  form  of  joint-disease  inflammatory  in  character,  or  spinal 
arthropathy.  It  is,  however,  a  remarkable  fact,  that  while  the  spinal  or  neu- 
ropathic eschar,  in  cases  where  the  cord  is  partly  divided,  appears  on  the  side 
of  the  sacrum  opposite  the  spinal  injury,  the  arthropathy  and  the  muscular 
atrophy  are  to  be  found  in  the  limb  belonging  to  the  same  side  as  the  spinal 
injury.  For  example,  in  the  case  of  a  man  who  was  admitted  into  Professor 
Nelaton's  ward  with  a  sword-wound  dividing  the  left  half  of  the  spinal  cord 
(already  twice  mentioned),  the  symptoms  showed  rapid  improvement  up  to 
the  twelfth  day  after  the  casualty  ;  on  that  day  it  was  remarked  that,- without 
apparent  cause,  the  leftleg^  still  more  sensitive  than  normal,  had  increased  in 
volume,  and  that  a  quantity  of  fluid  had  accumulated  in  the  left  knee-joint 
sufficient  to  float  the  patella  half  an  inch  above  the  condyles.  Two  or  three 
days  subsequently,  an  eschar  was  observed  occupying  the  right  lateral  part 
of  the  sacrum  and  the  right  gluteal  region.^ 

Another  very  instructive  example,  which  occurred  in  one  of  Dr.  Cusco's 
patients,  is  related  by  M.  Charcot,  and  I  will  present  a  brief  abstract  of  it : — 

A  man,  aged  40,  was  stabbed  with  a  poniard,  in  the  night  of  February  15-16,  1871, 
at  the  third  dorsal  vertebra,  and  on  the  left  side  thereof.  The  weapon  penetrated 
downward  and  toward  the  right,  and  divided  the  left  half  of  the  spinal  cord.  The  left 
leg  was  immediately  stricken  with  motor  paralysis,  while  the  right  was  not.  He  was 
at  once  brought  to  hospital.  In  the  morning  the  following  note  was  made  :  Left  lower 
extremity,  complete  motor  paralysis ;  limb  perfectly  flaccid  ;  no  trace  of  contraction, 
nor  of  rigidity  ;  no  spasmodic  movements,  nor  subsultus.  But  its  sensibility  is  greatly 
exaggerated  ;  the  least  touch  of  the  skin,  especially  near  the  foot,  causes  pain  ;  pressure 
has  the  same  effect ;  a  sHght  pinch  or  a  tickle  is  followed  by  very  painful  sensations  ; 
the  appHcation  of  a  cold  body  produces  painful  sensations  which  the  patient  compares 
to  prickings.  JRight  lower  extremity,  the  voluntary  motions  are  all  perfectly  normal, 
but  the  sensibility  is  almost  completely  destroyed  ;  complete  analgesia ;  sensitiveness  to 
touch  almost  null ;  the  contact  of  a  cold  body  causes  an  obscure,  dull,  prickUng  sensa- 
tion. The  insensibiUty  is  not  restricted  to  the  lower  limb  ;  it  ascends  to  a  level  with 
the  right  nipple.    The  urine  and  feces  passed  involuntarily. 

On  the  24th,  it  was  noted  that  the  left  (motor-paralyzed)  hmb  was  warmer  than  the 
right ;  and  that  the  patient  complained  of  feeling  constricted  or  compressed  at  the  base 
of  the  thorax. 

On  March  5th  (seventeenth  day),  the  patient  complained  of  troubled  sight :  left  pupil 
contracted  more  than  right  pupil ;  the  vessels  of  left  eye  more  numerous  and  volumi- 
nous than  those  of  right  eye.  The  evacuations,  for  the  last  two  days,  had  again  been 
voluntary.    The  state  of  the  lower  extremities  remained  unchanged. 

On  the  13th  (twenty -fifth  day),  the  right  buttock,  since  the  day  before,  had  been  the 
seat  of  livid  redness,  and  the  epidermis  had  already  fallen  off  from  a  part  of  the  erythe- 
matous patch. 

On  the  14th,  the  integuments  on  the  right  buttock,  near  the  sacrum,  were  denuded  to 
the  extent  of  a  crown-piece,  and  ecchymosed — that  is,  there  was  a  spinal  bed-sore.  The 
left  knee-joint  was  red  and  swollen,  and  hkewise  the  seat  of  spontaneous  pains,  which 
were  increased  by  moving  the  joint — that  is,  there  was  spinal  arthropathy. 

On  the  24th,  an  ulceration  had  occurred  on  the  right  buttock,  on  a  level  with  the 
ecchymosed  patch,  which  now  was  covered  with  granulations.  The  left  knee  was 
almost  free  from  redness  and  swelling,  as  well  as  from  pain.' 

The  following  very  instructive  example  of  acute  muscular  atrophy,  taken 
from  Dr.  W.  Miiller,  is  likewise  presented  by  M.  Charcot : — ^ 


1  Brown-Sequard,  Journal  de  la  Physiologie,  t.  iii.  p.  130. 

2  Op.  cit.,  p.  70.  ^  Ibid.,  pp.  70,  71. 


SACRO-GLUTEAL  ESCHARS. 


427 


The  patient  was  a  woman,  aged  21,  who  was  stabbed  with  a  knife  in  the  back,  at  the 
fourth  dorsal  vertebra;  the  weapon,  as  the  autopsy  afterwards  demonstrated,  divided 
the  left  lateral  half  of  the  spinal  cord,  two  millimetres  above  the  third  pair  of  dorsal 
nerves.  On  the  first  day,  complete  paralysis  of  motion  and  hyperaisthesia  were  observed 
in  the  left  lower  extremity  ;  tiie  opposite  limb  was  anaesthetic,  but  not  paralyzed.  On 
^  the  second  day  it  was  found  that  the  muscles  of  tiie  paralyzed  member,  and  of  the  lower 
part  of  the  abdomen,  gave  no  reaction  under  faradic  stimulation,  whilst,  in  the  corre- 
sponding parts  of  the  opposite  side,  the  electrical  contractility  continued  normal.  On 
the  eleventh  day,  a  neuropathic  or  spinal  eschar  was  formed,  which  occupied  tiie  right 
sacro-gluteal  region,  and  extended  to  the  right  gluteal  eminence.  It  was  also  remarked, 
on  this  day,  thaj  the  paralyzed  limb  had  notably  wasted  away,  and  measured  about  two 
inches  less  in  circumference  than  the  anaesthetic  member.  On  the  thirteenth  day,  death 
occurred.  At  the  autopsy,  the  borders  of  the  spinal  wound  appeared  tumefied,  and  of 
a  reddish-brown  color ;  a  thin  purulent  layer  covered  it.  Below  the  wound,  the  left 
lateral  column  presented  the  anatomical  characteristics  of  descending  myelitis,  throuo-h- 
out  its  whole  length.  ° 

Thus,  we  find  that  when  the  neuropathic  or  spinal  bed-sore  appears  on 
but  one  side  of  the  sacrum,  or  on  one  buttock  only,  in  consequence  of  injury 
or  division  of  the  lateral  column  belonging  to  the  opposite  side  of  the  spinal 
cord,  the  eschar  is  liable  to  be  accompanied  by  a  peculiar  joint-disease  of  spi- 
nal origin,  or  by  an  acute  muscular  atrophy,  also  of  spinal  origin,  which  affec- 
tions, however,  both  occur  on  the  side  opposite  the  neuropathic  eschar— tliat 
is,  in  the  lower  extremity  belonging  to  the  same  side  as  the  spinal  lesion. 
These  clinical  facts,  and  the  intimate  clinical  connection  which  exists  amono- 
these  disorders  when  they  are  developed  under  the  circumstances  just  met? 
tioned,  should  be  known  to  all  surgeons.^ 

Continuing  our  inquiry  into  the" clinical  relations  of  neurotrophic  or  neu- 
ropathic eschars,  we  shall  next  find  that  they  may  arise  from  those  forms  of 
traumatic  myelitis  which  are  not  attended  by  wounds  of  the  spinal  cord,  nor 
by  fractures,  nor  by  dislocations  of  the  spinal  column.  We  shall  likewise 
find  that  they  may  arise  from  this  cause  quite  as  rapidly  as  they  would  if 
the  spinal  column  were  also  fractured.  A  case  reported  by  Sir  W.  Gull, 
which  I  have  already  presented  on  page  414  {supra),  clinically  illustrates  in 
a  useful  manner  this  mode  of  causation : — 

The  patient  was  a  laborer,  aged  25,  who  felt  a  sudden  pain  in  his  back,  after  lifting 
a  heavy  weight.  On  the  morning  of  the  second  day  afterward,  his  lower  extremities 
were  completely  paralyzed.  Two  days  later  he  entered  hospital.  A  bed-sore  had 
already  began  to  form  near  the  sacrum,  and  ammoniacal  urine  dribbled  from  the  blad- 
der."   Death  occurred  forty-one  days  after  the  strain.    Autopsy  A  large  bed-sore  had 

bared  the  sacrum  in  its  whole  length.  The  bones  and  ligaments  of  the  spine  exhibited 
no  trace  of  injury.  The  spinal  cord  was  disorganized  by  myelitis  opposite  the  fifth  and 
sixth  dorsal  vertebrae. 

In  this  example  of  acute  myelitis  resultino^  from  a  strain  of  the  back,  the 
bed-sore  began  to  appear  within  four  days  "after  the  injurv,  and  two  davs 
after  the  symptoms  of  myelitis  had  declared  themselves.  1  have  also  pre- 
sented on  page  420,  as  will  be  remembered,  the  case  of  a  woman,  ao-ed  22, 
reported  by  Professor  Hammond,  in  which  myelitis  arising  from  concussion 
of  the  spmal  cord,  the  result  of  a  fall,  was  attended  with  the  formation  of  a 
large  sacral  eschar. 

>  There  are,  however,  unilateral  bed-sores  also  of  cerebral  origin— that  is,  bed-sores  which 
arise  from  diseases  of  the  brain,  such  as  cerebral  hemorrhage,  cerebral  embolism,  cerehral  soft- 
ening, etc  —which  appear  on  one  cheek  only  of  the  nates,  but  they  do  not  come  within  the 
scope  of  this  article.  I  will  merely  remark  here  :  (1)  that  the  acute  hed-sore  which  arises  from 
cerebral  diseases  does  not  essentially  differ  from  that  wliich  arises  from  spinal  lesions  (Charcot)- 
(2)  that  the  cerebral  bed-sore  can  usually  be  distinguished  with  ease  from  that  which  is  of  spi- 
nal origin  ;  and  (3)  that  a  full  account  of  the  genesis  of  cerebral  bed-sores,  illustrated  with  a 
wood-cut,  IS  to  be  found  m  Charcot's  Lectures  on  the  Diseases  of  the  Nervous  System  p  63 


428" 


INJURIES  OF  THE  BACK. 


But  sjyontcmeoiis  acute  myelitis,  as  well  as  traumatic  acute  myelitis,  very 
often  determines  the  precocious  formation  of  sacral  eschars,  especially  when 
it  sets  in  suddenly  and  its  evolution  is  rapid.  Manj'  instances  belonging  to 
this  category  have  been  placed  on  record  by  Gull,  Duckworth,  Joffroy, 
Engelken,  Voisin,  and  Cornil,  as  well  as  by  other  observers. 

We  may  also  see  a  sacral  eschar  rapidly  form  in  cases  of  spinal  disease 
where  the  evolution  is  slow,  should  a  new  irritation  of  an  active  character 
suddenly  intervene,  or  should  an  acute  inflammatoiy  process  be  suddenly 
superadded  to  the  preexisting  lesion,  ^ot  only  the  exacerbations  of  partial 
sclerotic  myelitis,  but  also  the  sudden  invasion  of  the  rachidian  cavity  by 
purulent  matter  emanating  from  an  abscess,  in  the  case  of  patients  sufiering 
from  vertebral  disease,  may  cause  the  rapid  formation  of  sacral  eschars. 
Should  a  tumor  occupying  the  central  part  of  the  cord  provoke  the  develop- 
ment of  acute  myelitis  by  its  presence,  the  same  result  will  follow.  Several 
examples  of  this  kind  are  on  record.  (Charcot.) 

^Neuropathic  sphacelus  of  the  integuments  on  the  sacrum  and  nates  may 
be  causecl  by  trawaaiism  of  the  cauda  equina^  as  well  as  by  morbid  excitation  of 
the  spinal  cord  itself.  This  important  fact  is  proved  by  a  case  reported  by 
M.  Couyba,^  and  mentioned  by  M.  Charcot: — ^ 

A  young  soldier  received  a  shot-wound  at  the  outpost  of  Clamart.  The  missile 
entered  his  left  side*  near  the  anterior  extremity  of  the  tenth  rib,  and  emerged  on  the 
right  side  of  the  spinal  column,  about  three  inches  from  the  spinous  process,  and  on  a 
level  with  the  second  lumbar  vertebra.  Paresis,  with  acute  hyperaesthesia,  of  the  lower 
extremities  ensued.  On  the  fifth  day  after  the  casualty,  a  bulla  appeared  on  the  right 
gluteal  eminence,  and  quickly  gave  place  to  an  eschar,  which  progressively  extended  so 
as  at  last  to  wholly  cover  the  sacro-gluteal  region.  On  the  nineteenth  day,  death 
resulted. 

Autopsy  A  layer  of  purulent  matter  covered  the  spinal  cord,  both  anteriorly  and 

posteriorly,  from  the  cauda  equina  up  to  the  cervical  region.  The  cord  itself,  when 
examined,  first  in  the  fresh  state,  next  in  numerous  hardened  sections,  did  not  exhibit 
any  alterations.  But  a  certain  number  of  nerve-tubes  in  the  nervous  cords  which 
form  the  cauda  equina,  presented  the  anatomical  characteristics  of  fatty  granular  degene- 
ration. Thus,  the  demonstration  that  a  morbid  excitation  of  the  cauda  equina  had 
existed  during  life,  was  made  complete.  Additional  examples  of  the  same  sort  might 
be  cited. 

Finally,  the  morbid  excitation  of  any  peripheral  nerve  may  be  attended 
with  the  rapid  formation  of  eschars  in  the  integument  belonging  to  its  area. 

For  example,  M.  Charcot^  relates  the  case  of  a  woman  at  La  Salpetriere,  who  had  an 
enormous  fibroid  tumor  on  the  left  side,  which  compressed,  in  the  pelvis,  the  roots  of 
the  crural  and  ischiatic  nerves  of  the  same  side.  There  had  resulted  a  paretic  state  of 
the  corresponding  member,  accompanied  by  acute  pains  running  along  the  track  of  the 
principal  nerve-trunks.  One  morning,  shortly  after  the  appearance  of  the  first  symp- 
toms of  compression,  it  was  remarked  that  an  eschar  had  rapidly  formed  on  the  left  of 
and  near  to  the  sacral  region.  Likewise,  on  the  left  knee's  inner  surface  some  pemphi- 
goid bullae  were  found,  in  a  spot  which  had  been  pressed  upon  by  the  right  knee  for  a 
considerable  time  during  the  night,  in  consequence  of  the  patient's  attitude  while 
asleep ;  these  pemphigoid  bullae  were  filled  with  a  brownish  liquid,  and  soon  gave  place 
to  an  eschar.    Nothing  of  the  kind  was  developed  on  the  right  knee. 

The  fact  that  eschars  of  the  integument  may  quickly  form  in  consequence 
of  morbid  excitation  of  the  spinarnerves  which  supply  the  peripheral  areas 
w^here  the  eschars  themselves  appear,  as  occurred  in  the  case  just  related, 
aftbrds  another  good  reason  why  the  terminology  of  such  eschars  should  be 


I  Th6se  de  Pans,  1871,  p.  53,  Obs.  xiii. 


2  Op.  cit.,  p.  75. 


»  Ibid. 


SACRO-GLUTEAL  ESCHARS. 


429 


characterized  by  a  name  which  distinctly  recognizes  their  neurotrophic  or 
neuropathic  origin. 

Course  and  Consequences  of  Neuropathic  Sphacelus  or  Eschars. — Should  the 
disease  spontaneously  abate,  or  should  the  treatment  prove  successful,  it  may 
happen:  (1)  that  the  initial  vesicles  or  blebs  will  wither,  dry  up,  and  leave  a 
healthy  surface  ;  or  (2)  that  the  erosions,  being  superficial,  will  take  on  healthy 
action,  granulate,  and  cicatrize ;  or  (3)  that  the  slough,  although  extending 
deeply,  will  become  surrounded  by  a  line  of  inflammatory  demarcation  sepa- 
rating the  dead  from  the  living  tissues ;  that  purulent  matter  will  form  throucrh- 
out  this  line  of  demarcation,  whereby  the  slough  will  become  detached  from 
the  living  tissues,  so  that  it  can  be  readily  taken  away  by  the  surgeon ;  that 
the  cavity  thus  formed  will  fill  up  by  the  granulating  process;  and,  Anally, 
that  the  space  occupied  by  the  slough,  whether  large  or  small,  will  become 
covered  with  new  integument  in  the  form  of  a  cicatrix. 

But  not  always,  nor  even  in  a  majority  of  instances,  is  this  fortunate 
issue  obtained  in  cases  of  neuropathic  sphacelus.  On  the  contrary,  this  dis- 
order often  proves  fatal,  and  that,  too,  in  certain  determinate  ways,  which  I 
will  now  proceed  to  point  out : — 

(1)  Occasionally,  this  disorder  directly  destroys  life  by  causing  acute  septi- 
ccemia.  That  is,  it  sometimes  happens  in  cases  of  neuropathic  sphacelus  that 
the  eschars  are  very  large,  and  at  the  same  time  do  not  become  environed  by 
any  lines  of  inflammatory  demarcation  which  plug  with  coagula  the  veins 
passing  from  the  dead  into  the  living  tissues ;  wherefore  these  vessels  remain 
open,  and  directly  convey  the  decomposing  blood,  and  putrid  juices  and 
putrid  gases  from  the  dead  parts,  into  the  general  current  of  the  circulation. 
Thus,  septic  poisoning  of  the  blood,  or  septicemia  in  its  most  acute  form, 
sometimes  occurs  in  cases  of  neuropathic  sphacelus,  and  quickly  destroys 
life.  Without  doubt  this  happened  in  the  case  reported  by  Dr.  Conant,  and 
already  presented  on  p.  419,  where  a  man  had  sustained  vertebral  fracture  at 
the  dorso-lumbar  junction  by  being  blown  off  from  the  riggino;  of  a  vessel 
while  at  work ;  for,  on  the  morning  of  the  following  Sunday,  a'large  blister 
of  mortiflcation  was  noticed  on  the  inner  side  of  each  thigh,  which  extended 
nearly  the  whole  length  thereof;  at  4  P.  M.  he  had  a  violent  chill,  and 
became  delirious ;  he  sank  rapidly,  and  died  quietly  at  7  o'clock  on  the  same 
evening ;  and  the  autopsy  revealed  no  cause  for  his  sudden  death,  excepting 
the  neuropathic  gangi-ene  and  the  consequent  septicaemia. 

A  case  of  simple  fracture  of  .the  first  lumbar  vertebra,  with  a  wood-cut  to 
dlustrate  it  (Fig.  862),  was  presented  on  page  351,  in  which  it  is  not  improb- 
able that  septicemia  arising  from  a  neuropathic  eschar  was  likewise  the 
immediate  cause  of  death  ;  for  "  the  parts  in  the  region  of  the  sacrum  were 
gangrenous,"  and  smelled  so  badly  that  it  was  necessary  to  apply  strong  disin- 
fectants (chlorides),  in  order  to  suppress  the  stench. 

(2)  ^sTeuropathic  bed-sores  not  unfrequently  destroy  life  by  inducing  puru- 
lent  infection,  or  pyxmia,  attended  with  the  production  of  metastatic  abscesses 
in  the  viscera.  I  have  already  mentioned  a  considerable  number  of  cases  in 
which  this  accident  occurred,  and  here  is  another  example:— 

J.  H.  Gray^  relates  the  case  of  a  boy,  aged  13,  who  fell  thirty-five  or  forty  feet, 
striking  his  back,  and  was  stunned.  Projection  of  tlie  sixth  or  seventh  dorsal  vertebra 
was  noted ;  also  delirium  ;  paralysis ;  priapism  ;  incontinence  of  urine  and  feces ;  ab- 
normal heat ;  excoriation  ;  on  ninth  day  cystitis ;  bed-sores.  He  did  well  for  three 
weeks,  but  then  rigors  occurred,  and  were  foUowed  by  death  twenty-eight  days  after  the 
accident.    Necroscopy  revealed  fracture  and  displacement  forward  of  the  sixth  dorsal 


'  London  Hospital  Reports,  vol.  i. 


430 


INJURIES  OF  THE  BACK. 


vertebra  ;  cord  crushed,  but  not  compressed  ;  metastatic  deposits  (abscesses)  in  several 
viscera.  (Ashhurst.) 

M.  Charcot  thinks  that  this  sequel  of  spinal  bed-sores  is  seldom  met  with. 
But  experience,  especially  that  gathered  in  old  or  perhaps  infected  hospitals, 
proves  the  contrary. 

(3)  Sphacelus  of  neuropathic  origin  not  unfrequently  proves  fatal  in  conse- 
quence of  the  formation  of  gangrenous  emboli^  or  the  occurrence  of  gangrenous 
embolism.  "  In  this  variety,"  says  M.  Charcot,  "  thrombi  impregnated  with 
gangrenous  ichor  are  transported  to  a  distance,  and  give  rise  to  gangrenous 
metastases,  which  are  principally  observed  in  the  lungs.  This  is  a  point 
upon  which  Dr.  Ball  and  myself  have  insisted  in  a  work  published  in  1857.^ 
But  long  before  us,  and  even  long  before  the  theory  of  embolism  had  been 
Germanized,  M.  Foville^  had  expressed  his  opinion  that  a  considerable 
number  of  cases  of  pulmonary  gangrene,  observed  in  the  insane,  and  in  dif- 
ferent diseases  of  the  nervous  centres,  are  caused  by  '  the  transport  into  the 
lungs  of  a  part  of  the  fluid  which  bathes  the  eschars  of  the  breech.'  I  give 
the  preceding  quotations  from  MM.  Foville  and  Charcot,  in  order  to  show- 
not  only  that  gangrenous  eschars  of  the  sacrum  may  cause  pulmonary  gangrene 
through  the  agency  of  pulmonary  embolism  and  pulmonary  infarction,  but 
also  that  French  observers  have  had  some  share  of  importance  in  developing 
the  theory  of  embolism  itself. 

(4)  ^Neuropathic  eschars  prove  fatal  most  frequently  of  all,  perhaps,  in  con- 
sequence of  exhaustion — that  is,  the  sufi:erers  die  worn  out  by  the  discharge 
and  irritation,  combined  with  a  certain  degree  of  septicaemia  which  is  almost 
always  present  in  such  cases.  The  process  of  mortification  tends  gradually 
to  invade  the  deeper  tissues,  as  well  as  to  spread  more  widely  on  the  surface. 
In  this  way,  the  trochanteric  synovial  bursse  may  be  laid  open,  the  trochanter 
itself  denuded  of  periosteum,  the  gluteal  muscles,  the  nerve-trunks,  and  the 
)loodvessels  of  a  certain  calibre  laid  bare.  But  I  can  best  describe  the  phe- 
nomena of  sacral  eschars  ending  in  death  from  exhaustion,  by  briefly  relating 
an  example : — 

A  female  domestic,  aged  30,  moderately  temperate,  and  of  good  constitution,  was 
admitted  into  Bellevue  Hospital,  on  the  afternoon  of  August  30,  on  account  of  frac- 
ture and  luxation  of  the  first  lumbar  vertebra,  with  the  following  history.  About  9  or 
10  o'clock  on  the  previous  evening,  while  in  a  somnambulistic  state,  she  walked  out  of 
a  third-floor  window,  and,  falling  two  floors,  struck  upon  the  slated  roof  of  a  shed.  She 
was  not  rendered  insensible,  even  for  a  moment,  but  could  give  no  account  of  the  direc- 
tion in  which  the  blow  was  received,  excepting  that  she  struck  upon  her  left  side.  No 
paralysis  nor  anaesthesia  followed  the  accident,  and  no  pain  except  upon  motion.  The 
left  leg,  however,  had  felt  "  numb"  ever  since.  No  urine  nor  feces  had  been  passed 
since  the  accident. 

Upon  examination,  slight  deformity,  a  slight  displacement  of  a  vertebra  backward, 
was  detected  at  the  position  of  the  last  dorsal  or  first  lumbar  vertebra,  and  very  slight 
tenderness  a  trifle  lower  down  ;  but  no  redness  nor  ecchymosis,  nor  any  other  external 
mark  of  injury.  The  respiration  was  natural  in  character  and  frequency;  the  pulse 
rather  frequent,  but  of  moderate  strength. 

The  urine  was  withdrawn  by  catheter  for  a  few  days,  and  after  that  was  passed  invol- 
untarily until  death.  The  bowels  acted  regularly.  In  the  course  of  eight  or  ten  days 
after  admission,  the  vertebral  prominence  increased  so  much  as  to  make  easy  a  diagnosis 
)f  luxation  backward  of  the  first  lumbar  vertebra.  No  motor  paralysis  nor  anaesthesia 
of  the  limbs  or  body  appeared  in  the  case.  The  very  intense  pain  occurring  upon  the 
slightest  attempt  at  motion,  which  originally  characterized  her  condition,  gradually 
diminished,  and  at  length  in  considerable  measure  disappeared. 

*  De  la  coincidence  des  gangrenes  viscerales  et  des  affections  gangrdneuses  exterieures.  L'Union 
Medicale,  26  et  28  Janvier,  1860. 

2  Dictionnaire  de  M6d.  et  de  Chirurg.  Prat.,  t.  i.  p.  556.  ^  Charcot,  op.  cit.,  p.  60. 


SACRO-GLUTEAL  ESCHARS. 


431 


Fig.  883. 


A  bed-sore  early  formed  over  the  sacrum,  and  slowly  proceeded  inward  or  deepened 
until  exposure  of  the  bone  was  effected.  Subsequently,  diarrhoea  supervened.  She 
sank  from  exhaustion  ;  and,  or  October  6,  she  died,  thirty-eight  days  after  the  accident. 

Autopsy  Crushing  of  the  body  of  the  first  lumbar  vertebra,  with  displacement  of 

the  entire  vertebra  backward,  was  revealed.  Firm  union  in  the  fractured  vertebra  had 
taken  place. ^ 

It  is  worthy  of  particular  mention  that  a  sacral  eschar  attacked  this  Avornan 
although  she  had  no  sensory  nor  motor  paralysis  whatever,  that  the  eschar 
soon  followed  the  accident,  that  it  steadily  deepened  until  it  laid  bare  the 
vsacrum,  and  that  it  caused  death  by  producing  exhaustion.  The  sacrum 
itself  was  probably  necrosed,  for  it  has  often  been  found  necrosed  in  analo- 
gous cases. 

(5)  Finally,  sacral  eschars  of  neuropathic  origin  pretty  often  prove  fatal  by 
destroying  the  sacro-coccygeal  ligament  and  thus  opening  the  sacral  canal, 
or  by  penetrating  this  canal  in  some  other  manner  ;  whereupon  there  quickly: 
supervenes  either  a  simple^  imrulent^  ascending  meningitis^  or  a  sort  of  ichorous, 
ascending  meningitis.  I  have  already  mentioned  a  number  of  instances  in 
which  the  sacral  canal  was  opened  by  bed-sores  with  fatal  effect.  Mr.  Hilton 
states  that  he  has  "  several  times  seen  fatal  mischief  result  from  a  bed-sore 
extending  to  the  interior  of  the  vertebral  canal,  and  causing  inflammation  of 
the  spinal  cord  and  its  membranes. He  likewise  presents  an  accurate  draw- 
ing made  from  a  preparation  illustrating  this  important  pathological  condition, 
of  which  the  accompanying  wood-cut  (Fig.  883)  is  a 
copy.  This  cut  will  remind  surgeons  of  the  close 
proximity  of  the  spinal  dura  mater  and  the  posterior 
wall  of  the  sacral  canal  to  bed-sores,  a,  a,  a.  A  ver- 
tical section  of  the  third,  fourth,  and  fifth  lumbar 
vertebrae.  6,  b.  A  vertical  section  of  the  sa(!rum.  d. 
A  portion  of  the  sacral  arch  turned  backward,  e. 
Short,  delicate,  and  elastic  ligaments,  seen  proceeding 
from  the  lower  part  of  the  spinal  dura  mater  to  the 
sacrum,  c.  Dura  mater,  containing  the  cauda  equina, 
spinal  pia  mater,  and  spinal  arachnoid  extending  to  a 
point  opposite  the  second  bone  of  the  sacrum.  Numer- 
ous strong  ligaments  are  shown  afiixing  the  dura  mater 
to  the  posterior  ligament  of  the  spinal  column,  oppo- 
site the  second  portion  of  the  sacrum.  Three  distinct, 
slender  ligaments  proceed  to  the  third,  fourth,  and 
fifth  pieces  of  the  sacrum.  (Hilton.)  The  fact  that 
the  spinal  membranes  extend  downward  as  far  as  the 
second  piece  of  the  sacrum,  is  well  shown  in  the  cut 
(Fig.  883).  In  one  of  Mr.  Hilton's  cases  death  re- 
sulted from  pyaemia  (pyaemic  pneumonia),  although 
the  bed-sore  had  reached  the  interior  of  the  vertebral 
canal,  and  involved  the  membranes  of  the  spinal  mar- 
row.3 

Of  the  ichorous  form  of  ascending  meningitis,  MM. 
Lisfranc  and  Baillarger  have  reported  many  remark- 
a])le  examples.  In  this  afiection,  it  is  found  that  a 
puriform,  grayish,  acrid,  and  fetid  liquid  steeps  the 
spinal  meninges  and  the  cord  itself ;  sometimes  only  the  lower  part,  some- 
times the  whole  cord  is  bathed  in  this  liquid,  Avhich,  occasionally,  is  also  found 


To  illustrate  the  penetration, 
of  tlie  sacral  canal  hy  bed-soros, 
and  the  occurrence  of  latal 
spinal  meningitis  therefrom. 
(Hilton.) 


'  New  York  Journal  of  Medicine,  March,  1859.  pp.  244,  245. 

2  Op.  cit.,  pp.  213,  214.  3' Op  cit.,  p.  43. 


432 


INJURIES  OF  THE  B^\CK. 


at  the  base  of  the  encephalon,  as  likewise  in  the  fourth  ventricle,  in  the  aque- 
duct of  Sylvius,  and  even  in  the  lateral  ventricles.  At  all  these  points  in 
such  cases,  the  cerebral  substance  is  discolored  on  its  surface  and  to  a  certain, 
depth,  acquiring  a  slaty-bluish  tint,  which  is  a  product  of  imbibition,  mace- 
ration, and  dyeing.  (Charcot.)  When  ichorous  cerebral  meningitis  has  a 
sacral  bed-sore  for  its  startuig-point,  the  slaty  hue,  but  more  pronounced,  is 
found  over  the  whole  extent  of  the  spinal  cord,  and  it  grows  more  strongly 
marked  as  one  approaches  the  bed-sore  which  has  opened  the  sacral  canal. 
Simple,  purulent,  ascending  meningitis,  however,  is  not  attended  with  this 
peculiar  discoloration ;  but  it  is  unnecessary  to  dwell  longer  on  this  point, 
although  it  is  by  no  means  an  unimportant  one. 

Pathogeny. — From  the  foregoing  exposition  of  whatever  facts  are  known 
concerning  the  variety  of  sphacelus  in  question  (that  is,  concerning  the  acute 
sacral  eschar,  etc.),  it'  is  evident  that  the  patient's  position,  or  pressure,  is 
never  the  chief  cause  of  its  production,  and  that  in  some  cases  pressure  does 
not  assist  at  all  in  originating  it. 

It  also  appears  that  its  causation  in  no  way  depends  upon  paralysis  of 
sensation  and  voluntary  motion ;  for,  in  a  case  where  the  first  lumbar  ver- 
tebra was  fractured  (it  is  related  on  page  430),  a  sacral  eschar  appeared  early 
and  progressed  steadily  until  it  produced  fatal  exhaustion,  although  there 
was  no  paralysis  whatever  of  sensation  and  voluntary  motion.  Other  exam- 
ples of  similar  import  have  likewise  been  mentioned  in  the  foregoing  pages. 

Furthermore,  it  appears  that  the  acute  bed-sore  does  not  arise  from  vaso- 
motor paralysis  (that  is,  from  paralysis  of  the  bloodvessels) ;  for,  in  the  hemi- 
paraplegia  which  ensues  when  one  lateral  half  of  the  spinal  cord  is  divided, 
the  eschar  never  appears  on  the  side  of  the  sacrum,  or  in  the  lower  extre- 
mity, where  the  vaso-motor  paralysis  is  to  be  found,  but  on  the  side  cf  the 
sacrum,  or  in  the  lower  extremity,  where  vaso-motor  paralysis  does  not  exist. 
The  inference  is,  of  course,  conclusive. 

Finally,  the  kind  of  sphacelus  in  question  does  not  result  from  the  mere 
absence  of  nerve-action ;  for,  in  several  cases  of  shot  and  other  fractures  of 
the  vertebrae  (related  above),  in  which  the  spinal  cord  was  partially  or  com- 
pletely divided,  no  bed-sores  appeared,  although  the  patients  survived  their 
injuries  several,  and,  in  some  instances,  many  days.  The  soldier  whose  verte- 
bral fracture  is  represented  by  Fig.  871  (p.  371),  survived  a  complete  division 
of  the  spinal  cord  for  twenty-nine  days,  and  yet  no  bed-sore  presented  itself. 
Hutin's  patient  lived  fourteen  years — although  the  right  half  of  the  cauda 
equina  had  been  divided  by  a  small-arm  missile  near  its  commencement,  the 
left  half  displaced  by  it, -and  its  substance  much  disorganized — and  ultimately 
died  of  Bright's  disease.  But  examples  almost  without  number  can  readily 
be  adduced  to  show  that  the  spinal  cord  may  be  divided,  either  partially  or 
completely,  without  the  supervention  of  bed-sores,  however  long  the  survival 
be  protracted. 

On  the  other  hand,  m  perusing  the  cases  of  spinal  injury  where  acute  bed- 
sores, or  analogous  sphacelations,  did  appear,  and  where  the  condition  of  the 
cord  revealed  by  post-mortem  examination  is  described  with  sufficient  minute- 
ness, we  generally  find  it  distinctly  stated,  either  that  the  cord  \\^as  sufifering 
from  active  mechanical  irritation  eftected  by  the  displaced  and  fractured  ver- 
tebrae, or  by  the  extravasation  of  blood,  or  that  the  cord-substance  had  under- 
gone certain  changes  which  we  know  result  from  the  inflammatory  process,  or 
that  the  spinal  membranes  were  inflamed.  Thus,  in  the  case  of  shot-fracture 
of  the  spinal  column,  represented  by  Fig.  870  (p.  371),  hi  which  the  missile 
divided  the  spinal  cord  and  lodged  in  the  spinal  canal  opposite  the  fifth  dorsal 
vertebra,  a  sacral  eschar  appeared ;  two  weeks  afterwards  "  sloughing  of  the 


SACRO-GLUTEAL  ESCHARS. 


43a 


lower  extremities"  was  noted ;  after  another  month, "  sloughing  extending"  was- 
part  of  the  record  made  ;  and  six  weeks  after  that,  death  from  exhaustion  ensued. 
At  the  autopsy  it  was  found,  not  only  that  the  spinal  cord  was  severed,  and 
that  the  missile  lay  in  the  spinal  canal,  hut  also  that  the  upper  section  of  the 
spinal  cord  was  much  softened,"  that  is,  exhibited  a  change  which,  under 
the  circumstances,  was  doubtless  inflammatory.  Most  of  these  particulars 
are  taken  from  the  Medical  and  Surgical  History  of  the  War  of  the  llebellion. 
First  Surgical  Volume,  p.  440,  where  the  case  is  fully  reported.  Many  similar 
instances  "have  been  mentioned  in  the  foregoing  pages,  where  acute  sacral 
eschars  or  other  sphacelations  of  an  analogous  character  were  attended  with 
either  an  active  mechanical  irritation  or  a  positive  inflammation  of  the  cord- 
substance,  as  w^as  proved  by  post-mortem  examination.  On  the  whole,  then, 
the  dominant  and  ever-present  fact  in  such  cases  is  the  active  irritation  of  a 
more  or  less  extensive  region  of  the  spinal  cord,  which  mostly  shows  itself, 
anatomically,  by  the  changes  that  characterize  inflammation  of  the  cord-sub- 
stance (myelitis),  and,  clinically,  by  the  outward  phenomena  or  symptoms  that 
arise  from  this  lesion.  Moreover,  this  conclusion  is  in  strict  conformity  with 
the  results  of  experiments  on  animals,  which  show  that  in  them  the  develop- 
ment of  gangrenous  ulcerations  over  the  sacrum  does  not  supervene  on  ordinary 
sections  of  the  cord,  but  only  in  cases  where  inflammation  occurs  in  the  cord- 
substance  or  membranes  around  the  traumatic  lesion.  So  much  concerning 
the  pathogeny  of  this  most  troublesome  and  destructive  disorder  appears 
certain. 

But  it  is  not  probable  that  all  the  constituent  parts  of  the  spinal  cord  are 
equally  liable,  w^hen  excited  by  irritation  or  inflammation,  to  provoke  the 
development  of  acute  bed-sores.  The  great  frequency  of  this  accident  in 
eases  of  h?ematomyelia,  and  of  acute  central  m3^elitis,  where  the  lesion  occu- 
pies chiefly  the  central  region  of  the  spinal  cord,  seems  to  designate  the  gray 
substance  as  playing  a  predominant  .part  in  this  respect.  (Charcot.)  This 
power  is  doubtless  shared  also  by  the  posterior  wdiite  fasciculi,  for  M.  Char- 
cot has  shown  that  irritation  of  certain  parts  of  these  fasciculi  has  the  effect 
of  determining  the  production,  not  only  of  various  cutaneous  eruptions,  but 
likewise  of  dermal  necrosis  with  deep  ulceration.^ 

Furthermore,  it  is  perfectly  established  that  traumatism  of  the  cauda 
equina,  and  other  irritative  lesions  of  the  peripheral  nerves,  may  give  rise  to 
an  acute  bed-sore,  on  the  one  hand,  or  to  sphacelation  of  the  integuments  in 
their  terminal  areas,  on  the  other  hand.  The  illustrative  examples  presented 
above  make  this  point  quite  clear;  and  there  are  many  other  examples  on 
record.  Perhaps,  irritative  lesions  of  the  spinal  ganglia  of  the  nervi  sympa- 
thici,  too,  may  sometimes  determine  the  rapid  formation  of  eschars.  But  on 
this  point  we  need  more  light  to  be  thrown  by  clinical  and  pathological 
observations,  as  well  as  b}-  experiments  on  animals. 

Finally,  in  regard^  to  the  essential  lesion  of  the  spinal  cord,  of  the  cauda 
equina,  or  of  the  peripheral  nerves  in  general,  which  determines  the  develop- 
ment of  acute  bed-sores  and  of  other  analogous  sphacelations  of  the  integu- 
ment, we  are  still  in  the  dark,  at  least  as  far  as  any  positive  knowledge  of 
the  subject  is  concerned.  But,  after  all,  it  may  in  time  yet  be  demonstrated 
that  there  really  are  trophic  nerves,  as  Samuel  has  supposed,  and  that  the 
pathological  excitation  of  these  nerve-fllaments,  whether  it  be  effected  in  the 
spinal  cord,  or  in  the  cauda  equina,  or  in  the  trunks  of  other  peripheral 
nerves,  is  attended  by  the  formation  of  tegumentary  eschars  in  the  areas 
where  the  disordered  nerve-filaments  terminate,  and  over  w^hose  nutrition  they 
preside. 


VOL.  IV. — 28 


1  Op.  cit.,  pp.  52,  73,  74. 


434 


INJURIES  OF  THE  BACK. 


Prognosis. — ^Neuropathic  bed-sores,  and  neuropathic  sphacelations  in  gen- 
eral, never  bode  any  good.  Still,  they  portend  more  of  evil  when  they  appear 
in  the  course  of  some  affections,  than  they  do  when  they  appear  in  the  course 
of  others.  For  instance,  a  sacral  eschar  very  seldom  presents  itself  in  a  case 
of  injury  or  disease  of  the  brain  which  is  to  have  a  favorable  termination ; 
its  appearance  in  such  cases,  therefore,  constitutes  a  most  inauspicious  sign. 
"We  mioiit  in  fact  call  it  sphacelus  ominosus,  the  ominous  bed-sore,  by  way  of 
distinction.  (Charcot.^)  This  accident,  I  repeat,  rarely  proves  deceptive  in 
cerebral  injuries  and  diseases  ;  and  inasmuch  as  its  existence  may  be  discerned 
from  its  very  incipiency,  it  becomes  of  great  value,  especially  in  doubtful 
cases.  The  only  prognostic  sign  that  can  at  all  rival  it  in  cases  of  sudden 
hemiplegia,  according  to  M.  Charcot,  is  a  very  marked  fall  of  the  central 
temperature  below  the  normal,  occurring  at  the  outset  of  an  attack.  Thus, 
the  vesicul^e  and  bullse  which  are  the  precursors  of  neuropathic  sphacelus 
will,  from  their  first  ax)pearance  on  the  scene,  enable  us  to  form  a  prognosis 
with  certainty  in  such  instances. 

But,  in  spinal  injuries  and  diseases,  recovery  may  yet  take  place  after  neu- 
ropathic bed-sores  have  appeared.  Many  such  examples  are  on  record,  and 
almost  every  experienced  surgeon  has  witnessed  several.  There  are,  how- 
ever, certain  phenomena  which  portend  an  unfavorable  issue  for  the  neuro- 
t  pathic  sphacelations  which  result  from  spinal  injury.  These  signs  of  impend- 
ing evil  are  the  following :  (1)  An  early  appearance  of  such  sphacelations — 
that  is,  their  occurrence  before  the  pressure  resulting  from  the  patient's  pos- 
ture in  bed  has  had  sufficient  time  to  share  in  tl^eir  causation ;  (2)  Their 
appearance  in  parts  where  pressure  has  had  very  little,  or  even  no  share  at 
all,  in  their  causation,  as,  for  example,  on  the  ankles,  legs,  inner  surface  of  the 
thighs,  etc. ;  (3)  Their  simultaneous  appearance  at  several  different  points  on 
both  lower  extremities ;  (4)  Their  very  rapid  enlargement  on  the  one  hand, 
or  their  steady  enlargement  in  spite*  of  treatment  on  the  other ;  (5)  The 
appearance  of  symptoms  denoting  that  septicaemia,  pysemia,  or  ascending  sup- 
purative meningitis  from  penetration  of  the  spinal  canal,  has  occurred — a  sign 
which  usually  denotes  that  the  end  is  not  far  ofl^  In  a  case  reported  by  Mr. 
Hilton,^  where  a  sacral  eschar  reached  the  interior  of  the  vertebral  canal  and 
involved  the  membranes  of  the  spinal  marrow,  x)y?emia  also  supervened,  and 
caused  death  in  nine  days.  On  autoi:)sy  the  whole  right  lung  was  found  pneu- 
monic, with  numerous,  well-defined,  small  collections  of  pus  in  difterent  parts 
of  it. 

Treatment.  The  causal  indications  should  be  sought  for  and  fulfilled  as  far 

as  possible.  To  this  end,  in  simple  fractures  and  dislocations  of  the  spinal 
column,  reduction  should  be  effected,  for  thus  the  risk  of  mechanical  irritation 
of  the  spinal  cord  or  its  membranes,  by  the  displaced  vertebrae,  will  be  more 
or  less  considerably  lessened.  In  gunshot  and  other  compound  fractures  of  the 
spinal  column,  all  foreign  bodies  should  be  removed  from  the  wounds.  In  cases 
where  spinal  meningitis  or  myelitis  is  present  and  acting  as  the  efficient  cause 
of  the  bed-sores  or  sphacelations  (and  these  cases  form  a  numerous  class), 
potassium  iodide,  ten  grains  three  times  a  day,  and  fluid  extract  of  ergot,  one 
drachm  three  times  a  day,  should  be  administered.  When  ergot  has  lost  its 
effect,  belladonna  in  rather  large  doses  has  sometnnes  been  exhibited  with 
benefit  in  cases  of  myelitis.  But  the  chief  internal  remedies  against  spinal 
con2:estion,  spinal  menhigitis,  and  spinal  myelitis,  are  potassium  iodide  and 
ergot,  and  both  drugs  must,  as  a  rule,  be  given  in  full  or  even  excessive  doses, 
to  secure  their  good  efiects  in  these  disorders.    I  advocate  the  trial  of  these 


[«  Charcot  uses  the  term  decubitus  oininosus.'] 


2  Op.  cit.,  p.  213. 


SACRO-GLUTEAL  ESCHARS. 


435 


remedies  in  bed-sores  and  other  sphacelations  of  spinal  origin,  not  only  on 
general  principles,  but  also  because,  in  several  instances  related  in  the  fore- 
going pages,  the  good  etiects  of  these  remedies  were  conspicuous  in  the  rapid 
healing  6f  the  ulcers,  and  in  the  disappearance  of  the  other  spinal  symptoms. 

Although  the  pressure  resulting  from  the  patient's  posture  in  bed  is  never 
the  chief  cause  of  neuropathic  bed-sores,  v^e  should  always  endeavor  to  pre- 
vent its  occurrence,  or  mitigate  its  effects,  by  placing  the  patient  upon  a  water- 
bed,  or  by  employing  the  various  expedients  which  were  mentioned  in  \^ol.  I. 
(p.  801) ;  but,  if  possible,  a  water-bed  should  be  obtained  for  such  cases, 
because  no  expedient  or  combination  of  expedients  will  answer  the  purpose 
nearly  as  well.  The  integuments  on  the  sacrum  and  nates  should  be  kept 
dry  and  clean,  that  is,  unsoiled  with  decomposing  urine  and  feces ;  and  these 
parts,  in  bed-ridden  people,  should  be  sponged  over  at  least  once  a  day  with 
diluted  alcohol  or  rectified  spirit. 

But  when  the  eschar  or  sphacelus  appears  notwithstanding  these  measures, 
what  more  is  to  be  done  ?  The  indication  then  is  to  limit  the  extent  of  the 
slough,  as  much  as  possible,  by  restoring  or  invigorating  the  circulation  of 
blood  in  the  affected  parts.  There  are  two  procedures  for  fulfilling  this  indi- 
€ation,  both  of  which  possess  great  value.  One  of  them  was  devised  by  M. 
Brown-Sequard,  and  I  shall  proceed  to  describe  it  in  his  own  words : — 

"  I  have  tried,"  he  says,  "  to  prevent  or  cure  those  sloughs  which  are  an 
evident  result  of  the  disturbance  of  nutrition  due  to  an  irritation  of  the 
nerves  of  bloodvessels,  by  acting  upon  the  bloodvessels  of  the  part  where 
the  sloughs  exist.  I  have  made  experiments  upon  animals,  showing  that 
applying  alternately  two  poultices,  one  of  pounded  ice,  the  other  a  very 
warm,  bread  or  linseed  poultice,  there  is  a  very  rapid  cure  of  the  sloughs 
[when]  due  to  a  nervous  irritation.  Several  medical  men  have  already 
obtained  the  same  results  in  man  that  I  have  obtained  in  animals,  by  follow- 
ing the  plan  of  treatment  that  I  have  proposed.  The  pounded  ice,  kept  in  a 
bladder,  is  to  be  applied  for  eight  or  ten  minutes,  and  the  warm  poultice  for 
an  hour  or  two,  or  even  a  longer  period.  ...  I  think  I  can  safely  say 
that,  in  cases  where  a  slough  is  begintiing,  its  progress  will  always  be  stopped 
by  the  means  I  propose."* 

The  other  method  is  that  of  galvanism,  which  was  first  suggested  and 
employed  by  Dr.  Crussel,  of  St.  Petersburg,  and  is  as  follows :  A  thin  silver 
plate,  no  thicker  than  a  sheet  of  paper,  is  to  be  cut  so  as  to  fit  the  exact  size  and 
shape  of  the  bed-sore.  A  zinc  plate  of  about  the  same  size  is  connected  with 
the  silver  plate  by  a  fine  silver  or  copper  wire,  six  or  eight  inches  in  length.  The 
silver  plate  is  then  placed  in  immediate  contact  with  the  bed-sore,  and  the  zinc 
plate  on  some  part  of  the  skin  above  it— a  piece  of  chamois-leather,  soaked  in 
vinegar,  intervening,  which,  however,  must  be  kept  moist,  or  thei-e  will  be  little 
or  no  action  of  the  battery.  Within  a  few  hours  the  beneficial  effect  becomes 
perceptible ;  and,  iu  a  day  or  two,  the  cure  is  in  most  cases  complete.  In  a 
few  instances  a  longer  time  is  required.  I  have  frequently  seen,"  Professor 
Wm.  A.  Hammond  says,^  "  bed-sores  three  or  four  inches  in  diameter,  and 
half  an  inch  deep,  heal  entirely  over  in  forty-eight  hours."  Mr.  Spencer 
Wells  states  that  he  has  often  witnessed  large  ulcers  covered  by  granulations 
within  twenty-four  hours,  and  completely  filled  up  and  cicatrization  begun 
in  forty-eight  hours,  under  this  treatment ;  and  that  it  is  the  best  ot^all 
methods  for  treating  ulcers  of  indolent  character,  and  bed-sores.  Professor 
Hammond  further  states :  "  During  the  last  twelve  years  I  have  employed  it 
to  a  great  extent  in  the  treatment  of  bed-sores  caused  by  disease  of  the  spinal 

^  Lectures  on  the  Physiplogy  and  Pathology  of  the  Central  Nervons  System,  etc.,  pp.  2&0,  261. 
2  Diseases  of  the  Nervous  System,  1881,  p.  453. 


436 


INJURIES  OF  THE  BACK. 


cord,  and  with  scarcely  a  failure— indeed,  I  may  say  without  any  failure 
except  in  two  cases  where  deep  sinuses  had  formed  which  could  not  be 
reached  by  the  apparatus."^  If  this  plan  of  treatment  should  prove  equally 
successful  in  other  hands,  a  large  share  of  the  mortality  which  arises  from 
spinal  injuries  may  be  avoided. 

In  the  absence  of  ice,  M.  Brow  n-Sequard's  method  may  be  employed  by 
alternately  applying  to  the  bed-sores  sponges,  one  of  which  is  saturated  with 
hot  water  and  the  other  with  cold  water.  This  should  be  done  several 
times  every  day,  for  five  or  ten  minutes  at  a  time;  the  eftect  is  to  increase  the 
vascular  activity  of  the  part,  and  to  promote  granulation. 


Disorders  of  the  Urinary  Organs  arising  from  Lesions  of  the  Spinal 

Cord. 

Disorders  of  the  urinary  bladder,  the  ureters,  and  the  kidneys,  result  from 
lesions  of  the  spinal  cord — from  the  so-called  idiopathic,  as  well  as  from  the 
traumatic  afiections  of  that  organ— with  even  greater  frequence  than  the  bed- 
sores and  other  neuropathic  sphacelations  which  have  just  been  described  ; 
for,  while  the  tegumentary  eschars  that  arise  from  spinal  lesions  are  always 
attended  by  more  or  less  important  disorders  of  the  urinary  organs,  the  latter 
not  unfrequently  present  themselves  in  cases  where  the  spinal  cord  is  injured 
or  diseased,  without  the  fellowship  of  the  former.  Moreover,  these  urinary 
affections  very  often  aid  materially  in  producing  death,  and,  not  unfrequently, 
are  the  chief  or  even  the  sole  proximate  cause  of  a  fatal  issue,  in  such  cases. 
These  disorders,  therefore,  possess  a  degree  of  importance  which  is  scarcely 
inferior  to  that  of  the  neuropathic  lesions  of  the  integuments  which  have  just 
been  discussed ;  and  they  likewise  should  be  attentively  considered  in  this 

place.  . 

The  urinary  affections  that  result  from  lesions  of  the  spinal  marrow  are 
quite  diversified,  but  may  all  be  embraced  and  arranged  under  the  following 
heads :  (1)  Paralysis  of  the  bladder ;  (2)  Alterations  of  the  urinary  secretion  ; 
(3)  Inflammation  of  the  kidneys,  of  the  ureters,  and  of  the  bladder. 

Paralysis  of  the  Bladder. — Inasmuch  as  the  muscular  apparatus  belong- 
ing to  the  urinary  bladder  consists  of  two  distinct  parts,  namely,  (1)  that  which 
is  employed  to  retain  the  urine  in  the  organ,  consisting  of  the  sphincter 
vesicce  muscle,  and  (2)  that  which  is  used  to  expel  the  urinary  secretion  from 
the  organ,  consisting  of  the  detrusor  iirincB  muscle ;  and,  inasmuch  as  each 
of  these  muscles  has  a  distinct  reflex  motor  centre  in  the  spinal  cord,  upon 
which  its  action  or  inaction  depends,  there  are  two  distinct  forms  of  vesical 
paralysis,  one  of  which  is  manifested  by  retention,  and  the  other  by  inconti- 
nence of  urine. 

The  reflex  motor  centre  of  the  detrusor  urinse,  according  to  Dr.  Bramwell,* 
is  situated  in  the  segments  of  the  spinal  cord  which  correspond  to  the  3d, 
4th,  and  5th  sacral  nerves,  and  the  normally  contracted  state  of  the  sphincter 
vesicJB  is  due  to  the  action  of  a  tonic  centre  which  is  situated  in  the  segments 
of  the  cord  corresponding  to  the  2d,  3d,  and  4th  sacral  nerves.  The  reflex 
motor  centres  of  these  muscles  are  not  only  quite  distinct  in  the  anatomical 
sense,  but  they  are  likewise  completely  antagonistic  in  their  motor  action. 
The  mechanism  of  normal  micturition,  then,  appears  to  be  as  follows: 
1.  When  the  bladder  becomes  full  enough,  the  sensory  nerve-flilaments  in  its 

1  Ibid.,  p.  453. 

«  Diseases  of  the  Spinal  Cord,  pp.  117-119.    New  York.  1882. 


DISORDERS  OF  THE  URINARY  ORGANS. 


437 


mucous  membrane  are  stimulated,  and  an  impression  is  conveyed  along  the 
sensory  nerves  to  the  reflex  centres  for  the  detrusor  and  sphincter  muscles  in 
the  spinal  cord,  and  to  the  sensorium.  2.  As  a  result  of  the  sensory  impres- 
sion conveyed  to  the  brain,  the  desire  to  urinate  is  experienced.  3.  As  a 
result  of  the  imi)ulse  carried  to  the  reflex  motor  centres  in  the  spinal  cord, 
the  action  of  the  detrusor  centre  is  excited,  while  the  action  of  the  sphincter 
centre  is  inhibited.  If  the  circumstances  for  urination  be  favorable,  an 
impulse  is  sent  from  the  brain  by  the  will  to  the  tonic  centre  for  the 
sphincter,  inhibiting  its  action,  and  causing  the  sphincter  muscle  to  relax ; 
also  to  the  centre  for  the  detrusor  urinai,  strengthening  the  excitation  of 
that  muscle  to  contract,  whi(;h  has  already  been  aroused  by  the  reflex  impulse 
from  the  bladder.  In  health,  all  these  processes  are  simultaneously  accom- 
plished, and  the  result  is  micturition.  When,  however,  the  circumstances 
are  not  convenient  for  performing  the  act,  it  can  be  delayed  or  prevented 
(a)  by  voluntarily  inhibiting  the  motor  centre  for  the  detrusor  urin^e ;  (b)  by 
causing  the  urethral  muscles  at  the  neck  of  the  bladder  to  contract,  likewise 
by  an  eftbrt  of  the  wi]l ;  and,  (c)  possibly,  by  strengthening  the  tonic  centre 
for  the  sphincter  vesicae,  in  the  same  manner,  and  at  the  same  time.  (Bram- 
well.)  Thus  it  will  be  perceived  that  three  distinct  sets  of  nerves  are  always 
concerned  in  the  act  of  voluntary  micturition,  namely- ,  (1)  a  set  by  which 
the  detrusor  urin?e  muscle  is  automatically  operated ;  (2)  a  set  by  which  the 
sphincter  vesicfe  is  also  operated  automatically  ;  and  (3)  the  conducting  fibres 
of  the  spinal  cord  through  which  the  sentient  being  is  enabled  to  perceive 
the  need  of  micturating,  and  to  send  the  mandate  of  the  will  down  to  mic- 
turate at  once  or  to  postpone  the  act,  as  circumstan(;es  may  determine. 
Moreover,  these  physiological  data  can  all  be  usefully  employed  in  diagnos- 
ticating the  injuries  and  diseases  of  the  spinal  cord  and  spinal  column. 

There  are  two  forms  of  retention  of  urine  which  arise  from  lesions  of  the 
spinal  cord.  In  one  of  them,  the  conducting  paths  in  the  cord  alone  are  at 
fault,  for  the  reflex  motor  centres  which  determine  the  action  of  the  vesical 
muscles  are  not  afl^ected.  In  such  a  case,  the  patient  cannot  micturate  volun- 
tarily, because  the  mandates  of  the  will  are  not  conveyed  by  the  conducting 
fibres  of  the  cord  down  to  the  motor  centres  for  the  vesical  muscles.  In  such 
a  case,  too,  the  bladder  will  continue  to  eiTipty  itself  automatically  from  time 
to  time ;  that  is,  as  soon  as  the  quantity  of  urine  collected  in  the  viscus 
becomes  suflficient  to  excite  reflex  contraction  of  the  detrusor  urinre  muscle, 
Avitli  inhibition  of  the  sphincter  muscle's  tonic  centre,  evacuation  of  the 
viscus  ensues.  Examples  of  this  form  of  urinaiy  retention  are  not  unfre- 
quently  afl:brded  by  lesions  of  the  spinal  coixl  occurring  in  the  cervical  or 
dorsal  regions,  when  the  nerve-injury  is  restricted  to  the  site  of  the  lesions 
themselves,  and  when,  consequently,  the  reflex  motor  centres  for  the  vesical 
muscles  are  unaflected.  In  such  cases,  the  act  of  urination  usually  occurs 
without  the  patient's  knowledge,  as  well  as  Avithout  his  consent.  In  the 
other  form  of  urinary  retention,  the  difficulty  arises  from  the  fact  that  the 
reflex  motor  centre  for  the  detrusor  urinse  has  ceased  to  act,  while  the  tonic 
centre  for  the  sphincter  still  continues  to  work,  that  is,  from  the  fact  that  the 
detrusor  muscle  is  paralyzed  while  the  sphincter  is  not  paralyzed.  In  exam- 
ples of  the  first-mentioned  form  of  urinaiy  retention,  catheterization  may  be 
unnecessary,  and  it  is  perhaps  from  his  experience  with  this  class  of  cases  that 
Mr.  Hutchinson^  has  been  led  to  think  that  catheterization  is  unnecessary  in 
all  cases  of  spinal  injury  above  the  loins,  unless  vesical  hypereesthesia  be  also 
present.  In  the  other  form  of  urinary  retention,  however,  that  in  which  the 
detrusor  muscle  is  paralyzed  wdiile  the  sphincter  continues  in  a  state  of  tonic 


1  London  Hospital  Reports,  vol.  iii.  1866. 


438 


INJURIES  OF  THE  BACK. 


contraction,  catheterization  performed  at  suitable  intervals  is  always  neces- 
sary, and  must  never  be  neglected  ;  in  fact,  the  operation  is  indispensable  in 
such  cases,  for,  if  it  be  not  performed,  the  urinary  secretion  will  continue  to 
accumulate  in  the  viscus,  until  it  becomes  distended  even  to  the  point  of 
bursting.  I  have  myself  seen  more  than  one  case,  in  civil  as  well  as  in 
military  practice,  of  vesical  paralysis  arising  from  spinal  injury,  in  which, 
from  want  of  catheterization,  the  bladder  became  so  much  distended  as  to 
cause  a  notable  tumefaction,  discernible  on  external  examination,  and  in 
which,  on  introducing  a  flexible  instrument,  a  great  quantity  of  urine,  an 
ordinary  chamber  utensil  more  than  half  full,  or  considerably  more  than 
half  a  gallon,  was  withdrawn,  and  that,  too,  when  there  were  no  signs  of 
urinary  overflow  present.  Inasmuch  as  these  two  forms  of  urinary  retention 
are  clinically  distinguishable  from  each  other  ou]y  by  experimentally  ascer- 
taining whether  reflex  motor  action  can  be  excited  in  the  detrusor  muscle, 
the  safest  course  for  the  surgeon  to  pursue,  in  both  forms,  is  to  draw  off  the 
w^ater  at  suitable  intervals  with  a  perfectly  clean,  flexible  instrument. 

Incontinence  of  urine,  when  it  results  directly  from  injury  or  disease  of  the 
spinal  cord,  is  always  due  to  paralysis  of  the  sphincter  muscle,  that  is,  to 
functional  inactivity  or  destruction  of  the  tonic  centre  in  the  cord  upon  which 
the  contraction  of  its  tibres,  and  the  closure  of  the  urethral  orifice  of  the 
bladder,  entirely  depend.  Paralysis  of  the  sphincter  vesicae  arising  from 
destruction  of  its  reflex  centre,  is  almost  invariably  associated  with  paralysis 
of  the  detrusor  urinse,  because  its  reflex  centre  is  also  destroyed.  These  reflex 
centres  may  be  directly  destroyed  by  injuries,  e.  g.,  by  fractures  or  disloca- 
tions of  the  lumbar  vertebrse,  or  by  hemorrhage  into  or  inflammation  of  the 
cord-substance.  But,  as  already  intimated,  paralysis  of  the  sphincter  vesicae 
is  very  rare  per  se.  It  is  nearly  always  accom^^anied  by  paralysis  of  the  de- 
trusor muscle,  and  by  paralysis  of  the  rectum. 

Interruptions  of  the  conducting  parts  to  and  from  the  brain,  in  the  spinal 
cord  above  the  reflex  centres  for  the  vesical  muscles,  are  of  frequent  occur- 
rence in  spinal  injuries.  When  the  lesion  of  the  cord  is  suddenly  produced^ 
it  may  be  accompanied  by  a  concussion  of  the  cord  which  temporarily  arrests 
the  reflex  motor  functions  of  all  the  segments  situated  below  the  lesion^ 
including  of  course  the  urinary  centres.  In  chronic  cases,  the  eftect  of  the 
rachidian  lesion  varies  with  its  position  and  extent.  When  the  sensory  con- 
ductors or  sensory  perceptive  centres  only  are  affected,  the  desire  to  urinate 
is  not  perceived  ;  the  reflex  arc  is  uninjured,  and,  as  soon  as  the  bladder  be- 
comes sufficiently  distended  with  urine,  it  is  unconsciously  evacuated.  It, 
therefore,  should  be  remembered  that  the  involuntary  discharge  of  urine  and 
feces,  in  cases  of  paraplegia  or  coma,  does  not  necessarily  imply  any  paralysis 
of  the  bladder  or  rectum. 

When  the  motor  and  inhibitory  conducting  fibres  of  the  cord  alone  are 
interrupted^  the  desire  to  urinate  is  perceived,  but  the  act  itself  takes  place 
quite  independently  of  volition.  It  can  neither  be  assisted  nor  deferred  by 
any  effort  of  the  will  in  such  cases. 

Concussion  of  the  spinal  cord,  especially  when  the  lower  part  of  it  alone  is 
affected,  may  be  attended  by  paralysis  of  the  detrusor  muscle,  indicated  by 
retention  of  urine,  when  no  other  portion  of  the  muscular  system  appears  to 
be  paralyzed. 

Concussion  of  the  spinal  cord,  when  severe  enough  to  produce  paraplegia 
(that  is,  both  voluntary-motor  and  sensory  paralysis  in  the  lower  part  of  the 
body),  may  also  suppress  for  a  time  the  reflex  motor  functions  of  the  urinary 
centres,  as  well  as  the  conducting  functions  of  the  rachidian  fibres ;  and  then 
paralysis  of  the  sphincter  muscle,  with  incontinence  of  urine,  will  also  be 
present. 


DISORDERS  OF  THE  URINARY  ORGANS. 


439 


Congestion  of  the  spinal  cord  coming  on  some  days,  it  may  be,  after  falls 
or  blows  upon  the  lower  part  of  the  spinal  column,  sometimes  causes  paralysis 
of  the  detrusor  muscle,  with  retention  of  urine,  when  no  such  paralysis  fol- 
lowed the  injury. 

Myelitis  causes  incontinence  of  urine  because  it  destroys  the  tonic  centre 
for  the  sphincter  vesic8e,  and  thus  paralyzes  that  muscle,  as  well  as  the 
sphincter  ani,  etc. 

Alterations  of  the  urinary  secretion  very  often  arise  from  injuries  and 
diseases  of  the  spinal  cord.  Briefly  stated,  these  alterations  consist  of  alka- 
linity, which  is  often  excessive ;  of  the  presence  of  an  abnormally  great  quan- 
tity of  the  phosphates ;  and  of  the  existence,  in  the  urine,  of  blood,  pus,  and 
mucus.  Occasionally  the  urinary  secretion  is  entirely  suppressed  in  such  in- 
stances. 

It  has  long  been  noticed  by  surgeons  that,  after  fractures  of  the  vertebral 
column  with  consecutive  lesions  of  the  spinal  cord,  the  composition  of  the 
urine  very  frequently  and  very  rapidly  becomes  altered.  In  almost  all  cases 
of  traumatic  myelitis,  it  soon  presents  a  remarkable  alkalinity.  I  have  also 
reported  two  cases  of  sphial  injury  with  marked  displacement  between  the 
fifth  and  seventh  cervical  vertebrae,  and  paraplegia,  in  which  it  was  observed 
on  the  second  day  after  the  accident  that  the  urine  when  withdrawn  by 
catheterization  had  a  strongly  ammoniacal  odor,  that  is,  was  strongly  alkaline, 
although  that  operation  had  been  thoroughly  performed  as  often  as  needful 
ever  since  the  accidents.  A  great  many  cases  have  likewise  been  mentioned 
in  the  foregoing  pages,  in  which,  soon  after  the  reception  of  spinal  injuries,  the 
urinary  secretion  was  found  to  be  alkaline  instead  of  acid.  Sir  B.  C.  Brodie* 
especially  called  attention  to  the  characteristics  presented  by  the  urine  in  the 
case^of  persons  stricken  with  traumatic  paraplegia.  He  observed  the  urine 
to  be  alkaline,  and  to  exhale  a  fetid,  ammoniacal  odor  at  the  moment  of  emis- 
sion, on  the  second,  on  the  third,  and  on  the  eighth  day.  Soon  afterward, 
this  secretion  contained  blood-clots,  muco-purulent  matter,  and  deposits  of 
aramoniaco-magnesian  phosphates.  It  would  be  easy  to  collect  from  authors 
of  repute  a  very  great  number  of  analogous  cases.  I  shall  mention  but  tw^o 
additional  observations. 

Dupuytren  pointed  out  tliat,  in  cases  of  spinal  fracture  with  lesion  of  the  cord,  the 
catheter  when  allowed  to  remain  in  order  to  guard  against  retention  quickly  became 
coated  with  a  calcareous  incrustation. 

Mr.  Shaw 'relates  the  case  of  a  young  man  who  had  fracture  of  a  dorsal  vertebra  and 
complete  paraplegia,  caused  by  falling  from  a  tree.  Extensive  sloughs  formed  on  the 
hates,  but  they  healed,  and  he  appeared  to  be  recovering  with  paralysis,  after  surviving 
eight  months.  During  most  of  this  time  his  water  flowed  continuously  into  a  urinal, 
and  the  catheter  was  not  used.  Eventually,  however,  his  urine  became  turbid  and 
fetid  ;  and  he  died  with  symptoms  of  aggravated  disease  of  the  bladder.  The  autopsy 
revealed  a  discolored  and  shreddy  state  of  the  vesical  mucous  membrane,  with  five 
phosphatic  calculi  as  large  as  pigeons'  eggs,  and  coated  with  mucus,  in  the  bladder; 
also  phosphatic  calculi  were  found  impacted  in  the  calices,  and  lying  loose  in  the  pelvis, 
of  each  kidney. 

The  alkaline  and  phosphatic  characters  of  the  urine  are  met  with  in  lesions 
of  the  spinal  cord  so  constantly,  that  their  presence  must  be  mainly  due  to 
the  operation  of  some  single  cause  which  acts  efficiently  in  nearly  all  the 
cases.  Some  hold  that  this  condition  of  the  urine  is  cau^ied  principally  by 
the  introduction  of  septic  matters  from  without  into  the  bladder.    But  this 

^     *  Medico-Chirurgical  Transactions,  1S36,  p.  148. 
2  Holmes's  System  of  Surgery,  vol.  ii.  p.  401,  2d  ed. 


440 


INJURIES  OF  THE  BACK. 


explanation  utterly  fails  to  account  for  a  numerous  class  of  cases  in  which  no 
catheters  excepting  those  perfectly  free  from  septic  matters  are  employed,  or 
in  which  the  urine  is  found  to  be  ammoniacal  and  phosphatic  on  the  very 
first  occasion  that  the  catheter  is  introduced,  or  in  which  catheterization  is 
not  employed  at  all  from  first  to  last,  and  still  the  urine  is  ammoniacal  and 
phosphatic.  Moreover,  the  use  of  catheters,  and  bougies,  and  sounds  is  a 
common  thing  in  the  practice  of  surgery,  and  yet  no  such  effects  appear  in 
any  other  class  of  cases.  I  have  no  doubt  that  these  effects  mainly  arise 
from  neurotrophic  or  neuropathic  disturbance  of  the  kidneys  and  bladder, 
as  was  originally  pointed  out  by  M.  Brown-Sequard.  The  sanguinolent 
or  muco-purulent  qualities  of  the  urine,  in  such  cases,  result  directly  from 
congestion  or  inflammation  of  the  kidneys  and  bladder.  I  have  also  seen 
some  cases  belonging  to  this  category  in  which  the  quantity  of  the  urinary 
secretion  was  much  increased  above  the  normal. 

Finally,  excess  of  phosphates  occurs  in  many  cases  of  cord-disease,  inde- 
pendently of  bladder-paralysis  (as  is  generally  known  and  admitted);  I,  there- 
fore, claim  that  the  neutral  or  alkaline  condition  of  the  urinary  secretion, 
with  its  remarkable  proneness  to  speedily  decompose,  which  is  often  witnessed 
in  the  same,  as  well  as  in  analogous  cases,  also  occurs  independently  of 
bladder-paralysis,  and,  like  the  former,  results  from  the  rachidian  lesion,  in 
consequence  of  the  disturbance  it  effects  in  the  working  of  the  kidneys.  In 
this  way  alone  can  be  satisfactorily  explained  the  strongly  ammoniacal  odor 
perceived  at  the  moment  of  emission,  in  urine  that  contains  neither  mucus 
nor  pus,  which  I  have  observed  in  at  least  one  instance  of  traumatic  para- 
plegia arising  from  displacement  of  the  lower  cervical  vertebrae,  in  less  than 
thirty  hours  after  the  accident,  when  the  subject  (a  man)  was  previously  in 
perfect  health,  and  when  it  was  not  possible  for  the  kidneys  or  bladder  to 
have  sustained  any  direct  injury.  The  urinary  secretion  became  abnormal  in 
this  case,  in  consequence  of  the  morbid  excitation  of  the  spinal  cord  which 
was  produced  by  the  injury. 

Inflammation  of  the  Urinary  Organs. — As  we  have  seen  that  important 
alterations  of  the  urinary  secretion  very  often  result  from  injuries  and  diseases 
of  the  spinal  cord,  and  as  we  have  found  that  acute  bed-sores  and  other  neuro- 
pathic sphacelations  of  the  integuments  not  unfrequently  arise  from  the  same 
causes,  so  also  we  shall  find  that  inflammation  of  the  kidneys,  and  of  the 
ureters,  and  of  the  bladder,  or  rather  of  the  mucous  membrane  which  lines 
these  organs,  often  has  an  identical  origin. 

This  foi*m  of  renal  and  vesical  inflammation  is  a  very  important  disorder, 
because  (1)  it  gives  much  trouble  to  patients  and  their  attendants,  and  (2)  it 
very  often  proves  fatal ;  for,  as  Mr.  Bryant  justly  remarks,  when  death 
occurs  as  a  result  of  injury  to  the  dorsal  region  of  the  spine,  suppuration  of 
the  kidneys,  cystitis,  and  bed-sores,  are  the  most  common  proximate  causes 
thereof  ^ 

M.  Brown-Sequard  first  called  attention  to  the  neuropathic  origin  of  this 
highly  destructive  form  of  renal  and  vesical  inflammation.  In  1858,  he 
said  : — 

"Another  morbid  change  due  to  a  mechanical  excitation  of  the  spinal  cord  may 
cause  death  after  a  fracture  of  the  spine  ;  it  is  the  alteration  which  takes  place  in  the 
kidneys  [and  bladder],  an  alteration  sometimes  amounting  to  a  real  inflammation.  We 
hardly  need  to  say  that  the  changes  in  the  urinary  secretion,  owing  or  not  to  an  inflam- 
mation of  the  kidneys,  also  the  hoematuria,  and  the  alterations  in  the  mucous  membrane 
of  the  bladder,  in  cases  of  fracture  of  the  spine,  are  morbid  phenomena  depending  upon 


>  Op.  cit.,  p.  202. 


DISORDERS  OF  THE  URINARY  ORGANS. 


441 


an  irritation  of  the  spinal  cord,  and  not  upon  a  paralysis  due  to  a  division  of  the  cord. 
For  on  the  one  hand,  a  [mere]  section  of  the  cord  is  never  followed  by  these  alterations 
in  the  kidneys  or  the  bladder ;  and,  on  the  other  hand,  we  often  observe  these  altera- 
tions too  quickly  after  the  spine  has  been  fractured,  to  admit  that  they  are  due  to  a 
paralysis."^ 

In  the  same  lecture  he  also  said: — 

"  The  influence  of  a  mechanical  excitation  of  the  spinal  cord  by  a  piece  of  broken 
bone  [or  of  a  pathological  excitation  of  the  cord  by  an  inflammatory  process],  deserves 
the  full  attention  of  the  physiologist  and  the  practitioner.  Among  the  alterations  of 
nutrition,  ...  in  cases  of  that  kind,  we  will  particularly  notice  the  sloughs  on  the 
sacrum,  and  the  various  morbid  changes  that  take  place  in  the  bladder  and  in  the 
urinary  secretion.  These  alterations  in  nutrition  and  secretion  are  certainly  frequent 
causes  of  death  after  fractures  of  the  spine.  Therefore,  it  is  of  the  greatest  importance 
to  find  out  the  mode  of  production  of  these  morbid  changes,  and  to  try  to  prevent  or  to 
cure  them."^ 

The  mode  of  causation^  as  well  as  the  2'>^^^^^omena  of  the  renal  and  vesical 
inflammations  which  result  from  lesions  of  the  spinal  cord,  can  be  most  briefly, 
as  well  as  clearly  set  forth,  by  presenting  a  few  examples  ;  and  a  very^  instruc- 
tive one  has  already  been  mentioned  on  page  343 : — 

A  young  infantry  soldier,  aged  19,  fractured  his  fifth  cervical  vertebra,  without  dis- 
})lacement,  while  bathing  in  the  Arkansas  River,  by  diving  headforemost  into  shallow 
water,  and  immediately  became  paraplegic  from  concussion  of  the  spinal  cord.  Intra- 
thecal extravasation  of  blood  ensued,  and,  on  the  following  day,  the  cord  showed  signs  of 
compression  arising  from  this  cause.  But  absorption  of  the  extra vasated  blood  occurred, 
the  symptoms  of  paraplegia  gradually  passed  away,  and  in  eight  days  he  became  able 
to  pass  his  urine  without  a  catheter.  He  continued  to  improve  during  the  next  four  or 
five  days,  until  traumatic  spinal  meningitis  rather  suddenly  supervened,  its  invasion 
being  marked  by  chills  and  by  a  rise  in  the  body-heat.  Myelitis  followed.  In  two  or 
tiiree  days  alterations  in  the  urinary  secretions  began  to  appear.  I  will  now  quote  the 
words  of  the  oflicial  report :  "  On  the  morning  of  the  18th,  the  urine  became  turoij." 
"  By  the  morning  of  the  20th,  the  pulse  had  become  so  frequent  that  it  could  not  be 
counted,  the  bowels  were  loose,  the  urine  was  ammoniacal  and  thick  with  mucus."  ''A 
very  high  temperature  (105°)  followed.  The  patient  at  this  time  was  still  able  to  pass  his 
urine  without  a  catheter;  but  [haematuria  supervened  and],  on  the  21st,  this  instrument 
was  used  with  difliculty,  owing  to  the  formation  of  clots  in  the  bladder.  The  patient 
also  suffered  from  decubitus  [bed-sores],  and,  by  the  24th,  his  stomach  became  so  irri- 
table as  to  retain  scarcely  anything.  On  the  day  following  his  appetite  was  entirely 
gone.  On  the  26th  the  temperature  was  91.8°.  He  died  at  noon  on  the  28th," 
t-v\'enty-five  days  after  the  accident,  and  ten  or  twelve  days  after  his  urine  first  began  to 
be  abnormal.  The  autopsy  revealed  the  following  urinary  lesions  :  "  The  kidneys  were 
enlarged  and  gorged  with  blood  ;  the  pelvis  of  the  left  being  filled  with  pus."  "  The 
ureters  were  very  dark,  and  one  of  them  contained  a  clot  at  the  entrance  of  the  bladder. 
The  walls  of  the  bladder  were  of  a  dark-purple  color,  inflamed,  and  thickened ;  the 
raucous  membrane  being  absent  in  patches."^ 

The  urinary  lesion.s  in  this  case  did  not  arise  from  injury  (traumatism)  of 
the  kidneys  or  bladder,  for  the  urinary  discharge  did  not  present  any  morbid 
appearances  until  a  fortnight  after  the  accident ;  they  were  not  due  to  par- 
alysis of  the  bladder,  for  the  urinary  paralysis  had  disappeared,  and  the  man 
had  passed  his  water  at  will  for  a  week  before  it  presented  any  abnormal 
change ;  they  were  not  caused  by  the  introduction  of  septic  matters  from 
without,  because  catheterization  had  been  discontinued  for  a  week  before  "  the 
urine  became  turbid,"  and  was  not  again  resorted  to  until  three  daj^s  after- 
ward, when  liBematuria  had  occurred,  and  the  urethral  outlet  of  the  bladder 


1  Op.  cit.,  p.  249.  2  Ibid.,  p.  248. 

3  Circular  No.  3,  S.  G.  0.,  August  17,  1871,  pp.  129-131. 


442 


INJURIES  OF  THE  BACK. 


had  become  choked  with  coagiila.  There"  remains,  then,  no  appreciable  or 
perceptible  cause  whatever  for  the  remarkably  inflamed  state  of  the  kidneys, 
ureters,  and  bladder,  which  the  autopsy  revealed  in  this  case,  excepting  the 
excitation  of  the  spinal  cord  by  the  secondary  meningitis  and  myelitis,  which 
had  supervened  two  or  three  days  before  the  urinary  secretion  became  tur- 
bid." Thus,  it  is  shown  that  the  urinary  lesions  in  this  case  had  a  neuro- 
pathic source.  Moreover,  an  acute  bed-sore — that  is,  a  neuropathic  eschar — 
presented  itself,  at  the  same  time,  over  the  sacrum,  in  this  patient;  this  cir- 
cumstance also  affords  presumptive  evidence  that  the  urinary  lesions  had  a 
similar  origin. 

The  urinary  lesions  appear  to  have  been  the  chief  proximate  cause  of  this 
patient's  death,  which  occurred  about  ten  days  after  the  signs  of  these  lesions 
first  became  visible.  This  neuropathic  nephritis  and  cystitis,  etc.,  therefore,' 
ran  a  remarkably  rapid  course,  and  quickly  proved  fatal.  The  symptoms 
presented  themselves  in  the  following  order :  On  the  first  day,  it  w^as  observed 
that  the  urinary  discharge  was  "turbid no  doubt  it  was  also  ammoniacal. 
Two  days  afterward,  it  was  remarked  that  the  urinary  discharge  w^as  highly 
"ammoniacal  and  thick  with  mucus,"  that  the  "bowels  were  loose,"  and  that 
2;reat  prostration  ^vith  "a  very  high  temperature  (105°)"  was  also  present. 
After  still  another  day,  hsematuria  supervened,  and  the  urethral  outlet  of  the 
bladder  becoming  plugged  with  clotted  blood,  it  was  necessary  to  introduce  a 
catheter.  On  the  same  day  it  was  noted  in  the  clinical  history  that  the  patient 
was  also  suflering  from  bed-sores.  In  three  days  more  there  was  extreme 
anorexia,  wdth  very  great  gastric  irritability ;  and  in  four  days  after  that 
death  ensued.  This  peracute  inflammation  of  the  urinary  organs  wa^ought 
the  following  structural  changes :  The  kidneys  were  intensely  hypersemic, 
and  therefore  enlarged,  while  the  pelvis  of  the  left  one  was  filled  wdth  puru- 
lent matter.  The  coats  of  the  bladder  were  intensely  inflamed,  dark-purple 
in  color,  and  thickened ;  its  mucous  membrane  had  also  sloughed  off  in  patches. 
The  ureters,  likewise,  were  very  dark  in  color  and  intensely  inflamed.  In 
consequence  of  these  structural  changes,  the  urinary  secretion  speedily  became 
loaded  with  muco-purulent  matter  and  blood.  The  hsematuria  which  occurred 
during  life  w^as  obviously  caused  by  the  rupture  of  the  over-distended  blood- 
vessels of  the  kidneys,  etc.  No  wonder,  then,  that  general  prostration  of  an 
extreme  character  should  rapidly  come  on  in  such  a  case  of  renal  and  cystic 
inflammation,  and  that  death  should  speedily  ensue. 

Another  hio-hly  instructive  example  of  neuropathic  inflammation  of  the 
kidneys,  ureters,  and  bladder,  has  likewise  been  mentioned  in  these  pages 
already  (p.  414) ;  but  it  is  well  worth  further  study,  and  I  shall  therefore 
speak  of  it  again.    It  was  originally  recorded  by  .  Sir  W.  Gull : — 

A  man,  aged  25,  contracted  acute  myelitis  of  the  dorsal  region  in  consequence  of 
straining  his  back  in  lifting  a  heavy  weight.  No  bones  nor  Hgaments,  however,  were 
injured.''  On  the  morning  of  the  second  day  after  the  accident  he  found  himself  para- 
plegic on  walking,  in  consequence  of  the  rachidian  inflammation.  On  the  fourth  day 
after  the  injury^'he  was  admitted  into  Guy's  Hospital.  There  was  already  complete 
[)araplegia,  together  with  a  sacral  eschar ;  and  ammoniacal  urine  constantly  dribbled 
from  liir  paralyzed  bladder.  Forty-one  days  after  the  accident,  or  thirty-seven  days  after 
entering  the  hospital,  he  died.  At  the  autopsy,  commencing  suppuration  in  the  cortical 
substance  of  the  kidneys  was  noted.  The  mucous  membrane  of  their  pelves  was  green- 
ish in  color,  with  patches  of  greenish-colored  fibrinous  exudation  thereon.  The  mucous 
membrane  of  the  ureters  and  bladder  was  in  tlie  same  condition.  The  bladder  con- 
tained  a  quantity  of  muco-purulent  fluid.  The  substance  of  the  spinal  cord  was  changed 
into  a  tliick,  greenish,  muco-puriform  liquid  throughout  its  entire  thickness,  opposite  the 
fifth  and  sixth  dorsal  vertebrae,  while  the  cervical  and  lumbar  portions  of  the  cord  were 
unchanged. 


DISORDERS  OF  THE  URINARY  ORGANS. 


443 


Is  there  any  room  for  doubt  in  regard  to  the  etiology  of  the  renal  and  vesi- 
cal inflammation  which  the  autopsy  revealed  in  this  case-''  Can  the  origin  of 
this  inflammation  be  assigned  with  propriety  to  any  cause,  excepting  the 
extremely  w^ell-marked  myelitis,  and  the  morbid  excitation  of  the  spinal 
cord  which  it  occasioned?  It  cannot  be  ascribed  to  the  introduction  of 
septic  matters  from  without,  because  there  is  no  evidence  nor  probability 
that  a  catheter  was  ever  used  in  this  case ;  and  it  does  not  appear  that 
any  necessity  ever  existed  for  using  a  catheter  on  this  man,  inasmuch  as 
his  urine  is  known  to  have  been  discharged  by  dribbling  (from  paralysis  of 
the  sphincter  vesicae)  almost  from  the  outset,  and  probably  was  discharged  in 
this  manner  from  the  very  outset  of  the  case.  Moreover,  an  acute  bed-sore  of 
large  size  presented  itself  in  the  sacro-gluteal  region,  and  this,  together  with 
the  urinary  lesions,  destroyed  the  man's  life ;  and,  as  the  sacral  eschar  had  a 
neuropathic  origin,  even  so  the  urinary  lesions  had  the  same  origin. 

Although  the  inflammatory  process  in  the  urinary  organs  was  much  less 
acute  in  this  than  it  was  in  the  preceding  example,  the  textural  changes 
produced  by  it,  and  revealed  by  the  autopsy,  were  quite  well  marked.  Tliey 
were  as  follows :  Suppuration  in  the  cortical  portion  of  the  kidneys ;  in- 
flammatory discoloration,  and,  no  doubt,  thickening  of  the  mucous  mem- 
brane lining  the  renal  pelves,  the  ureters,  and  the  bladder;  also  greenish- 
colored  flbrinous  exudation  collected  in  patches  on  every  part  of  this  mem- 
brane. The  greenish  hue  of  the  exudation,  as  well  as  of  the  inflamed  mucous 
membrane  itself,  was  due  to  staining  with  the  red  corpuscles  of  the  blood ; 
hiematuria  had  doubtless  supervened  some  time  before  death.  Finally,  the 
urinary  bladder  contained  a  quantity  of  muco-purulent  liquid,  the  muco-puru- 
lent  elements  of  wdiich  had  been  produced  by  the  inflammatory  process. 

Many  other  examples  belonging  to  the  same  category  have  been  presented 
in  the  foregoing  pages.  Should,  how^ever,  additional  evidence  be  required  in 
regard  to  the  etiology  of  the  urinary  disorders  under  consideration,  it  may 
readily  be  found  in  M.  Charcot's  Lectures,  already  so  often  quoted:  evidence 
Avhich,  although  weighty  and  convincing,  cannot  be  reproduced  here  for  want 
of  room. 

To  briefly  summarize  the  symptoms  which  usually  attend  the  neuropathic 
inflammations  of  the  urinary  organs  that  very  frequently  supervene  in  cases 
of  spinal  injury:  Soon  after  the  accident,  that  is,  w^ithin  a  period  beginning 
on  the  second,  and  ending  about  the  ninth  day  thereafter,  it  is  observed  that 
the  urine,  previously  acid  and  clear,  or  perfectly  normal,  suddenly  becomes 
alkaline,  and  exhales  a  pungent  ammoniacal  smell  at  the  moment  of 
emission.  Shortly  afterward,  it  is  noticed  that  the  urinary  discharge  has  a 
cloudy  and  turbid  look,  arising  from  the  admixture  of  mucus,  as"  well  as 
a  strongly  ammoniacal  odor.  The  quantity  of  this  mucus  gradually  in- 
creases until  the  urinary  discharge  becomes  ropy,  tenacious,  and  so  thick 
from  this  cause  that  it  even  adheres  to  the  bottom  of  the  vessel.  In  a  short 
time,  a  white  substance — the  phosphate  of  lime — is  found  mixed  with  the 
mucus.  Pus-corpuscles  and  blood-disks  also  present  themselves.  The  quan- 
tity of  the  former  may  be  so  great  as  to  cause  a  muco-purulent  appearance. 
Oftentimes,  the  blood-disks  present  themselves  in  such  large  number  as  to 
constitute  a  veritable  hemorrhage  from  the  urinary  organs,  technically  deno- 
minated hsematuria.  But  blood-disks  will  often  be  seen  with  a  microscope, 
when  to  the  unaided  eye  the  urinary  discharge  does  not  present  a  sanguino- 
lent  appearance.  In  the  chronic  cases,  and  near  the  end  of  most  of  the  fatal 
cases,  the  urinary  discharge  consists  apparently  of  a  muco-purulent  liquid, 
in  which,  how^ever,  blood-corpuscles  or  their  remains  are  almost  always 
found  by  microscopical  examination,  intermingled  with  pus-cells  and  renal 
and  vesical  epithelium,  that  is,  muco-pus,  with  vibriones  and  phosphates,  etc. 


444 


INJURIES  OF  THE  BACK. 


To  epitomize  the  anatomical  lesions  which  usually  accompany  the  neuro- 
pathic inflammations  of  the  urinary  organs  that  occur  in  cases  of  spinal 
injury :  They  are  hypersemia,  more  or  less  intense,  according  to  the  case, 
with  tumefaction  and  dark-red  or  purple  discoloration  of  the  mucous  mem- 
brane lining  the  kidneys,  the  ureters,  and  the  bladder ;  intense  hypersemia 
with  tumefaction  of  the  renal  parenchyma,  and  of  the  walls  of  the  ureters 
and  bladder ;  fibrinous  exudation  in  patches  on  the  mucous  membrane  lining 
these  organs ;  extravasated  blood  in  both  a  fluid  and  coagulated  state  in  the 
pelves  of  the  kidneys,  the  canals  of  the  ureters,  and  the  cavity  of  the  bladder; 
suppuration  of  the  secreting  portions  of  the  kidneys,  and  abscess  of  their 
pelves ;  inflammatory  thickening  of  the  coats  of  the  bladder  and  ureters, 
with  softening  and  erosions  of  their  lining  or  mucous  membrane.  In  such 
cases,  patches  of  the  mucous  membrane  are  apt  to  be  cast  oft'  as  sloughs,  and 
the  inflammatory  process,  being  violent,  generally  involves  also  or  extends  to 
the  other  tunics  of  the  bladder  and  ureters,  as  well  as  to  the  parenchyma  of 
the  kidneys :  As  a  rule,  the  inflammatory  process  in  such  cases  does  not 
•appear  to  start  in  the  bladder  and  spread  thence  into  tbe  kidneys,  nor  vice 
versa  ;  but  it  is  simultaneously  kindled  in  all  parts  of  the  mucous  membrane 
belonging  to  the  kidneys,  ureters,  and  bladder.  In  chronic  cases,  phosphatic 
calculi  fo'rm  in  the  kidneys,  as  well  as  in  the  bladder,  and  in  either  place  they 
may  set  up  fatal  irritation. 

Thus,  it  will  be  perceived  that  the  inflammatory  process  which  is  set  up 
in  the  mucous  membrane  of  the  urinary  organs  by  certain  morbid  excitations 
of  the  spinal  cord,  bears,  at  least  "  in  the  acute"  instances,  no  inconsiderable 
resemblance  to  the  necrotic  processes  w^hich  are  set  up  in  the  integuments  by 
the  operation  of  the  same  causes.  The  destructive  process  in  both  is  charac- 
terized by  intense,  dark-colored  hypereemia,  extravasation  of  blood  from  rup- 
tured capillaries,  and  sloughing  of  the  tissues  involved.  In  the  less  severe 
or  chronic  cases,  the  urinary  mucous  membrane  exhibits  pathological  changes 
quite  analogous  to  the  cutaneous  erythema  and  other  diffuse  phlogoses  of  the 
integuments  which  are  caused  by  similar  lesions  of  the  spinal  cord,  that  have 
been  described  above. 

Furthermore,  it  is  highly  probable  that  when  the  urinary  secretion  comes 
into  contact  with  the  inflamed  mucous  membrane  of  the  bladder,  ureters,  etc., 
it  suflfers  decomposition  in  consequence  of  such  contact,  just  as  happens  in 
ordinary  cystitis ;  by  which  decomposition  it  acquires  highly  irritating  pro- 
perties that  in  turn  may  react  upon  the  already  inflamed  mucous  membrane, 
and  augment  its  disorder.  The  urine  rots  wdiile  lying  in  the  bladder,  in  such 
cases,  not  because  the  walls  of  the  bladder  may  chance  to  be  paralyzed  at  the 
time,  as  Mr.  Shaw  and  others  have  vainly  asserted,  but  because  it  there 
becomes  tainted  with  the  products  of  the  inflammatory  process  which  is 
going  on  in  the  bladder,  the  ureters,  and  the  kidneys.  This  statement  is 
fully  borne  out  by  what  occurred  in  the  jperacute  example  just  novv  related— 
the  example  in  which  a  young  soldier  had  sustained  fracture  without  dis- 
placement of  the  fifth  cervical  vertebra  in  consequence  of  diving  headforemost 
into  shallow  water :  on  the  fifteenth  day  after  the  accident,  there  supervened 
a  neuropathic  inflammation  of  his  kidneys,  ureters,  and  bladder,  w^hich  caused 
death  in  ten  days,  although  he  had  been  able  to  pass  his  w^ater  at  will  for  a 
week  previously  (which  proves  that  the  bladder-paralysis  had  been  absent  for 
a  week),  and  although  it  was  not  necessary  to  use  a  catheter  on  him  again  until 
three  days  after  tlie  urinary  disorder  had  appeared,  and  then  the  instrument 
was  introduced,  not  Ijccause  the  bladder  was  paralyzed,  but  because  its  urethral 
orifice  was  choked  with  blood-clot  arising  from  hsematuria.  Moreover,  to 
say  that  in  such  a  case  the  rotting  urine  produced  an  inflammation  of  the 


TYMPANITES  ARISING  FROM  LESIONS  OF  THE  SPINAL  CORD. 


445 


bladder  which  subsequently  spread  to  the  kidneys,  would  be  to  blindly  put 
the  effect  in  the  place  of  the  cause,  and  perhaps  lead  to  erroneous  practice. 

Treatment — From  the  foregoing  account  of  the  urinary  lesions  that  result 
from  certain  morbid  excitations  of  the  spinal  cord,  it  is  obvious  that  any  plan 
of  treatment  which  does  not  fulfil  the  causal  indications — which  does  not  put 
to  rest  the  agencies  that  create  these  sad  lesions — cannot  do  much  good  in 
such  cases.  I  have  thus  patiently  and  thoroughly  inquired  into  the  etiology 
of  these  disorders  with  no  purpose  to  dig  up  and  exhibit  any  pathological 
curiosities ;  but,  rather,  in  doing  this  I  have  been^  moved  by  a  strong  desire 
to  devise,  if  possible,  some  plan  of  treatment  which  shall  prevent  and  per- 
haps even  cure  these  deplorable  lesions.  And,  inasmuch  as  they  generally 
arise  from  congestion  or  inflammation  of  the  spinal  cord,  or  of  its  mem- 
branes, or  are  greatly  augmented  by  these  affections  of  the  central  nervous 
system,  the  first  indication  to  be  fulfilled  in  treating  the  neuropathic  lesions 
of  the  urinary  organs,  is  to  subdue  the  central  nervous  afiections  upon  which 
their  existence  depends.  To  this  end  I  recommend  the  administration  per 
orera  of  fluid  extract  of  ergot,  of  potassium  iodide,  and  of  belladonna,  in 
the  doses  and  in  the  manner  already  laid  down  in  describing  the  treatment  of 
neuropathic  bed-sores  (page  434),  which,  it  is  not  necessary  to  repeat  in 
this  place.  All  other  means  of  fulfilling  the  causal  indications  which  are 
there  mentioned  should  be  employed  in  these  cases  also;  and  less  incon- 
venience w^ill  be  experienced  in  carrying  out  this  treatment  from  the  fact  that 
when  these  neuropathic  disorders  of  tbe  urinary  organs  make  their  appear- 
ance, neuropathic  bed-sores  almost  always  present  themselves  at  the  same 
time.  In  regard  to  the  results  of  this  plan  of  treatment,  I  find,  on  a  reperusal 
of  some  cases  in  which  it  was  advantageously  employed  for  bed-sores,  that  it 
proved  equally  useful  for  the  accompanying  urinary  lesions.  Belladonna 
plasters,  applied  over  the  kidneys,  may  do  good  in  all  such  cases. 

The  urine,  as  a  rule,  being  strongly  ammoniacal  and  therefore  very  pungent, 
should  not  be  allowed  to  stand  in  the  inflamed  bladder,  and  in  the  case  of  any 
paralytics  who  cannot  void  it  at  will,  or  from  whom  it  does  i)ot  flow  spon- 
taneously, it  should  be  withdrawn  by  catheterization  as  often  at  least  as  every 
four  or  six  hours  ;  but,  at  the  same  time,  every  precaution  must  be  taken,  by 
using  only  a  perfectly  clean  instrument,  etc.,  to  prevent  entirely  the  introduc- 
tion of  septic  matter  into  the  bladder. 

Hceriiatiiria  often  occurs  in  consequence  of  neuropathic  inflammation  of  the 
kidneys,  ureters,  and  bladder.  When  it  proves  dangerous  or  troublesome,  it 
should  be  treated  on  the  plan  already  prescribed  for  traumatic  hematuria 
(page  298  supra),  which  it  is  unnecessary  here  to  repeat.  It  will,  however, 
be  "necessary  to  break  down  and  wash  out  the  coagula  by  injecting  warm 
water  medicated  Avith  boracic  acid  through  a  large-sized  catheter,  more  fre- 
quently in  these  than  in  the  traumatic  cases. 

The  sloughs  fallijig  from  the  inflamed  mucous  membrane,  with  the  muco- 
purulent and  phosphatic,  or  mortar-like  matter  that  may  collect  in  the 
bladder  in  such  cases,  should  likewise  be  washed  out  by  injecting  warm 
water  impregnated  with  boracic  acid  through  a  double  catheter. 

Tympanites  arising  from  Lesions  of  the  Spinal  Cord. 

All  lesions  of  the  spinal  column  or  spinal  cord  that  cause  paraplegia,  niay 
be  attended  by  distension  of  the  abdomen  with  gaseous  substances  which 
are  generated  and  held  in  the  abdominal  portion  of  the  alimentary  canal, 
that  is,  in  the  stomach,  and  in  the  small,  as  well  as  in  the  large  intestines ; 
their  most  common  seat,  however,  being  the  arch  and  sigmoid  flexure  of  the 


446 


INJURIES  OF  THE  BACK. 


€olon.  In  such  cases,  the  distended  belly  is  tense  and  elastic ;  and,  on  per- 
cussion, it  sounds  like  a  huge  bladder  or  a  drum  filled  with  air.  This  kind 
of  abdominal  tumefaction  has  with  much  propriety  been  called  tympanites^ 
because,  when  struck,  it  sounds  like  a  drum.  The  intestinal  gases  accumulate 
within  the  digestive  tube  in  such  cases,  because  the  muscular  wall  of  the 
abdomen  and  the  muscular  coat  of  the  intestines,  being  paralyzed  in  conse- 
quence of  the  spinal  lesion,  are  no  longer  able  to  contract  and  thus  expel  them ; 
and  since,  through  loss  of  contractility,  the  abdominal  and  intestinal  muscles 
can  olFer  no  effective  resistance  to  the  accumulation  of  theee  gases,  it  often 
goes  on  until  the  abdominal  distension  becomes  enormous.  The  tympanites 
in  such  cases  is  symptomatic  of  the  spinal  lesion ;  and,  when  enormous  or 
even  very  considerable  in  degree,  it  is  usually  a  fatal  sign. 

But  tympanites  always  tends  in  &uch  cases  to  embarrass  the  patient's 
breathing  by  opposing  the  descent  of  the  diaphragm  during  the  inspiratory 
movement ;  and,  when  it  is  very  considerable,  it  causes  corresponding  dys- 
pnoea. It  is,  however,  in  those  cases  of  spinal  injury  where  the  paraplegia 
extends  up  to  the  root  of  the  neck — those  cases  wherein  the  respiratory  move- 
ments ar©  performed  by  the  diaphragm  alone,  and  where  consequently  the 
respiration  is  said  to  be  diaphragmatic  or  abdominal — it  is  in  such  cases  that 
tympanites  does  the  most  harm,  and  often  aids  with  no  inconsiderable  force 
in  shortening  life,  by  increasing  the  difficulty  of  breathing,  which  perhaps 
is  already  very  great.  Many  cases  have  been  mentioned  or  referred  to  above, 
in  which  this  very  thing  occurred.  But  probably  the  most  notable  example 
was  presented  on  page  410.  The  cas^  was  that  of  a  cavalry  soldier,  who  in 
a  brawl  received  a  shot- wound  of  the  neck,  which  fractured  the  spinous  pro- 
cess of  the  last  cervical  and  the  laminae  of  the  first  dorsal  vertebra,  opened 
the  spinal  canal,  ruptured  the  theca  vertebralis,  and  drove  several  small  frag- 
ments of  bone  into  the  substance  of  the  spinal  cord.  In  this  case,  "  the  par- 
alysis of  the  abdominal  and  intestinal  muscles  allowed  an  accumulation  of 
gases  to  take  place  within  the  intestines,  to  such  an  extent  as  greatly  to  aug- 
ment the  already  existing  difficulty  of  respiration.  It  was  found  expedient 
to  introduce  an  elastic  tube,  from  time  to  time,  through  which  the  gases 
found  vent,  when  pressure  was  made,  externally,  on  the  abdomen."^  Tym- 
panites, therefore,  not  unfrequently  constitutes  in  cases  of  spinal  injury  a 
complication  which  urgently  demands  the  surgeon's  attention. 

Treatment. — The  kind  of  tympanites  in  question  is  always  symptomatic 
of  some  affection  of  the  spinal  cord  which,  as  a  rule,  interrupts  its  reflex- 
motor,  as  well  as  its  conducting  functions.  The  nature  of  this  central  ner- 
vous affection  should  be  ascertained,  and,  if  possible,  the  disease  itself  should 
be  removed ;  which  can  often  be  done,  if  it  consist  in  concussion,  congestion, 
or  one  of  the  less  severe  types  of  inflammation  of  the  spinal  cord  or  its  mem- 
branes, by  carrying  out  the  corresponding  plans  of  treatment  which  have 
already  been  laid  down  in  these  pages. 

When  immediate  relief  from  the  tympanitic  distension  is  urgently  de- 
manded, it  has  been  proposed  by  some  surgeons  to  resort  to  the  operation  of 
paracentesis^  performed  on  the  descending  colon  with  a  long  narrow  trocar 
and  canula ;  but,  inasmuch  as  this  operation  is  never,  in  my  opinion,  justifi- 
able, I  shall  not  take  space  to  describe  the  steps  that  pertain  to  it.  The  best 
way  to  let  the  wind  out  in  such  cases  is  by  introducing  a  flexible  tube  of 
suitable  size  and  length,  through  the  anus  and  rectum  into  the  sigmoid  flex- 
ure of  the  colon,  as  was  originally  done,  I  believe,  with  success  in  analogous 
cases,  by  Dr.  O'Beirne,  who  used  an  oesophagus  tube  for  the  purpose — a 
method  which  likewise  was  successfully  employed  in  the  case  just  related, 

I  CLrcular  No.  3,  S.  G.  O.,  August  17,  1871,  pp.  21,  22. 


PRIAPISM  IN  CONSEQUENCE  OF  SPINAL  INJURIES. 


447 


Should  it  be  necessary  to  discharge  the  wind  from  the  stoniacli,  or  from  the 
small  intestines,  by  an  operation,  it  might  be  done  with  comparative  safety 
by  aspiration. 

Antispasmodics  and  carminatives,  fether,  ol.  anisi,  assafoetida,  tinct.  carda- 
momi,  tinct.  zingiberi,  tinct.  rhei,  or  ol.  terebinthinse,  will  of  coarse  be 
administered,  by  the  mouth  or  by  the  rectum,  in  these  cases;  and  warm  purga- 
tive medicines,  and  warm  purgative  clysters,  should  likewise  be  employed. 

Priapism  in  Consequence  of  Spinal  Injuries. 

The  term  priapism  is  here  used  to  signify  a  more  or  less  complete  erection 
of  tlie  penis  (but  most  often  it  is  incomplete),  which  is  unattended  by  volup- 
tuous sensations,  and  which  is  caused  by  injury  or  disease  of  the  spinal  cord, 
instead  of  by  sexual  desire  or  normal  excitation. 

This  condition  of  the  penis  is  very  often  observed  in  cases  of  spinal  injury. 
It  will  therefore  be  instructive,  as  well  as  interesting,  to  consider  briefly  the 
clinical  relations,  the  etiology,  and  the  import  or  signification  of  this  disorder 
of  the  male  sexual  organs. 

Phenomena  of  Pricqnsm. — Priapism  is  usually  described  as  a  mere  "turges- 
cence,"  or  bare  "stifl:ness"  of  the  penis,  which  does  not  amount  to  an  erection 
in  the  true  sense  of  the  term.  For  it  is  commonly  observed  in  priapism, 
that  while  the  "  turgescence,"  or  stiftness,"  does  not  attain  the  rigidity  of  a 
true  erection,  it  likewise  does  not  cauvse  the  head  of  the  penis  to  rise  upward 
beyond  a  line  drawn  perpendicularly  to  the  long  axis  of  the  body.  Moreover, 
the  penis  does  not  of  necessity  become  increased  in  length  and  breadth,  or 
diameter,  in  priapism,  as  it  does  in  normal  erection,  or  in  that  state  of  the 
organ  which  renders  it  capable  of  intromission  ;  for  I  have  observed  at  least 
one  case  of  vertebral  injury  in  which  the  penis,  although  in  a  state  of  undoubted 
priapism  that  lasted  as  long  as  life  continued,  measured  only  one  inch  and  a 
half  in  length  ;  while  after  death^  when  complete  relaxation  had  taken  place, 
it  measured  two  and  one-half  inches  in  length.  But  the  foregoing  description 
does  not  embrace  the  phenomena  tliat  are  witnessed  in  all  the  cases  of  priapism 
arising  from  spinal  injury  ;  for  while  this  description  holds  good  in  most  cases, 
there  are  at  least  occasional  instances  of  spinal  injury  in  which  the  priapism 
amounts  to  a  "  strong  erection,"  as  was  olDserved  in  an  example  already  pre- 
sented for  another  purpose  on  page  423.  The  case,  in  brief,  was  that  of  a  stable- 
man, aged  30,  having  transverse  fracture  with  dislocation  of  the  seventh  cervical 
vertebra,  caused  by  falling  dow^n  stairs,  who  was  admitted  into  Bellevue  Hos- 
pital twenty-three  hours  after  the  accident,  with  complete  sensory  and  volun- 
tary motor  paralysis  of  the  lower  extremities  and  trunk  up  to  the  third  or 
fourth  ribs  ;  also  diaphragmatic  breathing,  retention  of  urine,  etc.,  and,  at  the 
same  time,  "  the  penis  was  strongly  erected."  This  state  of  vigorous  erection 
must,  in  great  measure,  have  subsided  not  very  long  after  admission,  for  on 
the  third  day  this  entry  w^as  made  in  the  clinical  record  gf  the  case :  "  pria- 
pism always  induced  by  passing  the  catheter."  That  night  the  man  died  of 
asphyxia,  caused  by  traumatic,  ascending  myelitis.  Thus  it  appears  that 
the  clinical  phenomena  of  priapism  may  vary  in  different  cases,  or  in  difterent 
periods  of  the  same  case,  from  those  of  bare  turgidity  or  slight  stiffness  of  the 
penis,  on  the  one  hand,  through  all  the  ascending  grades  of  turgidity  and 
stiffness  up  to  strong  erections  of  the  organ,  on  the  other. 

Another  erroneous  statement  in  regard  to  priapism  is  frequently  made, 
namely,  that  it  occurs  only  in  cases  where  the  cervical  or  the  upper  dorsal  ver- 
tebrae are  fractured  or  dislocated.  But  the  truth  is,  that  it  is  also  met  with 
not  unfrequently  in  cases  where  the  middle  dorsal,  or  the  lower  dorsal,  or  the 


448 


INJURIES  OF  THE  BACK. 


upper  lumbar  vertebrae  are  fractured  or  dislocated.  For  instance,  I  have 
already  related  for  another  purpose,  on  page  390,  the  case  of  a  derrick-man, 
aged  41,  who  had  his  tenth  dorsal  vertebra  fractured  by  being  thrown  from  a 
cart,  and  was  admitted  into  Bellevue  Hospital  two  hours  after  the  accident, 
in  a  state  of  profound  collapse,  with  the  pulse  too  frequent  and  feeble  to  be 
counted,  and  with  the  lower  extremities  and  body  completely  paralyzed  as 
to  sensation  and  voluntary  motion  up  to  the  sixth  intercostal  space ;  still, 
there  was  moderate  priapism  observed.  I  have  likewise  already  men- 
tioned, on  page  375,  the  case  of  an  officer,  which  was  originally  reported  by 
Surgeon  C.  S.  Tripler,  U.  S.  Army,  and  in  which  there  was  a  shot-fracture  of 
the  spinal  column  at  the  junction  of  the  dorsal  and  lumbar  regions,  attended 
with  paraplegia,  retention  of  urine  and  feces,  and  priapism.  Furthermore,  I 
have  mentioned^  on  page  337,  the  case  of  a  man,  aged  25  (it  was  related  by 
J3r.  Parker),  who  sustained  a  dislocation  of  the  twelfth  dorsal  upon  the  first 
lumbar  vertebra,  with  slight  fracture,  in  consequence  of  being  struck  by  a 
fallino;  door,  and  who  had  priapism  as  well  as  paraplegia ;  and,  no  doubt,  in 
several  other  instances  of  inferior  dorsal  or  lumbar  fractures  or  dislocations 
of  the  vertebrae  that  are  related  or  referred  to  above,  there  was  priapism  as 
well  as  paraplegia  present. 

In  addition  to  these  observations,  I  will  take  space  only  to  mention  a  case 
reported  by  Dr.  Hutchison,^  of  Brooklyn,  i^.  Y.,  in  which  the  eighth,  ninth, 
tenth,  and  eleventh  dorsal  vertebrae  were  fractured,  in  a  man,  aged  35,  by  fall- 
ing fifteen  feet  from  a  scafibld,  and  in  which  paralysis,  priapism,  etc.,  ensued  ; 
another  case  reported  by  MM.  A.  Pousson  and  F.  Lalesque,^  in  which  a  man, 
aged  40,  sustained  dislocation  of  the  eleventh  dorsal  vertebra  combined  with 
fracture  of  its  laminse,  and  in  which,  besides  paraplegia,  there  were  priapism, 
ete. ;  and  a  third  case  recorded  by  Mr.  Hilton,^  in  which  a  man,  aged  30,  fell 
through  a  trap-door,  sixteen  or  eighteen  feet,  fractured  his  eleventh  dorsal 
vertebra,  and  completely  divided  his  spinal  cord,  with  the  effect  of  producing 
complete  paraplegia,  etc.,  as  well  as  priapism,  which  appeared,  however,  on  the 
second  day.  I  have  no  doubt  that  if  a  search  were  specially  instituted  for  the 
purpose,  a  considerable  number  of  additional  cases  could  be  collected  m  which 
fractures  or  dislocations  of  the  vertebrae  in  the  lower  dorsal  and  lumbar 
regions  were  attended  by  priapism,  as  well  as  by  paralysis.  This  peculiar 
disorder  of  the  male  genitalia  is,  however,  met  with  much  more  frequently 
in  the  cervical  and  upper  dorsal  regions  than  elsewhere,  but  it  should  also  be 
borne  in  mind  that  fractures  and  dislocations  of  the  vertebrae  occur  much 
the  most  frequently  in  these  regions. 

It  may  be  of  interest  to  remark,  in  this  connection,  that  Professor  Agnew 
states  that  he  has  seen  priapism  present  itself  after  injuries  of  the  head,^  as 
well  as  after  those  of  the  spinal  column. 

But  priapism  may  likewise  appear  in  cases  of  concussion  or  contusion  ot 
the  spinal  cord,  and  in  consequence  of  those  injuries.  I  have  already  pre- 
sented two  examples  belonging  to  this  category  on  pages  384  and  38b  ;  one 
of  these  was  reported  by  Sir  W.  Gull,  and  the  other  by  Mr.  Savory.  In  Sir 
W.  Gull's  case,  the  only  lesions  of  the  cord  observable  were  ecchymosis  and 
hyper^emia,  mostly  in  the  gray  substance,  opposite  the  fourth  and  fifth  cer- 
vical vertebrae.  The  priapism  disappeared  in  a  few  hours,  but  returned  on 
the  following  day.  In  Mr.  Savory's  case,  there  was  complete  loss  of  sensa- 
tion and  voluntary  motion  in  the  lower  extremities,  and  in  the  trunk  nearly 

»  American  Medical  Times,  1861. 

2  Medical  News  and  Abstract,  March,  1881,  pp.  179,  180. 

8  Guy's  Hospital  Reports,  3d  series,  vol.  xi. 

4  Principles  and  Practice  of  Surgery,  vol.  i.  p.  829. 


PRIAPISxM  IN  CONSEQUENCE  OF  SPINAL  INJURIES. 


449 


up  to  the  clavicles,  the  respiration  was  entirely  diaphragmatic,  and  no  reflex 
action  could  be  excited  in  the  lower  extremities  or  elsewhere ;  still  there  was 
partial  priapism.  Death  occurred  in  thirty  hours;  and  the  autopsy  showed 
a  clot  of  blood  in  the  substance  of  the  cord  opposite  the  fourth  cervical 
vertebra. 

Furthermore,  priapism  may  be  caused  by  inflammation  of  the  spinal  cord. 
There  was  a  marked  degree  of  priapism  observed  in  a  case  of  acute  and  very 
extensive  myelitis,  terminating  fatally  in  ten  or  twelve  days,  that  was  re- 
corded by  Dr.  C.  B.  Radclifte.'  Motor  and  sensory  paralysis  extended  up  to 
a  line  drawn  around  the  body  four  inches  below  the  ensiform  cartilao-e. 
Reflex  movements  were  also  absent,  but  there  was  retention  of  ui-iiie.* 
Priapism  may  be  an  important  indication  that  myelitis  is  present.  Dr. 
Hammond  enumerates  among  the  symptoms  of  acute  myelitis  frequent  and 
almost  constant  erections.^  Dr.  Braniwell  in  describing  the  symptoms  of 
acute  myelitis  states  that  priapism  is  often  present  among  them.'*  In  Mr. 
Hilton's  case,  mentioned  above,  the  priapism  which  supervened  on  the  second 
day  after  the  accident  probably  arose  from  inflammation  of  the  cord-substance. 
Thus,  we  have  shown  that  priapism  not  unfrequently  occurs  in  cases  of  con- 
cussion, contusion,  and  inflammation  of  the  spinal  cord,  as  well  as  in  cases  of 
fracture  and  dislocation  of  the  spinal  column  ;  the  conclusion  to  be  drawn 
therefrom  is  irresistible  that  the  essential  lesion,  or  the  peculiar  patholoo-ical 
condition  upon  which  the  occurrence  of  priapism  depends,  is  seated  in*  the 
spinal  cord,  and  not  in  the  spinal  column  nor  in  the  exterior  parts. 

What  is  the  essential  lesion^  what  the  physiological  apparatus  from  the 
disorder  of  which  priapism  arises  ?  The  fact  tha^t  the  location  or  site  of 
the  essential  lesion  must  be  sought  for  in  the  spinal  cord  itself,  at  once 
disposes  of  the  theory  which  ascribes  the  causation  of  priapism  to  lesions  of 
the  cervical  or  dorsal  ganglia  of  the  nervi  sympathici  which  lie  alono-  the 
spinal  column.  It,  however,  does  not  dispose  of  another  theory  which 
ascribes  the  cause  of  priapism  to  lesions  of  those  filaments  of  the  nervi  sym- 
pathici which  exist  in  the  spinal  cord,  and  to  vaso-motor  paralysis  of  the 
bloodvessels  arising  therefrom.  Professor  Agnew  seems  inclined  to  adopt 
this  theory,  for  he  says :  "  These  erections  of  the  penis  are  not  due  to  action 
of  the  muscles,  as  the  latter  partake  of  the  general  paresis,  but  are  the  result 
of  inefliciency  of  the  vaso-motor  nerves  allowing  the  blood  to  flow  into  the 
spongy  structure  of  the  corpora  cavernosa  and  corpus  spon2:iosum,  through 
the  want  of  resistance  in  the  muscular  walls  of  the  vessels."*  "P>ut  this  theory 
of  erections  arising  from  passive  congestion  of  the  penis  is  untenable,  because 
it  utterly  fails  to  account  for  the  rather  numerous  examples  of  priapism  in 
which  there  are  strong  or  even  moderate  erections  observed,  and  in  which 
the  distension  of  the  organ  is  produced  obviously  by  an  active  process.  More- 
over, vaso-motor  paralysis  is  always  attended  with  a  notable  rise  of  tempera- 
ture in  the  part  of  the  body  where  it  exists,  especially  if  such  paralysis  be 
suddenly  eftected.  How,  then,  can  the  occurrence  of  priapism  be  explained 
by  the  theory  of  vaso-motor  paralysis  in  such  instances  as  the  followino- 
which  was  reported  by  Mr.  Hutchinson,^  in  which  "there  was  marked  pria- 
pism," but  attended  with  a  remarkable  depression  of  the  body-heat,  both 
general  and  local,  below  the  normal  standard  :—  ' 

The  patient  was  a  man,  aged  24,  who  fractured  liis  fifth  cervical  vertebra  and 
severely  injured  his  spinal  cord  by  falling  from  a  ladder  with  a  load  of  bricks  on  his 

*  Lancet,  December  3,  1864. 

*  New  Sydenham  Soc.  Year-Book,  1864,  p.  83. 

8  Diseases  of  the  Nervous  System,  p.  457.    New  York,  1881. 

*  Diseases  of  the  Spinal  Cord,  p.  243.    New  York,  1882.  s  Qp.  cit.  p.  829.  ^ 
^  New  Sydenham  Soc.  Biennial  Retrospect,  1S73-74,  pp.  351,  352.       '      *'  ' 

VOL.  IV. — 29 


450 


INJURIES  OF  THE  BACK. 


shoulder.  When  seen  on  the  following  day ,  his  lower  extremities  were  completely 
paralyzed,  and  the  line  of  anaesthesia  extended  as  high  as  an  inch  above  his  nipples. 
The  breathing  was  solely  diaphragmatic.  There  was  marked  priapism.  The  tempera- 
ture was  98°.  The  pupils  were  equal  and  of  a  small  size  in  a  dull  light.  Next  day  the 
pulse  was  noted  at  36  per  minute,  and  small.  In  the  evening,  the  temperature  in  the 
rectum  was  only  95.8°  ;  in  the  distended  penis  it  was  only  93°.  He  died  on  the  sixth 
day  after  the  accident.  The  vaso-motor  theory  of  the  production  of  priapism  is  insuffi- 
cient to  account  for  such  cases,  as  well  as  for  those  instances  in  which  the  erections  are 
more  or  less  vigorous,  and  in  which  the  distension  of  the  penis  is  obviously  effected  by 
the  operation  of  active  agencies. 

The  nervous  apparatus,  the  disordered  action  of  which  produces  priapism,  is 
doubtless  the  same  as  that  by  which  normal  erections  are  efiected.  The  pro- 
cess is  a  reflex  one,  the  centre  for  which  (that  is,  the  sexual  centre)  is  situated 
in  the  lumbar  portion  of  the  spinal  cord.  The  sexual  centre  may  be  put  into 
action  by  peripheral  impressions  conveyed  to  it  from  the  penis,  especially  the 
glans,  by  the  sensory  nerves ;  also,  by  cerebral  impressions  (they  are  usually 
emotional  influences)  conveyed  to  it  by  the  conducting  fibres  of  the  cord. 
"  As  the  result  of  the  stimulation  of  the  sexual  centre,  an  impulse  is  gene- 
rated which  travels  along  the  nervi  erigentes  and  inhibits  the  local  nervous 
mechanism  in  the  bloodvessels  of  the  corpora  cavernosa ;  vascular  dilatation, 
engorgement,  and  erection  follow."^  Thus,  it  is  not  difficult  to  conceive  how 
priapism  may  be  caused  in  cases  where  the  spinal  cord  is  injured  or  diseased 
in  the  cervical  or  dorsal  regions ^  etc.,  and  where  paraplegia,  both  sensory  and 
voluntary-motor,  is  present  in  consequence  thereof,  namely,  by  irritating  the 
"  excitor"  fibres  which  pass  from  the  cerebrum  to  the  reflex  sexual  centre,  as 
pointed  out  by  Dr.  Bramwell.^  In  the  same  way,  cerebral  injury  or  disease 
may  also  produce  priapism.  This  view  as  to  the  reflex  origin  of  priapism  in 
spinal  injuries  is  supported  by  a  fact  noted  in  the  clinical  history  of  a  para- 
plegic case  related  above,  from  Bellevue  Hospital,  viz.,  that  the  introduction 
of  a  catheter  always  brought  on  priapism.  Finally,  in  order  to  show  that  the 
paralysis  of  the  muscular  apparatus  is  not  of  necessity  so  complete  in  cases  of 
seemingly  perfect  paraplegia  that  priapism  cannot  be  caused  in  l^his  way,  as 
asserted  by  Professor  Agnew,  it  is  only  necessary  to  state  that,  in  practice, 
priapism  is  very  often  found  associated  with  retention  of  urine  and  feces, 
and  that  the  presence  of  the  latter  condition  is  due  to  the  fact  that  the 
sphincter  muscles  are  not  paralyzed. 

In  regard  to  the  significance  of  priapism  as  a  symptom,  or  as  a  prog- 
nostic, in  cases  of  vertebral  injury,  while  it  shows  that  the  spinal  cord  is 
involved  in  the  lesion,  it  can  be  stated  with  certainty  that  it  is  not  necessa- 
sarily  a  fatal  sign,  inasmuch  as  recovery  resulted  in  two  cases  mentioned 
above,  in  which  Its  presence  was  recorded.  One  of  these  cases  was  reported 
by  Dr.  Parker,  and  the  other  by  Surgeon  C.  S.  Tripler,  U.  S.  Army. 

Special  treatment  is  seldom  required  for  priapism.  In  severe  cases,  how- 
ever, pulverized  camphor,  camphor  monobromate,  or  potassium  bromide, 
may  be  administered  with  benefit. 

Injuries  of  the  Sacrum  and  Coccyx. 

Fractures  of  the  Sacrum.^ — Simple,  uncomplicated  fracture  of  the  sacrum 
sometimes,  though  very  rarely,  occurs.  The  structure,  shape,  and  position 
of  this  bone  in  the  skeleton  are  such  as  to  render  it  peculiarly  free  from  a 
liability  to  sustain  solutions  of  continuity,  by  itself,  in  the  ordinary  accidents 


«  Bramwell,  op.  cit.,  p.  129. 


2  Ibid.,  pp.  61,  131. 


INJURIES  OF  THE  SACRUM  AND  COCCYX. 


451 


of  civil  life.  It  is  more  often  found  fissured  and  even  comminuted  in  the 
severe  crushes  of  the  pelvic  bones  in  general,  which  are  not  unfrequently  met 
with.  In  simple,  uncomplicated  fracture,  the  lower  half  of  this  bone  is  the 
part  most  liable  to  be  found  broken,  (1)  because  it  is  less  strong,  and  (2)  because 
it  is  more  exposed  than  the  upper  half. 

Specimens  illustrating  this  lesion  are  exceedingly  uncommon  in  pathological 
cabinets.  The  museum  of  the  Royal  College  of  Surgeons,  however,  contains 
one  example,  according  to  the  statements  of  both  Erichsen  and  South.  In  it 
the  sacrum  is  vertically  fractured ;  the  patient  died  of  suppuration  six  weeks 
after  the  accident,  and  no  union  of  the  fragments  whatever  had  taken  place.^ 
Erichsen  has  seen  but  one  instance.  The  injury  was  caused  by  a  blow  from 
the  butfer  of  a  railway  carriage,  and  proved  rapidly  fatal,  ^^'ot  long  ago  the 
follow^ing  remarkable  case  was  observed  in  Paris : —  * 

A  woman,  aged  36,  was  brouglit  into  the  St.  Lazare  Hospital  with  the  history  of 
having  fallen  about  eight  feet  upon  her  buttocks  ;  she  fainted,  and,  when  she  became 
conscious,  was  quite  unable  to  sit.  A  slight  transverse  depression,  corresponding  to 
the  middle  of  the  sacrum,  was  readily  felt  from  behind ;  the  injured  part  was  very 
tender,  and  pressure  gave  fine  crepitus.  Extensive  ecchymosis  quickly  occurred  over 
the  whole  sacrum.  The  line  of  fracture  was  readily  feU  also  from  the  rectum  and 
vagina  ;  the  projection  forward  of  the  lower  half  of  the  sacrum  was  readily  verified,  and 
this  part  of  the  bone  was  easily  moved,  with  crepitus.  Reduction  was  effected  without 
difficulty  by  the  finger  pressing  backward  from  the  front,  and  displacement  did  not  recur. 
A  bandage  was  firmly  applied  round  the  pelvis  and  the  patient  kept  in  bed.  Defecation 
gave  intense  pain,  and  the  woman  was  unable  to  lie  on  her  back  for  a  fortnight ;  but  she 
sat  up  in  bed  on  the  twenty-eighth  day,  and  got  up  in  the  ward  on  the  forty-second  day. 
There  were  no  signs  of  pressure  upon,  or  other  injury  of,  the  lower  sacral  or  coccygeal 
nerves.'^  ° 

In  this  case  the  sacrum  was  fractured  transversely ;  in  the  specimen  con- 
tained in  the  Royal  College  of  Surgeons  Museum,  mentioned  above,  it  was 
fractured  vertically;  it  is  also  stated  that  this  bone  may  be  fractured  obliquely; 
but,  in  simple,  uncomplicated  cases,  these  fractures  are  most  commonly  trans- 
verse. 

Etiology.— ThQ  most  frequent  causes  of  the  simple,  uncomplicated  fractures 
are  powerful  blows  struck  directly  over  the  sacrum,  as,  for  example,  a  blow 
from  the  buffer  of  a  railway  carriage;  heavy  falls  with  direct  impingement 
upon  the  sacrum,  as  was  observed  in  the  instance  just  related;  and  the  sudden 
application  of  great  weight  or  pressure,  such  as  may  occur,  for  example,  in 
1he  passage  of  a  cart-wheel  over  the  sacrum.  Great  force,  when  indirectly 
applied,  may  also  cause  such  fractures;  but  the  indirect  fractures  of  the 
sacrum  are  usually  associated  with  similar  lesions  of  the  other  pelvic  bones, 
as  already  intimated.  Mr.  Erichsen  has  seen  one  case  of  simple,  uncompli- 
cated fracture  of  the  sacrum  which  was  caused  by  a  blow  from  the  buffer  of 
a  railway  carriage,  and  which  rapidly  proved  fatal. 

Symptoms. — The  pain  in  the  injured  part  is  usually  very  acute,  and  aggra- 
vated by  all  muscular  movements  which  disturb  the  injured  part,  such  as 
flexion  or  extension  of  the  body,  etc.  All  straining  efforts  in  defecation, 
urination,  coughing,  or  sneezing,  produce  extreme  suffering.  All  pressure 
applied  externally  likewise  increases  the  distress  ;  and  the  patients  themselves 
will  generally  have  noticed  that  from  the  moment  of  receiving  the  injury 
they  have  been,  from  this  cause,  unable  to  sit  upright.  On  examina'tion,  angular 
deformity  may  be  visible  posteriorly,  as  well  as  a  subcutaneous  ecchymosis, 
which  quickly  spreads  over  the  whole  sacral  region.   On  applying  the  fingers 

»  South's  Notes  to  Chelius's  System  of  Surgery,  vol.  i.  p.  595,  Am.  ed. 
2  Lancet,  November  20,  1880. 


452 


INJURIES  OF  THE  BACK. 


to  the  injured  part,  great  tenderness  is  discovered,  together  with  crepitus  and 
one  or  more  lines  of  depression  corresponding  to  the  fracture  and  displace- 
ment. On  introducing  a  finger  into  the  rectum,  and  pressing  against  the 
coccyx,  both  crepitus  and  abnormal  mobility  may  be  detected.  With  a  linger 
of  one  hand  in  the  rectum  and  the  lingers  of  the  other  hand  applied  externally, 
the  kind  and  degree  of  the  displacement  can  for  the  most  part  be  readily  de- 
termined. The  displacement  usually  consists  in  a  forward  projection  of  the 
inferior  fragments,  as  was  observed  in  the  example  of  sacral  fracture  above 
related,  and  is  due  to  the  operation  of  two  causes,  (1)  the  blow  itself,  and  (2) 
the  contractions  of  the  gluteus  maximus,  coccygeus,  and  sphincter  ani  muscles. 
Lateral  distortion  is  not  likely  to  occur,  because  the  lesser  and  the  greater 
sacro-sciatic  ligaments  would  counteract  such  a  change  in  the  position  of  the 
fragments.  Moreover,  paralysis  of  the  bladder  and  rectum  may  likewise  be 
present,  inasmuch  as  both  organs  receive  nerves  from  the  sacral  plexus. 

Prognosis. — Of  the  three  examples  mentioned  above,  two  ended  in  death, 
and  but  one  in  recovery.  The  successful  case,  however,  shows  that  when 
simple  fracture  of  the  sacrum  is  not  complicated  with  other  lesions,  especially 
with  injuries  of  the  pelvic  viscera,  the  fragments  on  being  placed  in  apposi- 
tion readily  unite,  and  recovery  speedily  ensues ;  for  in  that  case  the  union  on 
the  twenty-eighth  day  was  already  so  firm  that  the  patient^  sat  up  in  bed, 
resting  of  course  the  whole  weight  of  her  trunk  upon  the  injured  bone  in  so 
doing.  When,  therefore,  fractures  of  the  sacrum  do  not  end  in  recovery,  the 
fatal  result  is  2;enerally  due,  not  to  the  fractures  themselves,  but  to  lesions  of 
the  adjacent  pelvic  viscera  with  which  they  are  associated.  Unhappily,  how- 
ever, any  application  of  force  that  may  suffice  to  disrupt  the  sacrum,  is  very 
liable  to  do  so  much  harm  to  the  neighboring  pelvic  organs,  at  the  same  time, 
as  to  make  a  fatal  result  inevitable.  "  Thus,  it  appears  that  the  prognosis  m 
sacral  fractures  depends  rather  upon  their  complications  than  upon  the  frac- 
tures themselves,  and  that  it  is  generally  unfavorable. 

When  the  lesion  consists  in  the  breaking  off  of  a  layer  of  bone  attached  to 
the  cartilage  at  one  or  both  of  the  sacro-iliac  synchondroses,  that  is,  in  modi- 
fied diastasis,  the  issue  is  not  of  necessity  mortal.  Dr.  Banks^  has  recorded  an 
example  of  this  lesion  in  which  there  was  displacement  upward  to  the  extent 
of  one  inch,  and  still  the  patient  recovered.  Moreover,  a  cure  is  sometimes 
obtained  in  still  more  unpromising  instances,  where  the  fracture  is  compound, 
and  at  the  same  time  complicated  with  injury  of  the  bladder ;  for  Dr.  Bur- 
lingham^  has  reported  a  very  remarkable  case  of  compound  fracture  of  the 
sacrum  in  which  the  urine  flowed  for  some  time  through  the  wound,  and  m 
which,  notwithstanding  this  condition  of  affairs,  the  patient  entirely  re- 
covered. 

Treatment— Fvd^iiiuvQ^  of  the  sacrum  should  always  be  reduced  when  prac- 
ticable, and  the  reduction  can  generally  be  effected  without  much  difficulty 
when  the  fracture  is  situated  in  the  lower  half  of  the  bone  (which  is  the  part 
most  liable  to  be  broken),  especially  if  it  happen  to  be  transverse.  Eeduction 
is  to  be  effected  even  when  the  displacement  is  but  slight,  because,  from  the 
close  proximity  of  the  rectum,  any  displacement  whatever  of  the  fragments 
that  might  be  allowed  to  remain,  would  correspondingly  tend  to  irritate  that 
viscus,  and  to  excite  suppurative  inflammation  in  the  loose  connective  tissue 
between  it  and  the  injured  bone.  It  should  be  remembered  in  this  connection 
that  death  resulted  from  such  a  suppuration,  six  weeks  after  the  accident,  in 
the  case  the  sxjecimen  from  which  is  preserved  in  the  Eoyal  College  ol  Sur- 
geons (mentioned  above),  and  that,  as  might  well  be  expected  under  the  circum- 

1  Atalanta  Medical  and  Surgical  Journal,  May,  1866. 

2  American  Journal  of  the  Medical  Sciences,  April,  1868. 


INJURIES  OF  THE  SACRUM  AND  COCCYX. 


453 


stances,  no  union  of  the  fragments  whatever  had  taken  place.  Xo  doubt  too 
the  remarkable  success  which  attended  the  treatment  of  tlie  illustrative  ex- 
ample related  above,  was  mainly  due  to  the  fact  tliat  the  displaced  bone  was 
put  back  again  into  its  normal  position  without  delay,  and  that  an  exact  appo- 
sition of  the  fragments  was  uninterruptedly  maintained.  Oftentimes,  reduc- 
tion can  easily  be  accomplished  by  pressing  upon' the  displaced  bone  with  a 
finger  in  the  rectum. 

The  second  indication  in  the  treatment  of  sacral  fractui'cs  is  to  keej)  the 
fragments  in  apposition.  This  indication  was  readily  fultilled  in  the  illustra- 
tive example  presented  above,  by  firmly  ai)plying  a  bandage  around  the  [)elvis, 
and  by  keeping  the  patient  in  bed.  But  the  main  difficulty  in  the  treatment 
of  these  cases,  where  the  fracture  is  the  sole  injury,  is  the  intense  degree  of 
pain  with  whi(di  the  act  of  defecation  is  accompanied,  and  the  local  disturb- 
ance wdiich  it  produces.  Some  surgeons  have,  by  administering  opium,  kept 
the  bowels  in  a  state  of  confinement ;  and  then  emptied  the  rectum  every 
week  or  ten  days  by  means  of  an  enema.  It  is,  however,  still  better  to  diet 
the  patient  very  carefully  with  a  view  to  restrain  the  production  of  feces  to 
the  smallest  possible  (juantity,  w^hich  may  then  be  easily  and  almost  painlessly 
removed  every  three  or  four  days  by  means  of  an  enema.  Whenever  pain  is 
present  in  these  cases,  it  must  be  subdued  by  administering  opium  or  morphia 
in  doses  that  are  sufficiently  large,  and  at  intervals  that  ai-e  sufficiently  briet 
Should  intra-pelvic  inflammation  arise,  it  must  be  combated  by  leeches  and 
hot  fomentations,  as  w^ell  as  by  opiates.  Should  retention  of  urine  be  present, 
catheterization  must  be  employed  every  eight  hours.  Should  the  bladder  be 
wounded  in  a  male  patient,  but  es^DCcially  should  it  be  ruptured,  it  may  be 
advisable  to  open  it  at  once  by  perineal  section  in  order  to  allow  the  urine  to 
escape  as  fast  as  secreted,  and  thus  avoid  all  chance  of  urinary  infiltration. 
Cases  belonging  to  this  category  may  be  saved  by  the  timely  performance  of 
this  operation,  which  is  not  dangerous  per  se^  and  which,  if  I  remember  aright, 
has  already  proved  successful  in  one  or  more  examples  of  this  sort,  simply 
because  it  prevented  the  pelvic  fractures  from  becoming  complicated  with 
urinary  infiltration. 

But  should  the  broken  bone  manifest  a  disposition  to  slip  out  of  place 
again  after  its  reduction  has  beeu  effected,  notwithstanding  the  firm  applica- 
tion of  a  bandage  around  the  pelvis,  a  mechanical  api)aratus  must  be  em- 
ployed to  overcome  this  disposition.  For  this  purpose,  Al.  Indes  used  simply 
a  piece  of  wood,  cylindrical  in  shape,  five  inches  in  length  by  three  inches  in 
circumference,  which  w^as  inserted  into  the  rectum,  and  there  retained  in 
position  by  graduated  compresses  together  with  a  T-bandage.  On  every 
third  day  this  plug  or  splint  was  temporarily  withdrawn,  and  the  bowel  was 
washed  out  with  an  enema.  The  patient  recovered.  For  the  same  purpose, 
M.  Bermond  used  a  silver  canula,  with  a  bag  attached,  which  when  stuffed 
formed  an  inner  and  an  outer  tampon.  The  end  of  the  tube  was  kept  closed 
Avith  a  cork,  in  order  to  prevent  the  escape  of  feces.  It  was  removed  only 
twice  during  the  course  of  treatment,  namely,  on  the  seventh  and  nineteenth 
days  respectively.    This  patient  also  recovered. 

The  patient  should  be  rigidly  confined  to  bed  until  the  fragments  have 
united.  The  posture  therein  should  be  that  which  is  attended  with  the 
smallest  amount  of  discomfort  to  the  patient,  and  with  the  smallest  liability 
to  the  recurrence  of  displacement. 

Gunshot  Fractures  of  the  Sacrum. — Hennen  mentions  three  cases  in  each 
of  which  a  musket-ball  passed  through  the  sacrum,  about  three  inches  above 
the  tip  of  the  coccyx,  and  penetrated  obliquely  upward.  In  two  of  them  the 
rectum  w^as  also  wounded.   In  the  third,  the  bladder  was  perforated  as  well  as 


454 


INJURIES  OF  THE  BACK. 


the  rectum,  and  "  urine  passed  after  the  first  few  hours  from  the  posterior 
wound."  This  patient  expired  on  the  third  day,  "laboring  under  the  symp- 
toms of  the  most  violent  peritonitis."  In  each  of  the  other  cases  the  missile 
lodged,  and  was  passed  by  stool  about  two  months  after  the  casualty.  One 
of  these  unfortunate  men  "  survived  for  two  years,  when,  a  discharge  of 
feces  coming  on  through  the  orifice  in  the  bone,  he  died,  exhausted  by  a 
complication  of  sufterings ;  but  no  paralytic  afiection  ever  appeared."  The 
remaining  case  was  seen  by  Dr.  Thomson  in  the  military  hospital  at  Berlin, 
under  the  care  of  Dr.  Reich,  but  the  result  is  not  stated. ^  From  this  it 
would  appear  that  shot  fractures  of  the  sacrum  are  highly  dangerous  to  life. 
Pare,  however,  asserted  that  he  had  many  times  seen  the  sacrum  fractured 
by  bullets  when  the  subjects  recovered.  During  the  late  civil  war  one  hun- 
dred and  forty-five  cases  were  reported.  In  three  of  them  the  result  has  not 
been  determined.  Of  the  remaining  one  hundred  and  forty-two  instances, 
sixty-two,  or  43.7  per  cent.,  were  fatal.^  Thus  it  appears,  (1)  that  gunshot 
fractures  of  the  sacrum  not  unfrequently  occur,  and  (2)  that  more  than  one- 
half  of  the  cases  recover. 

The  following  very  instructive  example  eventuated  in  recovery  : — 

Lieutenant  W.  A.  C.  Ryan,  Co.  G,  132d  New  York  Volunteers,  aged  21,  was 
wounded  at  Bachelor's  Creek,  N.  C,  February  1,  1864,  by  a  conoidal  ball,  which  frac- 
tured the  last  lumbar  vertebra,  and  lodged  in  the  sacrum.  He  was  at  once  taken  to  a 
general  hospital  where  simple  dressings  were  applied  to  the  wound.  On  June  12,  it 
was  noted  that  the  wound  discharged  very  freely  ;  that  the  patient  although  feeble  was 
in  a  very  good  condition  ;  that  an  ulcer  had  formed  across  the  sacrum,  about  three 
inches  in  fength  by  one  and  a  half  inches  in  width,  with  a  sinus  leading  to  the  ball ; 
and  that  the  missile  was  extracted,  with  some  difficulty,  from  the  bone  in  which  it  was 
firmly  imbedded,  on  that  day.  The  wound  healed  rapidly  after  the  operation.  The 
treatment  consisted  of  tonics,  with  a  generous  diet.  On  October  9,  the  patient  was  dis- 
charged. There  is  no  record  of  him  at  the  pension-office.^  His  recovery  was,  therefore^ 
in  all  probability  complete. 

Recovery  resulted  in  the  next  example  also : — 

Lieutenant  S.  W.  Russell,  Co.  B,  49th  New  York,  and  A.  D.  C.  Sixth  Corps,  aged 
26,  was  wounded  at  Rappahannock  Station,  November  7,  1863,  by  a  conoidal  ball 
which  "entered  the  left  hip,  passed  across  the  upper  portion  of  the  sacrum,  and  emerged 
from  the  rio-ht  hip.  The  surface  of  the  sacrum  was  fractured."  On  the  9th  he  was 
admitted  into  Armory  Square  Hospital,  and  on  February  3,  1864,  he  was  transferred 
to  Seminary  Hospital,  Georgetown.  He  returned  to  duty  on  May  16  following, 
where  he  appears  to  have  remained  until  June  27,  1865,  when  he  was  discharged  from 
the  service  and  pensioned.  The  pension-examiner  noted  at  the  time  that  the  wound 
was  still  unhealed.    On  June  4,  1873,  he  was  still  on  the  pension  list.'' 

Among  the  cases  of  recovery  from  shot  fractures  of  the  sacrum,  reported 
during  the  late  civil  war,  were  four  in  which  the  bladder  was  penetrated.  In 
nine  instances  the  rectum  was  wounded,  and  eight  of  these_  cases  resulted 
favorably.  In  addition  to  the  complications  attending  shot  injuries  of  the 
OS  innominatum,  paralysis  and  other  disorders  referable  to  lesions  of  the 
nerves  were  common  after  shot  fractures  of  the  sacrum.^ 

In  the  cases  of  shot  fracture  of  the  sacrum  which  were  observed  during 
our  late  civil  war,  it  was  common  for  one  or  both  of  the  posterior  spinous 
processes  of  the  ilium  to  be  found  fractured  at  the  same  time,  as  is  shown  in 

1  Hennen,  op.  cit.,  p.  351.  .    i      i  oAa 

2  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Second  Surgical  Volume,  P-  246. 

3  Ibid.,  First  Surgical  Volume,  p.  461.  "  Ibid.,  Second  Surgical  Volume,  p.  ^46. 
6  Ibid.' 


INJURIES  OF  THE  SACRUM  AND  COCCYX. 


455 


the  preparation  represented  by  Fig.  884,  and  as  probably  happened  in  the  case 
of  Lieutenant  Russell,  which  has  just  been  related.^ 

Shot  fractures  of  the  sacrum  were  Jiot  unfrequentl}^  found  by  our  military 
surgeons  to  become  complicated  with  pycema,  as  was  observed  in  the  follow- 
ing instance : — 

Private  George  F.,  aged  23,  was  wounded  at  Cold  Harbor,  June  3,  1804.  He  was 
treated  in  the  field  hospitals  until  the  12th,  when  he  was  transferred  to  Washington, 
and  admitted  to  Douglas  Hospital.  At  this  time  he  was  suffering  from  partial  para- 
plegia.   He  died  from  well-marked  pyaemia  on  the  21st,  eigliteen  days  after  the  casualty 


Fig.  884.  Fig.  885. 


Shot  fracture  of  the  sacrum  and  ilium.  Shot  perforation  of  the  sacrum. 

(Spec.  1353,  A.  M.  M.)  (Spec.  3o68,  A.  M.  M.) 


occurred.  Autopsy.. — The  ball  was  found  in  two  pieces  in  the  sacro-ischiatic  notch, 
having  perforated  the  sacrum  to  the  right  of  the  median  line,  as  shown  in  the  accom- 
panying wood-cut  (Fig.  885),  which  represents  the  osteological  specimen  that  was  ob- 
tained from  the  case,  and  is  now  preserved  in  the  Army  Medical  Museum.  Both  lungs 
contained  extensive  pyaemic  patches ;  the  liver  and  spleen  were  softened,  and  the  latter 
enlarged.    There  had  been  icterus  before  death .'^ 

Pypemia  was  reported  as  the  cause  of  death  in  eight  of  the  sixty-two  fatal 
cases  belonging  to  this  category,  or  12.9  per  cent.^ 

The  specimen  represented  by  Fig.  886  was  obtained  from  the  corpse  of  a  soldier, 
aged  41,  who  was  wounded  at  Petersburg,  July  30,  1864,  by  a  conoidal  ball.    He  was 


Fig.  886.  Fig.  887. 


Upper  two-thirds  of  the  sacrum  obliquely  fractured  Right  half  of  the  sacrum  ^Tooved  by  a  conoidal 

by  a  conoidal  musket-ball.    (Spec.  3oS6,  A.  M.  M.)  musket-ball.    (Spec.  2.30,  A.  M.  M.) 

admitted  to  Douglas  Hospital  on  August  3,  and  died  after  symptoms  cliaracteristic  of 
pyaemia  on  the  10th,  twelve  days  after  the  casualty  occurred.    For  three  days  after 


1  Ibid. 


2  Ibid.,  p.  247. 


Ibid. 


456 


INJURIES  OF  THE  BACK. 


admission  catheterization  was  required,  but  after  that  his  water  passed  freely.  There 
was  no  other  sign  of  paraplegia.^ 

The  specimen  represented  by  Fig.  887  was  obtained  from  the  cadaver  of  a  soldier, 
aged  19,  who  was  wounded  at  West  Point,  Va.,  May  7,  1862,  and  who  died  in  Judiciary 
Square  Hospital,  at  Washington,  on  the  23d,  with  symptoms  of  pyaemia,  sixteen  days  after 
the  wound  had  been  inflicted.  The  injury  was  reported  as  a  "gunshot  wound  of  the 
lumbar  region  near  the  nates,  and  also  through  the  lower  part  of  the  right  chest."  "Pos<- 
mortem  section  of  the  injured  parts  showed  a  deep  wound  of  the  sacrum  ploughing  the 
bone,"  as  is  well  shown  in  the  accompanying  wood-cut.^ 

In  the  following  instance  the  sacrum  was  transversely  grooved  or  perforated 
by  a  small-arm  missile : — 

Corporal  Amos  E.  C,  aged  18,  was  wounded  at  Chancellorsville,  May  3,  1863,  by 
a  conoidal  musket-ball,  which  entered  the  left  buttock  behind  and  above  the  great 
trochanter,  and  emerged  through  the  right  side  of  the  sacrum.  He  remained  in  the 
hands  of  the  enemy  for  nine  days,  during  which  time  his  wound  was  entirely  neglected. 
On  June  14  he  was  sent  to  Washington,  and  was  admitted  to  Douglas  Hospital  in  a 
very  nervous,  weak,  and  anaemic  condition.  There  were  bed-sores  over  the  projec- 
tions of  the  hips,  back,  and  sacrum,  so  that  it  was  impossible  to  lay  him  in  a  comfortable 
position.  He  died  on  July  9,  apparently  in  consequence  of  these  bed-sores.  Autopsy. — 
Pleuritic  adhesions  were  found,  but  no  signs  of  peritoneal  inflammation.  The  sacrum, 
as  shown  in  the  accompanying  wood-cut  (Fig.  888),  was  perforated  from  side  to  side, 
with  loss  of  substance  at  the  junction  of  the  fourth  and  fifth  pieces  of  the  bone.  The 
fragments  were  carious,  and  there  was  a  slight  osseous  deposit  on  the  anterior  surface.' 

The  specimen  of  shot  fracture  of  the  sacrum  which  is  represented  by  Figs. 


Fig.  888. 


Fig. 


Showing  the  sacrum  grooved 
transversely  by  a  conoidal  musket- 
ball.    (Spec.  1642,  A.  M.  M.) 


The  sacrum  and  last  lumbar 
vertebra.  A  ball  is  impacted  in 
the  left  upper  sacral  foramen. 
(Spec.  2902,  A.  M.  M.) 


Posterior  view  of  the  same 
specimen. 


889  and  890,  was  obtained  at  the  autopsy  of  a  soldier,  aged  23,  with  the  fol- 
lowing history : — 

He  was  wounded  at  Spottsylvania,  May  10,  1864,  and  taken  to  a  field  hospital  of 
the  Fifth  Corps.  On  the  14th  he  was  transferred  to  Carver  Hospital,  at  Washington. 
"  The  missile  entered  about  two  inches  to  the  left  of  the  sacrum,  passed  a  little  down- 
ward and  to  the  right,  fractured  the  sacrum,  and  remained  in  the  wound.  When 
admitted,  the  patient  was  not  much  emaciated;  there  was  great  pain,  with  tumefaction 
of  the  aodomen  ;  the  bowels  were  constipated,  and  there  was  complete  retention  of 
urine.  The  bladder  was  greatly  distended  with  urine  ;  the  pulse  about  140;  the  tongue 
thickly  coated  with  dark-colored  fur ;  sordes  on  the  teeth.    There  was  also  partial 


1  Ibid. 


2  Ibid, 


3  Ibid.,  p.  248. 


INJURIES  OF  THE  SACRUM  AND  COCCYX. 


457 


paraplegia*  The  catheter  was  introduced  and  the  bladder  relieved.  The  missile  was 
searched  for  unsuccessfully.  Opiates  were  then  administered.  He  continued  to  sink 
and  was  perfectly  unconscious.  The  pulse  was  IGO."  He  died  May  15,  that  is,  five 
days  after  the  wound  was  inflicted.* 

The  cause  of  death  is  not  stated,  but,  judging  from  the  symptoms  as  de- 
tailed above,  it  was  traumatic  peritonitis.  At  any  rate,  peritoneal  inflam- 
mation must  be  a  frequent  consequence  of  shot  wounds  such  as  this.  This 
case  is  doubly  interesting  because  of  the  paralysis  of  the  bladder  and  lower 
extremities  which  resulted  from  the  injuries  sustained  by  the  sacral  nerves. 

The  following  example  is  very  instructive,  as  well  as  interesting,  because 
of  the  peculiar  form  of  paralysis,  and  the  haematuria,  which  resulted  from  the 
primary  lesion : — 

Private  Peter  K.,  aged  32,  having  been  wounded  at  the  South  Side  Railroad,  on 
April  1,  1865,  was  sent  to  Washington,  and  admitted  to  Douglas  Hospital  on  the  6th. 
A  conoidal  musket-ball  had  entered  the  left  buttock  nearly  on  a  level  with  the  second 
vertebra  of  the  sacrum,  about  four  inches  from  the  spinous  process  thereof,  had  passed 
through  or  across  the  sacral  portion  of  the  spinal  canal,  and  had  lodged  in  the  right  wing 
of  the  sacrum,  near  its  junction  with  the  ilium.  There  was  complete  paralysis  of  the 
bladder  and  rectum,  with  constant  hoematuria;  but  no  paralysis  of  the  lower  extremities. 
On  the  8th,  the  patient  failed  rapidly,  and  became  partially  insensible.  He  died  on  tiie 
9th,  from  exhaustion,  eight  days  after  the  casualty  occurred.^  The  specimen  is  repre^ 
sented  by  the  accompanying  wood-cut  (Fig.  891).  The  vesico-rectal  paralysis  observed 
in  this  case  is  easily  accounted  for  ;  but  what  caused  the  haematuria?  Did  it  arise  from 
a  neuropathic  congestion  of  the  kidneys,  such  as  we  have  seen  occurs  not  unfrequently 
in  cases  of  spinal  injury  ? 


Showing  the  sacrum  with  a  ball  impacted  at  the  left  Showing  a  shot  fracturp  of  the  sacrum, 

second  intervertebral  notch.  (Spec.  2542,  A.  M,  M.)  (Spec.  3001,  A.  M.  M,) 

In  the  next  case  there  was  a  complete  transverse  fracture  observed : — 

Private  P.  McC,  aged  20,  was  wounded  at  Carrion  Crow  Bayou,  La.,  November 
i>,  1863.  He  was  treated  on  the  field  until  the  8th,  when  he  was  admitted  to  Univer- 
sity Hospital,  New  Orleans,  where  he  died  on  the  22d,  nineteen  days  after  the  infliction 
of  the  wound.  The  case  is  described  as  a  gunshot  fracture  of  the  sacrum  ;  "  the  missile, 
passing  obliquely  from  the  left,  entered  near  the  median  line  at  the  junction  of  the 
second  and  third  sacral  vertebras,  and  escaped  into  the  pelvis  tlirough  the  right  portion 
of  the  second  vertebra.  The  sacrum  was  completely  fractured  transversely  at  that 
point."    The  specimen  is  represented  by  the  accompanying  wood-cut  (Fig.  892).^ 

In  the  following  example,  traumatic  spinal  meningitis  with  tetanic  spasms 
occurred : — 

Private  W.  M.  R.,  aged  22,  was  wounded  at  Winchester,  July  20,  1864,  by  a  conoidal 
musket-ball,  which  penetrated  the  sacral  region  five  inches  above  the  anus,  and  one 


I  Ibid. 


'  Ibid. 


'  Ibid.,  p.  249, 


458 


INJURIES  OF  THE  BACK. 


inch  to  the  left  of  the  median  line,  passed  obliquely  upward  and  forward,  and  lodged. 
There  was  retention  of  urine,  but  no  paralysis  of  sensation  or  voluntary  motion.  On 
the  25th  he  was  very  restless,  and  suffered  great  agony  from  the  wound.  But  little 
change  was  noted  until  August  6,  when  slight  tetanic  spasms,  with  delirium  and  un- 
consciousness, occurred.  They  continued  with  increasing  severity.  On  the  8th, 
opisthotonic  spasms  recurred  at  frequent  intervals,  the  pupils  were  largely  dilated  and 
fixed,  and  he  died  on  that  day.  Autopsy — The  missile  was  found  about  three  inches 
from  the  point  of  entrance,  embedded  in  muscular  tissue.  The  spinal  column  was  in  a 
suppurating  condition.  The  osteological  specimen,  represented  by  Fig.  893,  was  sent 
to  the  Army  Medical  Museum.  It  consists  of  a  wedge-shaped  portion  of  the  sacrum, 
showing  a  fracture  into  the  spinal  canal  at  the  second  sacral  vertebra,  with  the  first  and 
second  spinous  processes  wanting  from  being  broken  off.^ 


Fig.  893.  Fig.  894. 


Showing  a  shot  penetration  of  the  sacral  canal.  (Spec.  Showing  the  sacrum  and  a  part  of  the  right  iliam, 

4258,  A.  M.  M.J  with  the  bullet  which  perforated  the  former.  (Spec, 

1245,  A.  M.  M.) 

This  case,  in  whicli  the  upper  part  of  the  sacral  canal  was  opened  hy  a  gun- 
shot missile,  is  a  very  important  one,  becalise  traumatic  spinal  meningitis 
ensued.  The  symptoms  appeared  on  the  fifth  day,  and  were  extreme  rest- 
lessness, and  "great  agony"  from  pain  in  the  wound,  followed  hy  tetanic 
spasms,  which  steadily  "increased  in  severity  until  opisthotonos  followed,  with 
delirium,  unconsciousness,  and  death.  The  autoj^sy  revealed  a  suppurating 
condition  of  the  spinal  canal.  Another  instance  of  shot-fracture  of  the  sacrum 
in  which  death  resulted  from  spinal  meningitis  and  myelitis,  is  likewise  re- 
ported in  the  same  volume,  on  page  248.  (Case  726.)  ^'^'The  lower  part  of 
the  spinal  cord  was  softened,  and  of  a  dark  appearance."  In  this  case,  too, 
the  missile  after  striking  the  sacrum  lodged. 

The  very  interesting  specimen  w^hich  is  represented  by  Fig.  894,  was  obtained  at 
the  autopsy  of  a  soldier,  aged  26,  who  was  wounded  by  a  conoidal  musket-ball  at 
Chancellorsville,  May  3,  1863,  and  died  at  Douglas  Hospital  nineteen  days  afterward, 
apparently  from  septicaemia.  The  case  is  also  remarkable  for  the  absence  of  peritonitis 
and  paralysis.^ 

In  the  next  example  the  missile  lodged  in  the  spinal  canal,  and,  notwith- 
standing that  the  Cauda  equina  was  compressed  hy  it  (through  the  meninges), 
the  sensibility  and  motility  of  the  lower  extremities  were  not  affected  : — 

Private  Michael  H.  was  wounded  June  27,  1862,  at  Gaines's  Mills,  Virginia,  and 
died  of  exhaustion  on  December  27.    The  wound  closed,  and  there  were  no  symptoms 


i  Ibid. 


8  Ibido 


INJURIES  OF  THE  SACRUM  AND  COCCYX. 


459 


for  about  three  months.  On  October  20,  after  dissipation,  lie  complained  of  pain  in  the 
left  knee,  at  times  very  intense,  depriving  him  of  rest.  The  wound  reopened  and  dis- 
charged freely ;  a  slough  formed  over  the  lower  part  of  the 
sacrum,  tliree  or  four  inches  in  diameter,  and  so  deep  as  to  lay 
the  bone  bare.  A  lumbar  and  psoas  abscess  developed  itself ; 
the  pain  in  the  left  knee  increased  greatly,  and  the  left  leg  be- 
came swollen  and  tender  to  pressure.  The  abscess  in  the  loin 
was  opened  by  a  valvular  incision,  and  three  pints  of  pus  were 
discharged,  with  great  relief  to  the  pain  in  the  leg,  etc.  Both  legs 
became  swollen  about  December  20,  and  he  died  as  stated  above, 
exactly  six  months  after  the  occurrence  of  the  casualty.  At  no 
time  was  there  any  paralysis  of  motion  or  sensation  in  the  lower 
extremities  or  elsewhere.  Necroscopy — An  immense  abscess 
extending  from  the  left  kidney  to  Poupart's  ligament  was  found. 
In  the  pelvis,  in  contact  with  the  sacrum,  there  was  another 
abcess,  while  the  tissues  of  the  pelvis,  at  its  back  part,  were 
buried  in  effusions  of  plastic  matter.  The  ball  was  found 
lodged  in  the  spinal  canal,  opposite  the  fifth  lumbar  vertebra,  as 
shown  in  the  accompanying  w^ood-cut  (Fig.  895).  It  had  en- 
tered on  the  right  side  of  the  spinal  ridge  of  the  sacrum,  about 
its  middle,  passed  diagonally  upward,  and  spent  its  force  on  the 
left  wall  of  the  canal  of  the  first  sacral  and  fifth  lumbar  vertebrte. 
The  left  lamina  of  the  first  sacral  bone  was  carried  away.  The 
missile  had  passed  up  the  spinal  canal  outside  of  the  theca  verte- 
bralis.  The  bodies  of  the  fourth  and  fifth  lumbar  vertebrae  were  ca- 
rious, and  the  intervertebral  cartilage  between  them  was  entirely 
destroyed.    The  first  and  second  sacral  vertebrae  were  necrosed 

and  discolored,  as  was  also  the  fifth  throughout  its  thickness.  The  first  and  second  left 
sacral  nerves  seemed  most  involved  by  the  diseased  bones,  but  the  left  lumbar  plexus 
was  entangled  in  the  diseased  mass  which  occupied  the  basin  of  tlie  pelvis.^ 


Showing  the  sacrum  and 
last  three  lumbar  vertebrae, 
with  a  ball  lodged  in  the 
spinal  canal  opposite  the 
fifth  lumbar  vertebra.  (Sp. 
1198,  A.  M.  M.) 


The^  complete  closure  of  the  wound,  and  the  development  of  caries  and 
necrosis  in  the  bony  structures  which  had  sustained  the  shock  or  impact  of  the 
missile,  after  the  lapse  of  three  months,  are  worthy  of  special  remark  in  this 
place,  as  well  as  the  fact  that  no  paralysis  whatever  occurred. 

Frorn  the  foregoing,  it  appears  that  the  chief  risks  which  were  encountered 
in  treating'  shot  fractures  of  the  sacrum  during  our  civil  war,  were  the  super- 
vention of  (1)  pymnia  or  septiccemia,  (2)  tmumatic  spinal  meningitis  and  mye- 
litis^ {^)p>eritonitis^  and  {^)  caries  and  necrosis  oi  the  injured  bones,  with  the 
formation  of  corresponding  abscesses  in  the  pelvis,  as  well  as  in  the  sacral  and 
lumbar  regions. 

Treatment. — When  the  missile  lodges,  in  cases  of  shot-fracture  of  the  sacrum, 
it  should,  if  possible,  always  be  extracted.  One  case  has  already  been  related 
in  which  this  was  done  with  an  excellent  result.  I  shall  now  present  two 
additional  cases  in  which  important  operations  wqvq  performed  to  the  same 
end,  with  good  effect. 

Surgeon  J.  J.  Chisolm  relates^  the  case  of  a  young  Confederate  soldier  belonsing  to 
the  26th  Alabama  Regiment,  who  was  shot  in  the  back.  The  missile  passed  througli 
the  sacrum  an  inch  from  its  spinous  processes,  and  one  inch  below  the  level  of  the  crest 
of  the  ilium,  and  lodged.  Eight  months  after  the  reception  of  the  wound,  he  applied  to 
Dr.  G.  for  relief,  inasmuch  as  he  had  a  constant  discharge  of  pus  from  both  the  wound 
in  the  back  and  a  fistulous  passage  in  the  left  groin.  Upon  examination  with  a  probe, 
which  penetrated  four  inches,  traversing  the  sacrum,  the  foreign  body  was  detected,  the 
bulb  of  the  probe  entering  the  cup  of  the  minie  ball.  By  enlarging  the  hole  through 
the  sacrum  with  a  gouge,  room  was  obtained  to  draw  the  ball  from  the  pelvic  cavity. 
The  patient  recovered. 


1  Ibid.,  First  Surgical  Vol.,  p.  449. 

2  Manual  of  Military  Surgery,  1863,  p.  356. 


460 


INJURIES  OF  THE  BACK. 


In  the  following  instance  a  trephine  was  applied  for  the  same  purpose  : — 

Private  H.  F.  Norcross,  aged  20,  was  wounded  in  the  right  gluteal  region,  at  Drury's 
Bluff,  May  16,  1864.  The  track  of  the  ball  was  traced  to  the  second  segment  of  the 
sacrum,  and  the  missile  was  apparently  embedded  deeply  in  the  bone.  On  March  9, 
1865,  Dr.  E.  B.  Lyon  reported  that  "  there  was  an  open  sinus  on  the  right  buttock 
communicating  with  the  lodgment  of  the  ball  in  the  sacrum,  and  discharging  freely. 
The  constitutional  condition  was  comparatively  good.  Ether  was  administered,  and  an 
oblique  incision,  six  inches  in  length,  was  made,  exposing  the  orifice  in  the  sacrum. 
A  trephine  was  then  used  to  enlarge  the  orifice  in  the  bone.  The  ball  was  divided  and 
removed  in  seventeen  parts.  Simple  dressings  were  applied."  The  wound  healed 
kindly.  On  July  10,  he  was  discharged  from  the  service  and  pensioned.  In  Septem- 
ber, 1873,  he  was  still  on  the  pension  hst,  his  disability  being  rated  at  one-half.^ 

For  the  removal  of  injured  or  diseased  bone,  or  for  the  extraction  of  im- 
pacted projectiles,  there  were  in  all  twenty-five  operations  performed  during 
our  civil  w^ar,  in  cases  of  shot  fracture  of  the  sacrum.  In  one  instance, 
where  the  missile  was  discovered  "  firmly  embedded  in  the  body  of  the 
sacrum,  beyond  the  reach  of  forceps,  it  was  extracted  by  means  of  a  common 
ramrod,  a  piece  of  which  remains  in  the  bullet  as  when  taken  out."  The  spe- 
cimen is  represented  by  the  accompanying  wood-cut  (Fig.  896).  It  is  pre- 
served in  the  Army  Medical  Museum.^ 


Fig.  896. 


Showing  a  conoidal  ball  which  was  extracted  from  the  sacrum  with  a  ramrod.    (Spec.  1123,  A.  M.  M.) 

The  most  important  points  in  the  treatment  of  shot  fractures  of  the  sacrum 
are  the  following :  (1)  The  removal  of  all  foreign  bodies,  under  which  term 
all  loose  fragments  of  bone,  all  pieces  of  clothing  and  accoutrements,  etc.,  as 
well  as  the  missiles  themselves,  are  included  ;  (2)  the  application  of  antisep- 
tic dressings  to  the  wounds  ;  and  (3),  the  early  and  thorough  use  of  Chassaig- 
nac's  drainage-tubes.  By  antisepsis  and  prompt  drainage  of  the  wounds  the 
risk  of  pyaemia  and  septicaemia  will  be  greatly  lessened._  Any  tendency  to 
peritonitis  or  to  inflammation  of  the  spinal  membranes,  which  may  be  evinced, 
must  be  combated  by  administering  opium  or  morphia  in  full  doses  at  short 
intervals.  Should  spinal  meningitis  supervene,  it  will  require  the  exhibition 
of  ergot  and  potassium  iodide  in  full  doses,  as  already  pointed  out. 

Simple  Fractures  of  the  Coccyx. — In  the  years  1859  and  1860, 1  made  the 
surgical  examination  of  an  old  pensioner  from  the  war  with  Great  Britain,  of 
1812-15,  whose  disability  had  resulted  from  simple  fracture  of  the  os  coccygis 
caused  by  the  kick  of  a  horse,  and  found  that  bone  bent  strongly  forward 
and  to  one  side,  and  rigid  in  that  position.  He  stated  that  his  injury  ^yas 
still  the  source  of  almost  constant  discomfort,  that  it  always  interfered  with 
the  act  of  defecation,  and  sometimes  made  it  painful,  and  that  it  still  made  it 
impossible,  most  of  the  time,  for  him  to  sit  while  working  at  his  trade  of 
saddler  and  harness-maker.  , 

Professor  Ash  hurst'  mentions  a  case  taken  from  the  records  of  the  Pennsylvania 
Hospital,  in  which  there  was  fracture  of  the  coccyx,  as  well  as  comminuted  fracture  of 


1  Medical  and  Surgical  History  of  the  War  of  the  Rebellion,  Second  Surgical  Vol.,  p.  251. 

2  Ibid.  ^  Op.  cit.,pp.  116,  117. 


I>^JURIES  OF  THE  SACRUM  AND  COCCYX. 


461 


tlie  lumbar  vertebrae  and  fractures  of  both  legs,  caused  by  falling  from  the  sixth  story. 
Death  ensued  in  one  day.  The  autopsy  showed  that  the  cause  of  death  was  internal 
(post-peritoneal)  hemorrhage  and  exhaustion. 

Professor  Agnew'  states  that  he  has  known  a  case  in  which  this  accident  resulted 
^rom  a  rider's  coming  down  upon  the  back  of  the  saddle  in  an  attempt  to  mount  a  res- 
tive horse. 

Mr.  South'^  says  he  has  known  two  cases  where  this  accident  was  not  recovered  from 
for  nearly  two  years:  "  The  one  followed  sitting  down  suddenly  on  the  edge  of  a  snuff- 
box, whicli  was  jammed  in  between  the  side  of  the  coccyx  and  the  spine  of  the  haunch 
bone  ;  and  the  other  by  the  patient  having  been  thrown  from  a  horse  upon  a  heap  of 
stones.  In  these  cases  the  pain  was  not  so  great  as  usually  said  to  be  in  walking,  because 
the  patients  learned  to  walk  without  disturbing  the  bone  ;  but  the  pain  was  agonizing 
when  they  incautiously  sat  down  on  a  soft  seat.  Leeching  afforded  only  temporary 
relief;  and  the  cure  was  at  last  effected,  after  months,  by  protecting  the  coccyx  from 
all  possibility  of  pressure,  by  constantly  wearing  a  pair  of  very  thick  oblong  pads  on 
the  ischial  tuberosities,  so  that  in  sitting  the  point  of  the  coccyx  was  in  a  deep  pit." 

Simple  fractures  of  the  coccyx  are  said  sometimes  to  occur  during  parturi- 
tion, in  consequence  of  the  pressure  exerted  by  the  foetal  head  while  passing 
through  the  inferior  strait  of  the  pelvis ;  but  it  is  probable  that  such  cases 
often  consist  of  luxation,  or  rupture  of  the  coccygeal  ligaments,  instead  of 
fracture. 

This  accident  is  of  infrequent  occurrence.  It  may  be  caused  by  kicks,  by 
blows,  by  falls,  and  by  injuries  sustained  during  parturition.  Though  seem- 
ingly a  very  trivial  accident,  it  is  often  exceedingly  painful  and  annoying  for 
many  months  or  years,  or  even  for  a  lifetime. 

The  displacement  in  fracture  of  the  coccyx  is  forward,  and  it  is  produced 
by  the  same  agencies  as  those  which  cause  the  deformity  in  simple  fracture 
of  the  sacrum,  namely,  the  contractions  of  the  muscles  which  are  inserted 
into  the  coccyx,  as  well  as  the  general  direction  of  the  fracturing  force. 

Treatment — Although  the  injury  at  first  sight  may  appear  inconsiderable, 
the  victims  of  this  accident,  for  reasons  presented  above,  should  always  be 
confined  to  bed,  in  that  posture  which  is  least  painful,  and  which  causes  least 
disturbance  of  the  injured  bone.  Any  forward  displacement  should  be  cor- 
rected by  inserting  a  finger,  well  oiled,  into  the  rectum,  and  pressing  the  bone 
back  into  its  normal  position.  If  the  deformity  returns,  it  may  become 
advisable  to  employ  such  tampons  as  have  been  described  while  discussing 
fractures  of  the  sacrum.  Should  much  inflammation  supervene  in  the  in- 
jured part,  the  application  of  leeches,  followed  by  a  lotion  composed  of  lead- 
water  and  laudanum,  will  prove  useful  in  subduing  the  inflammatory  action, 
and  in  diminishing  the  liability  to  the  occurrence  of  neuralgia,  necrosis, 
abscess,  and  fistula.  Should,  however,  the  ligamentous  tissue  surrounding 
the  bone  continue  inflamed  and  painful,  notwithstanding  the  treatment,  and 
especially  should  the  apex  of  the  injured  bone  be  incessantly  dragged  forward 
by  spasmodic  action  of  the  sphincter  ani  and  other  muscles  which  are  inserted 
into  the  os  coccygis,  it  may  be  proper  to  forcibly  stretch  the  sphincter,  under 
ether,  as  in  cases  of  anal  fissure,  so  that  the  fibres  of  that  muscle  may  be 
paralyzed  for  a  time,  and  that  defecation  may  take  place  without  spasm  and 
without  restraint.  After  such  patients  leave  their  beds,  it  will  often  be  use- 
ful for  them  to  protect  the  coccyx  from  injury  by  constantly  wearing  a  pair 
of  thick  oblong  pads  on  the  tuberosities  of  the  ischium,  as  recommended  by 
Mr.  South. 

1  Op.  cit.,  vol.  i.  p.  923. 

*  Notes  to  Chelius's  Surgery,  vol.  i.  pp.  595,  596,  Am.  ed. 


462 


INJURIES  OF  THE  BACK. 


Fig.  897. 


Gunshot  Fractures  of  the  Coccyx. — In  shot  wounds  of  this  sort,  the  lesion 
of  the  bone  is  commonly  but  a  small  part  of  the  whole  injury.  There  were 
seventeen  cases  of  shot  fracture  of  the  os  coccygis  reported  during  our  civil 
war,  of  which  six,  or  35.3  per  cent.,  were  fatal.  In  twelve  cases,  with  five 
deaths,  the  coccyx  was  the  only  bone  involved ;  in  four  cases,  terminating 
favorably,  there  were  attendant  fractures  of  the  sacrum  ;  two,  one  of  which 
was  fatal,  were  associated  with  fractures  of  the  pubis.  In  one  case  a  ball  is 
said  to  have  been  found  imbedded  in  the  coccyx.  In  all  the  fatal  cases,  death 
a]3pears  to  have  resulted  from  the  injuries  sustained  by  other  parts.  Still, 
visceral  lesions  were  less  frequently  present  as  complications  of  shot  fractures 
of  this  bone,  than  would  be  anticipated  from  its  anatomical  relations.^ 

In  regard  to  treatment,  the  irregularity  and  variety  of  the  complications 
preclude  the  establishment  of  any  special  rules.  The  early  removal  of 
sequestra  and  foreign  bodies  is,  of  course,  indispensable.  Free  though  cau- 
tiously directed  incisions  may  -be  requisite  to  prevent  the  burrowing  of  pus. 
Extreme  attention  to  cleanliness,  and  to  the  prevention  of  fecal  accumulation 
in  the  rectum,  as  well  as  watchfulness  over  the  state  of  the  bladder,  are 
precautions  that  must  not  be  overlooked.^  The  wounds  must  be  dressed 
antiseptically,  and  drainage  tubes  must  likewise  be  inserted,  in  many  cases,  in 
order  to  insure  that  no  confinement  of  inflammatory  products  shall  take  place. 

CoccYaoDYNiA. — The  damage  sustained  by  the  sacro-coccygeal  and  other 
spinal  nerves,  in  connection  with  injuries  of  the  os  coccygis,  often  gives  rise 

to  an  exceedingly  painful  state  of  the 
soft  parts  overlying  the  bone,  which 
has  been  denominated  coccygodynia. 
The  accompanying  wood-cut  (Fig. 
897),  which  indicates  the  numerous 
nerves  of  sensation  that  are  distri- 
buted over  the  coccyx,  and  to  the 
lower  part  of  the  rectum  as  well  as 
to  the  margin  of  the  anal  aperture, 
shows  at  a  glance  the  anatomical  and 
physiological  explanation  of  this  dis- 
tressing affection. 

For  the  relief  of  coccygodynia,  it 
was  advised  by  the  late  Sir  James  Y. 
Simpson,  to  introduce  a  narrow  bis- 
toury between  the  soft  parts  and  the 
bone,  and  completely  sever  the  con- 
nections between  them.  Should  this 
simple  procedure  fail,  and  the  symp- 
toms continue  severe,  it  may  be  neces- 
sary to  excise  the  bone  itself  When 

a,  Sacrum,    b,  Coccyx,    c,  Tuberosity  of  ischium.  CarlcS  Or  llCCrOsis  is  prCSCUt,  CXcisioil 

d,  Greater  sacro-sciatic  ligament,    e,  Lesser  sacro-sci-  ^^f  -j-J^^  boUC  is  alwayS  UCCCSSary. 

atic  ligament,  with  pudic  nerve  on  its  posterior  aspect.  j                  .         OpCrativC  prOCCdurCS, 

/,  Sphincter  am.     ^,  Levator  am.     7i,  Fatty  and  con-  ^^i?*^                i                   t  ' 

nective  tissue.  Van  Onscuoort  and  01  her  have  extir- 

1,  Pudic  nerve  and  its  branches.  patcd  thc  coccyx  for  caries,  and  i^ott, 

2,  Posterior  branches  of  the  2d,  3d    and  4th  sacral     gji^pgoi,    ^y^^   ^laUV  OthcrS  haVC  pCr- 
nerves  proceeding  to  posterior  aspect  of  the  coccyx.  n  i  "  j.'  •  ^.X^  ' 

.3,  Sacro-coccygealnerve  distributed  over  apex  of  the     lOrmed   thC   SaUlC  OpCratlOU  With  im- 
coccyx  and  adjacent  soft  parts.     (Hilton.)  pUllity  for  nCUralgla  (cOCCygodyuia). 


1  Medical  and  Surgical  History  of  the  W&r  of  tlie  Rebellion,  Second  Surgical  Vol.,  pp.  252,  253. 

2  Ibid.,  253,  254. 


KEMOTE  EFFECTS  OF  SPINAL  INJURIES. 


463 


Dr.  James  E.  Garretson^  has  proposed  and  successfiillj  performed  the 
operation  of  removing  the  coccyx  without  disturbing  the  perinoid  anatomy, 
by  the  employment  of  a  dental  engine.  This  operation  was  done  at  l^eini 
Manor,  on  the  person  ot  a  lady  who  had  suffered  from  coccygodynia  for 
thirteen  years.  Exposure  of  the  coccyx  revealed  it  as  fractured  and  stand- 
ing at  right  angles  with  the  sacrum.  Dr.  Garretson's  proposition  was  to 
remove  the  bone  by  simple  enucleation  ;  in  other  words,  to  remove  the  osseous 
tissue  from  its  envelope  of  periosteum  without  disturbing  the  under  layer 
thereof  which  is  the  surface  of  attachment  for  the  soft  parts  constitutinii;  the 
posterior  perineum,  and,  of  course,  without  disturbing  the  relations  of  the 
structures  which  constitute  the  perineum  itself.  The  operation  was  performed 
in  the  following  manner : — 

The  patient  being  etherized  and  placed  partially  upon  her  abdomen,  an  arm  being 
under  the  body  at  the  region  of  the  diaphragm,  to  secure  freedom  in  respiration,  an 
incision  was  made  through  the  skin  and  superiicial  fascia,  the  length  of  tlie  coccyx. 
These  tissues  being  carried  to  either  side  by  means  of  retractors,  a  second  incision  was 
made  through  the  periosteum,  and  by  means  of  a  chisel-sliaped  knife  this  structure  was 
raised  and  everted.  In  this  last  is  the  peculiarity  of  tlie  operation  :  it  is  as  though  one 
might  cut  down  the  centre  of  the  upper  surface  of  an  envelope,  exposing,  in  the  turn- 
ing aside  of  the  paper,  a  letter  lying  on  the  lower  face  of  the  envelope,  the  turned- 
aside  upper  part  being  of  continuity  with  the  bottom  of  the  paper.  A  succeeding  step 
employs  the  engine.  A  circular  burr,  the  face  side  alone  of  which  is  cut,  is  placed  in 
the  grasp  of  the  handpiece,  and  while  in  revolution  to  the  extent  of  ten  thousand  times 
to  the  minute,  is  applied,  with  delicacy  of  manipulative  touch,  to  the  surface  of  the 
bone.  In  the  case  here  recorded,  live  minutes  sufficed  for  the  disappearance  of  the 
coccyx  in  the  shape  of  bone  dust,  the  under  face  of  the  periosteum  remaining  as  undis- 
turbed as  though  it  had  never  been  in  relation  with  the  coccyx.  The  wound,  a  super- 
ficial one,  was  put  up  to  heal  by  first  intention. 

I  believe  this  operation  to  be  a  very  good  one,  and  therefore  I  have  taken 
the  space  requisite  to  describe  it. 


Remote  Effects  of  Spinal  Injuries,  Railway  Spine,  etc. 

When  fractures  or  dislocations  of  the  spinal  column  eventuate  in  recovery, 
there  occurs,  as  a  rule,  anchylosis,  with  immobility  or  inflexibility  of  the 
injured  part  of  the  column.  Any  vertebral  displacement  which  may  have 
been  allowed  to  remain  will  constitute  a  deformity.  Among  the  remote 
effects  of  spinal  fractures  and  dislocations,  anchylosis,  stiffness  or  inflexi- 
hility,  and  deformity  must  therefore  be  enumerated.  In  cases  Avhere  the  cer- 
vical portion  of  the  column  has  been  thus  injured,  the  inflexibility  and  defor- 
mity may  cause  much  inconvenience  in  many  ways,  and  may  also  interfere, 
seriously  and  persistently,  with  the  act  of  swallowing.  These  points  are 
well  illustrated  by  the  following  case : — 

George  Reid,  aged  29,  a  tailor,  was  admitted  into  Bellevue  Hospital  (Dr.  Stephen 
Smith's  Ward)  on  August  5,  1858,  for  cephalalgia,  the  result  of  an  injury.  He  was 
short  in  stature,  but  well  made  and  well  nourished,  and  free  from  constitutional  taint 
and  tendency. 

Upon  external  examination,  the  fifth  cervical  vertebra,  its  spinous  process,  etc.,  were 
found  displaced  fbrward  ;  upon  examination  througli  the  mouth,  the  body  of  this  ver- 
tebra was  felt  projecting  forward,  and  forming  a  large  prominence  in  the  pharynx.  He 
was  unable  to  swallow  solid  food  to  any  considerable  extent.  This  dysphagia  and  the 
necessarily  awkward  position  in  which  he  was  forced  to  carry  his  head  were  the  only 

1,  Annals  of  Anatomy  and  Surgery,  March,  1882. 


464  INJURIES  OF  THE  BACK. 

local  difficulties  now  present,  which  resulted  from  the  vertebral  displacement.  The 
vertebrae  themselves  were  firmly  fixed  in  their  new  position.    His  general  health  was 

^^^History  In  September,  1856,  the  patient  fell  backward  down  fifteen  stairs,  and 

struck  upon  the  back  of  his  head  and  neck.  He  was  rendered  insensible,  and  remained 
so  for  three  hours.  He  has  never  been  able  to  recollect  anything  in  regard  to  his  fall, 
his  memory  otherwise  being  unimpaired.  There  was  no  wound  nor  contusion,  nor  any 
other  external  evidence  of  injury  upon  his  neck.  With  returning  consciousness  he  did 
not  become  aware  of  his  injury  until  he  attempted  to  rise  from  the  bed.  He  then  felt 
an  acute,  spasmodic  pain  in  the  back  of  his  neck,  which  subsided  immediately  on  lying 
down  ao-ain.  This  pain  in  the  back  of  his  neck,  on  motion,  continued  three  months. 
Tliree  weeks  subsequent  to  the  accident,  he  began  to  have  severe  pain  in  the  back  of 
his  head— usually  nocturnal— and  at  that  time  was  admitted  to  this  hospital  in  the 
service  of  Dr.  Charles  D.  Smith.  Excepting  the  pains  just  mentioned,  and  dysphagia, 
he  has  not  had  any  subjective  symptoms  of  spinal  injury.  There  have  been  no  anaes- 
thesia, no  paralysis,  no  difficulty  in  breathing,  micturating,  or  defecating,  and  no  in- 
crease of  temperature.  .    i     •  j. 

His  general  health  being  good,  he  was  discharged  as  affiardmg  no  particular  indica- 
tion for  treatment.^ 

The  "  awkward  position"  mentioned  above  in  which  the  patient  was  com- 
pelled  to  carry  his  head  is  not  described  in  words,  but  it  was  doubtless  the 
following :  Inasmuch  as  the  original  lesion  of  the  spinal  column  consisted  m 
a  forward  dislocation  of  the  body  of  the  fifth  cervical  vertebra  upon  that  of 
the  sixth,  there  occurred  in  consequence  of  the  action  of  the  muscles  directly 
or  indirectly  involved,  together  with  the  superimposed  weight  of  the  head,  a 
forward  bend  in  the  spinal  column  ^t  the  place  of  injury,  which  widely  sepa- 
rated the  spinous  process  of  the  fifth  cervical  vertebra  from  that  of  the  sixth, 
and  likewise  caused  the  neck  and  head  to  present  a  "  thrust-forward"  appear- 
ance, as  well  as  to  acquire  a  "  thrust-forward"  position.  It  certainly  must 
have  been  very  awkward  for  the  patient  to  carry  his  head  always  m  that 
manner.  And  had  the  deformity  been  removed  at  the  outset  by  reducing 
the  dislocation,  it  would  have  been  much  better  for  the  patient,  because  by 
so  doins:  his  difficulty  in  swallowing  would  have  been  obviated,  and  his  head 
would  have  been  placed  in  a  much  more  comfortable  position. 

The  pain  in  the  back  part  of  this  patient's  neck  and  head  which  followed 
the  accident,  and  still  persisted  two  years  afterward  in  a  troublesome  or  dis- 
tressful degree,  was  probably  due  to  meningeal  irritation,  or  a  low  grade  ot 
meningeal  inflammation,  which  itself  resulted  from  the  fact  that  the  disloca- 
tion was  not  reduced,  and  that  the  theca  vertebralis  was  consequently  stretched 
and  irritated  by  the  injured  vertebrse  in  their  abnormal  positions.  Thus  it 
appears  that  pains  arising  from  meningeal  irritation  and  inflammation  (both 
spinal  and  cerebral)  must  also  be  enumerated  among  the  remote  etiects  ot 
vertebral  fractures  and  dislocations.  Moreover,  much  difiiculty  will  otten  be 
experienced  in  controlling  this  meningeal  disorder,  unless  perchance  the  causal 
indication  in  its  treatment  has  previously  been  fulfilled,  by  "  setting  the 
fractured  or  dislocated  vertebrae,  and  thus  removing  the  displacement  upon 
which  its  existence  mainly  depends.  The  remedial  measures  to  be  employed 
in  such  cases  are  dry  cupping  and  setons,  together  with  the  administration  ot 
potassium  iodide  in  fulf  doses,  alternated  with  corrosive  sublimate,  for  a  long 

Among  the  remote  eflTects  of  sprains,  wrenches,  and  twists  of  the  sphial 
column  are  chronic  ivflammation  of  the  vertebral  joints  that  are  implicated, 
which  is  often  suppurative  in  character,  destruction  of  the  articular  cartilages 
and  the  intervertebral  substances  that  are  involved,  and  canes  or  7iecrosis  ot 


I  New  York  Journal  of  Medicine,  March,  1859,  p.  246. 


REMOTE  EFFECTS  OF  SPINAL  INJURIES. 


46^ 


the  adjoining  vertebral  bodies.  In  such  cases,  tlie  destructive  process  begins 
more  frequently  at  the  junction  of  the  vertebrae  with  the  intervertebral  sub- 
stances than  in  the  intervertebral  substances  or  vertebrae  themselves,  because, 
as  Mr.  Hilton  has  pointed  out,  we  know  that  in  accidents,  at  least  as  far  as  we 
have  been  able  to  discover,  "  the  most  frequent  lesion  in  injury  to  the  spine 
is  a  partial  severance  of  the  vertebra  from  the  intervertebral  substance."^ 

A  number  of  illustrative  examples  have  already  been  presented,^  and 
inasmuch  as  this  topic  has  already  been  pretty  thoroughly  discussed,  no 
apparent  need  exists  for  presenting  any  additional  instances  of  the  same  sort. 
I  will,  however,  take  space  to  present  a  very  instructive  case,  in  which  there 
simultaneously  occurred  lurabo-sacral  abscess  and  suppurative  spinal  menin- 
gitis, ii^  consequence  of  a  blow  on  the  spinal  column : — 

A  lad,  aged  15,  employed  with  his  parents  in  a  travelling  show,  was  in  good  health 
until  May  12,  1856,  when,  while  playing  with  another  lad,  he  received  a  blow  on  the 
back  with  the  fist.  He  thought  little  of'  it  at  the  time  ;  but,  subsequendy,  the  pain 
becoming  severe,  he  applied  for  and  obtained  admission  into  Guy's  Hospital  on  May  15. 
After  the  application  of  leeches  he  was  so  much  relieved  that  he  thought  of  going  out, 
but  the  pain  soon  returned  more  severely,  and  fever  ensued.  An  abscess  formed  on  tlie 
right  side  of  the  sacrum,  which  was  opened,  and  continued  to  discharge,  tlie  flow  of 
pus  being  increased  by  pressure  on  the  abdomen.  He  continued  to  get  worse  daily, 
having  much  irritative  fever  and  severe  pain  in  the  back.  During  the  last  week  of  his 
life  he  was  exceedingly  restless,  and  often  delirious  ;  and  he  complained  of  pain  in  all 
parts  of  his  body,  but  particularly  in  the  extremities.  His  head  was  generally  drawn 
backward  as  in  tetanic  opisthotonos.  On  one  or  two  occasions  he  had  loss  of  power 
over  the  bladder  and  rectum,  but  had  no  other  symptoms  of  paraplegia,  and  could  move 
freely  in  bed.  On  June  4  he  died,  twenty-two  days  after  the  casualty,  and  nineteen 
days  after  entering  the  hospital. 

Autopsy — An  aperture  in  the  integuments  at  the  right  side  of  the  sacrum  led  into 
a  very  extensive  abscess,  external  to  the  peritoneum,  which  occupied  the  forepart  of  the 
sacrum  behind  the  rectum,  and  extended  to  the  ilia  on  both  sides  behind  tiie  psoas 
muscles.  The  bones  were  exposed  but  not  diseased.  Although  the  abscess  had  dis- 
charged externally  on  the  right,  it  was  most  extensive  on  the  left.  It  had  burrowed 
up  to  the  left  side  of  the  last  lumbar  vertebra,  and  through  the  sacro-vertebral  foramen 
into  the  spinal  canal.  When  the  theca  was  opened,  it  was  found  to  contain  a  quantity 
of  greenish  pus,  spread  over  its  inner  surface  and  over  the  cord  itself.  The  spinal  dura 
mater  (theca)  at  the  point  indicated,  was  softened  and  destroyed,  and  the  cauda  equina 
was  lying  bathed  in  the  pus  which  filled  the  sacral  canal.  The  membranes  of  the  cord 
were  inflamed  throughout  their  whole  extent,  and  there  was  purulent  eflTusion  as  high  as 
the  dorsal  region.  The  spinal  dura  mater  was  thickened,  its  inner  surface  had  lost  its 
smoothness  and  transparency,  and  was  of  a  dull-green  color.  Pus  could  be  squeezed 
out  from  beneath  the  visceral  arachnoid  in  considerable  quantity.  The  spinal  cord 
itself  was  firm,  and  the  microscope  revealed  no  morbid  condition  in  its  substance.  On 
opening  the  cranium,  traces  of  acute  arachnitis  were  found  over  the  whole  surface  of  the 
brain,  greenish-colored  lymph  being  effused  into  the  sub-arachnoid  tissue,  especially  at 
the  base.  The  inner  surface  of  the  dura  mater,  around  the  foramen  magnum  and  on 
the  adjacent  part  of  the  occipital  fossa,  was  of  a  greenish  color,  from  lymph  effused 
upon  it.  Bronchial  tubes  filled  with  tenacious  mucus.  Lumbar  and  bronchial  glands 
slightly  enlarged.    All  other  organs  entirely  healthy.^ 

The  purulent  infiltration  of  the  spinal  meninges  w^hich  was  observed  in 
this  case,  occurring  coincidently  with  the  formation  of  a  lumbo-sacral  abscess, 
but  without  the  production  of  paralysis,  could  scarcely  have  happened  unless 
the  sacro-vertebral  articulation  had  previously  been  opened,  both  externally 
and  internally,  by  disease  of  the  articulation  itself,  in  such  a  manner  as  to 
allow  the  products  of  inflammatory  action  to  flow  freely  out  of,  as  well  as 

1  Op.  cit.,  pp.  47,  48.  2  See  pp.  280-303  supra. 

3  Guy's  Hospital  Reports,  1856,  pp.  158,  159. 
VOL.  IV. — 30 


466 


INJURIES  OF  THE  BACK. 


into,  the  spinal  canal.  Otherwise,  the  suppurative  meningitis  would  pretty 
certainly  have  caused  paralysis  by  compressing  the  spinal  cord  with  the  in- 
fiammatory  products. 

The  clinical  history  of  this  lad's  case,  interpreted  by  the  post-mortem  ap- 
pearances, appeai-s  to  have  been  as  follows :  The  blow  on  his  back  wrenched 
the  sacro-vertebral  articulation,  and  caused  a  suppurative  inflammation  to 
be  lighted  up  therein,  particularly  on  the  left  side,  and  in  consequence  of 
this,  purulent  matter  escaped  in  an  outward  direction,  and  led  to  the  forma- 
tion of  an  immense  lumbo-sacral  abscess  ;  it  likewise  escaped  in  an  inward 
direction,  and  caused  the  theca  vertebralis  to  become  softened  and  perforated, 
and  extensively  destroyed,  and  a  diffuse  suppurative  inflammation,  which 
extended  upward  to  the  brain,  to  be  kindled  in  the  spinal  arachnoid.  More- 
over, the  account  of  the  case  presented  above  gives  the  symptoms  by  which 
each  of  these  periods,  or  stages,  in  the  progress  of  the  case  was  characterized. 

The  symptoms  indicative  of  the  joint  inflammation  were  pain  in  and  sore- 
ness of  the  joint  itself,  and  these  were  to  some  extent  relieved  by  leeching.  The 

Fig.  898. 


Showing  the  lower  part  of  the  spinal  cord,  and  the  distribution  in  the  trunk  of  the  corresponding  spinal  nerves. 
(Swan.)  a,  The  spinal  cord,  h,  The  posterior  branches  of  the  spinal  nerves,  proceeding  to  the  muscles  and  integu- 
ments  of  tlie  loins,  etc.  c,  The  radiating  lines  indicate  the  anterior  branches  of  certain  dorsal  nerves  which  are 
distributed  to  the  muscles  and  integuments  of  the  upper  half  of  the  abdominal  walls,  d,  The  anterior  branches 
of  the  lumbar  nerves  which  are  distributed  to  the  lower  part  of  the  abdominal  walls,  ee,  Anterior  part  of  the 
abdominal  walls.  /,  The  rectus  abdominis  muscle,    p-,  The  obturator  nerve.    7t,  The  diaphragm.  (Hilton.) 

formation  of  the  lumbo-sacral  abscess  was  attended  by  a  return  of  the  joint- 
pain,  followed  by  pyrexia,  and  by  the  appearance  of  a  swelling  which,  on  being 
opened,  discharged  purulent  matter.  The  spinal  meningitis  set  in  with 
severe  pahi  in  the  spinal  column,  and  irritative  fever,  followed  by  extreme 


REMOTE  EFFECTS  OF  SPINAL  INJURIES. 


467 


restlessness  and  general  bypersesthesia  of  a  severe  character.  Tetanic  spasms 
and  opisthotonos  ensued. 

The  remote  effects  of  spinal  injuries  a^-e  to  be  still  further  traced  in  the 
occurrence  of  chronic  spinal  arachnitis  of  a  fatal  character,  without  the  super- 
vention of  any  vertebral  joint  inflammation  whatever. 

Sir  W.  Gull  has  recorded  the  following  instructive  case  of  traumatic, 
chronic,  spinal  arachnitis  : — ^ 

A  railway  porter,  aged  22,  strong  and  muscular,  had  his  neck  and  shoulders  squeezed 
between  the  buffers  of  two  carriages,  on  September  20,  1855.  For  three  or  tour  weeks 
afterward,  he  was  unable  to  work,  and  felt  much  pain  in  the  right  arm,  as  also  in  the 
scapular  region  and  down  the  back,  especially  between  the  seventh  and  tenth  dorsal 
vertebra?.  The  pain  was  increased  by  any  sudden  twist  of  the  body,  and  extended  to 
the  abdomen.  About  the  first  of  February,  1856,  he  was  again  obliged  to  quit  work, 
on  account  of  the  severity  of  the  pain  along  the  spine.  On  Feb.  6,  he  was  admitted 
to  the  hospital  under  Dr.  Addison's  care.  There  were  pain  on  pressure  over  the  lower 
d©rsal  vertebne,  pain  in  the  abdomen,  and  occasional  tingling  in  the  hands  and  feet. 
The  abdomen  itself  was  full  and  hard,  with  pain  on  suddenly  turning  the  back,  extend- 
ing from  the  ribs  below  the  umbilicus.  Nothing  abnormal  was  found  in  the  chest; 
pulse  78  ;  tongue  furred  in  the  centre;  bowels  regular;  appetite  defective.  He  was 
treated  by  cupping,  mercurials,  and  laxatives.  On  the  11th,  the  pain  in  the  back  w^as 
increased  He  also  had  headache,  and  his  nights  were  restless  and  disturbed  by 
dreams.  The  shooting  pain  in  the  abdomen  continued,  and  it  was  noted  that  the 
integuments  were  remarkably  hot  and  dry.  The  pulse  was  72,  with  a  noticeable  sharp- 
ness in  the  beat.  From  this  date  he  became  slightly  affected  by  mercurial  action,  and 
was  apparently  improving.  He  left  his  bed  for  several  hours  in  the  day,  without  incon- 
venience;  still,  however,  complaining  of  his  former  symptoms,  and  of  pain  through 
the  chest.  On  the  28th  he  had  general  febrile  symptoms,  with  cough,  and  hurried 
breathing,  and  signs  of  pleurisy  at  the  base  of  left  lung.  The  abdomen  was  tense  ; 
constipation  ;  pulse  112  ;  sleep  disturbed  by  dreams,  and  by  frequent  spasmodic  twitch- 
ings  of  the  extremities.  He  complained  very  much  of  pain  in  the  lumbar  region,  on 
each  side  of  the  vertebral  column,  and  down  the  sacrum.  On  March  11,  there  was 
retention  of  urine.  On  the  13th,  slight  delirium,  and  a  marked  decline  of  strength. 
He  was  scarcely  able  to  move  his  legs,  but  the  sensation  on  pinching  was  acute.  He 
lay  supine,  sinking  to  the  foot  of  the  bed,  his  arms  being  too  weak  to  help  him  to  sup- 
port himself  From  this  date  he  rapidly  became  worse,  with  much  cerebral  oppression. 
The  urine  drawn  off  daily  by  the  catheter  w^as  ammoniacal,  with  large  deposit  of  phos- 
phates The  feces  escaped  involuntarily.  Frequent  convulsive  twitchings,  both  of  the 
upper  and  lower  extremities.  Breathing  hurried  and  laborious.  Tongue  dry  and 
brown.  Pulse  108  On  the  day  before  death,  he  lay  nearly  insensible,  frequently 
moaning  and  sighing,  pulse  90,  feeble  and  irregular;  urine  copious,  and  drawm  off  by 
catheter,  feces  passed  involuntarily.  On  the  17th  he  died,  about  six  months  after  the 
accident 

Autopsy. — No  injury  of  the  vertebrce  or  ribs  was  discovered  ;  spinal  canal  and  exter- 
nal surface  of  the  spinal  dura  mater  healthy.  On  opening  the  dura  mater,  the  spinal 
arachnoid  appeared  remarkably  thickened  and  flocculent,  from  the  effusion  of  lymph 
beneath  it.  The  effusion  was  greatest  on  the  posterior  surface  of  the  cord  along  the  me- 
dian line,  but  at  the  lower  part  of  the  cord  (a  segment  of  it  corresponding  to  the  lower 
cervical  and  eighth  upper  dorsal  vertebra3  only  was  allowed  by  the  friends  to  be  exam- 
ined), the  effusion  extended  around  it  to  the  anterior  surface,  and  upward  for  a  short 
distance.  The  cord  itself  was  not  softened  ;  and,  on  repeated  microscopical  examination  of 
the  cord-substance,  at  different  sections,  no  traces  of  exudation  were  discovered.  The 
theca  vertebralis  had  undergone  no  alteration,  excepting  that  the  inner  layer  was  rather 
opalescent.  One  or  two  very  small  fibroid  plates  on  the  visceral  arachnoid.  The 
fiocculent  effusion  covering  the  cord  (that  is,  found  in  the  meshes  of  the  pia  mater), 
presented  under  the  microscope  the  usual  appearances  of  inflammatory  exudation  on 
serous  surfaces  in  the  stage  of  organization  into  permanent  adhesions.  Examination 


Guy's  Hospital  Reports,  1856,  pp  156,  157. 


468 


INJURIES  OF  THE  BACK. 


of  head  not  allowed.  Old  adhesions  over  the  surface  of  the  upper  lobes  of  both  lungs. 
At  lower  part  of  left  chest,  about  a  cupful  of  purulent  fluid  was  found.  Parenchyma 
of  both  lungs  stuffed  with  softish,  yellow,  miliary  tubercles,  equally  diffused  from  apex 
to  base.  Kidneys  large  ;  their  cortical  portion  studded  with  miliary  tubercles.  The 
splenic  tissue  similarly  affected.    Heart  and  liver  healthy. 

The  phenomena  of  subacute,  traumatic,  spinal  meningitis,  when  it  runs  a 
chronic  course  to  a*  fatal  termination,  are  well  shown  by  this  case.  The 
symptoms  characteristic  of  the  disease  were  pain  in  the  affected  part  of  the 
spinal  column,  increased  by  suddenly  twisting  or  bending  it ;  also  pain  felt 
in  the  peripheral  extremities  of  all  the  spinal  nerves  issuing  from  the  affected 
part  of  the  spinal  column,  particularly  in  the  abdomen,  in  the  loins,  and  in 
the  lower  extremities.    The  abdominal  pain  was  attended  with  hot  and  dry 
integuments,  and  probably,  if  carefully  looked  for,  oscillations  of  temperature 
would  have  been  observed.    These  peripheral  pains  arise  from  the  excitation 
of  the  sensory  filaments  of  the  corresponding  spinal  nerves  by  the  inflammatory 
action  that  is  going  on,  within  the  spinal  canal,  in  the  membranes  of  the  cord 
adjoining  their  roots  ;  for  instance,  in  cases  where  such  peripheral  pains  are  felt 
at  the  epigastrium,  the  sensory  filaments  of  the  sixth  or  seventh  dorsal  nerves 
are  excited  by  the  inflammatory  process  in  the  spinal  arachnoid  and  pia  mater 
mvesting  them  before  they  enter  the  intervertebral  foramina.    When  the 
sensory  filaments  of  the  eighth  or  ninth  dorsal  nerves  are  irritated  in  this 
manner,  the  peripheral  pains  are  felt  lower  down  in  the  abdominal  walls,  in 
the  parts  thereof  which  are  supplied  by  the  irritated  nerve-fibres  ;  and  when 
the  sensory  filaments  of  the  remaining  dorsal,  or  of  the  lumbar  nerves,  are 
excited  in  a  similar  manner,  the  peripheral  pains  are  felt  still  lower  down, 
in  the  respective  terminal  extremities  of  the  excited  nerve-filaments.  ^  Excita- 
tion (intra-spinal)  of  the  motor  filaments  of  the  spinal  nerves  arising  from 
the  same  cause,  in  this  case,  was  denoted  "  by  frequent  spasmodic  twitchings 
of  the  extremities,"  by  the  "  tense"  and  "  hard"  condition  of  the  abdominal 
muscles  which  arose  from  tetanoid  (tonic)  spasm  thereof,  and  by  the  per- 
sistently stiflt'  or  contracted  feeling  in  the  muscles  of  the  extremities,  particu- 
larly the  lower  ones,  which  doubtless  was  present,  and  would  have  been  re- 
vealed by  asking  the  patient  about  it.  .    t    „     -,  i 

The  altered  sensations  of  the  patient  in  this  case,  the  "  tingling  and  the 
"  numbness"  in  his  feet  and  hands,  and  the  acute  sensation  produced  by 
"pinching"  his  legs  (hypersesthesia)  after  paraplegia  had  set  in,  were  due 
either  to  inflammatory  excitation  of  the  cord-substance  by  the  contiguous 
membranes,  or  to  compression  of  the  cord-substance  by  the  inflammatory 
products  effused  in  the  meshes  of  the  spinal  pia  mater.  The  vesical  paralysis, 
the  alkaline  urine,  the  anaesthesia  (insensibility)  and  motor  paralysis  (or 
paraplegia)  which  appeared  near  his  end,  were  caused  by  compression  of  the 
cord-substance  efiected  in  the  way  just  mentioned. 

The  inflammatory  eflPusion  was  found  at  the  autopsy  of  this  case,  as  usual, 
under  the  so-called  visceral  layer  of  the  sphial  arachnoid  alone,  that  is,  m 
the  interstices  of  the  pia  mater,  but  principally  on  the  posterior  surface  of  the 
cord,  to  which  it  had  probably  settled  by  gravitation.  The  exudation  itvself 
did  not  contain  pus-corpuscules,  and  would  have  been  capable  of  becoming 
organized,  if  it  had  not  caused  death  by  its  quantity,  and  by  the  compres- 
sion which  it  exerted  upon  the  cord  substance.  The  tabercular  infiltration  of 
the  pulmonary,  renal,  and  splenic  tissues,  which  was  revealed  by  the  autopsy, 
must  be  held  to  have  probably  resulted  from  the  pathological  state  of  the 
spinal  cord-substance.  .  . 

But,  among  the  remote  eftects  of  spinal  injuries,  chronic  spinal  meningitis, 
combined  with  chronic  myelitis,  and  running  their  joint  course  pari  passu, 


REMOTE  EFFECTS  OF  SPINAL  INJURIES. 


4(39 


must  likewise  be  mentioned.  The  following  example  will  serve  to  illustrate 
the  phenomena  of  traumatic  spmal  meningitis  and  myelitis,  when  they  are 
subacute,  and  run  a  chronic  course  together  to  a  fatal  ending. 

Sir  W.  GulP  relates  the  case  of  a  coal  wagoner,  aged  49,  w'no  was  forced  backward 
from  his  seat  by  striking  his  head  against  a  beam,  whilst  driving  under  an  archway  i 
several  ribs  on  the  left  side  were  fractured.  Some  montlis  afterward,  he  began  to  sulfer 
pain  extending  from  the  occiput  down  over  the  shoulders  ;  and,  in  about  a  year,  the 
muscles  of  tiie  upper  extremities  began  to  waste.  After  two  years,  incontineixce  of 
urine  gradually  came  on.  He  was  admitted  to  Guy's  Hospital,  February  11,  IH;)?, 
three  years  after  the  accident.  He  then  presented  a  remarkable  example  of  muscular 
atrophy  without  actual  paralysis.  The  upper  extremities  were  princi{)ally  affected. 
The  extensors  of  the  right  hand,  the  muscles  of  the  thumb,  and  the  interossei  were 
extremely  wasted.  The  wTist  dropped.  The  muscles  of  the  shoulder  and  arm,  including 
the  pectoralis  major  and  minor,  were  much  w^asted,  but  in  a  marked  degree  less  so  than 
those  of  the  forearm  and  hand.  Very  slight  diminution  of  sensation.  He  could  still 
lift  the  arm  over  the  head.  The  left  arm  was  similarly,  but  less  affected  than  the 
right,  as  far  as  regarded  muscular  atrophy,  but  there  was  numbness  through  the  whole 
arm  down  to  the  fingers,  and  the  patient  suffered  severely  from  neuralgic  pains  in  it 
which  greatly  depressed  him,  and  which  he  described  as  a  compound  of  smarting  and 
numbness.  The  trapezii,  serrati  postici  superiores,  rhomboidei,  and  all  the  long  mus- 
cles of  the  neck  and  backj  were  remarkably  atrophied.  The  spinous  processes  were 
very  prominent.  No  deformity  nor  tenderness  on  pressure  at  any  point.  Theintercos- 
tals  were  so  weak  that  the  only  respiratory  movement  was  through  the  diaphragm. 
The  supra-spinati  were  atrophied,  but  not  to  the  same  extent  as  the  infra-spinati  and 
the  levatores  angulorum  scapularnm.  The  legs  were  wasted  and  weak,  but  he  was  able 
to  walk.  Sphincter  weak.  Dribbling  of  urine.  Constipation.  The  thorax  looked  narrow 
and  ill-developed  from  the  w^asting  of  the  pectorals,  the  mtercostals,  and  the  erectores 
spinae  muscles.  The  muscles  of  the  back  of  the  neck,  and  the  sterno-mastoids,  were  so 
weak  that  the  head  could  not  be  supported  erect.  Sight  dim  ;  drooping  of  left  eyelid. 
Frequent  hiccough  for  many  months.  After  admission,  his  principal  complaint  w^as  of 
pain  in  the  left  arm  from  the  clavicle  to  the  fingers-  He  described  it  as  a  severe  smarting 
with  a  sense  of  numbness.  His  distress  from  this  cause  was  very  great.  Early  in 
March,  febrile  symptoms  set  in  ;  tongue  became  dry  and  brown  ;  frequent  hiccough  and 
vomiting;  pain  in  left  arm  severe.  On  March  25th,  he  died,  more  than  three  years 
after  the  accident 

Autopsy. — The  cranial  arachnoid  was  opalescent,  with  spots  of  white,  from  fatty 
degeneration,  mottling  the  more  opaque  parts  ;  subarachnoid  fluid  in  excess  ;  ependyma 
of  lateral  and  fourth  ventricles  granular,  in  the  latter  extremely  so. 

The  spinal  dura  mater  was  much  thickened  on  the  posterior  surface  of  the  cord  ;  the 
arachnoid  adhered  to  it  in  patches  along  this  surface,  and  was  much  thickened  by  the 
effusion  of  lymph  of  an  old  date.  Sections  of  the  cord,  examined  with  the  naked  eye, 
gave  no  distinct  evidence  of  disease  There  was  a  slight  yellowishness  of  the  posterior 
columns,  with  increased  vascularity  and  thickening  of  the  pia  mater  covering  them. 
In  these  columns,  but  especially  in  the  right  one,  an  abundance  of  granule  cells  was 
discovered  by  the  microscope.  The  exudation  was  greatest  in  the  middle  and  lower 
thirds  of  the  cervical  enlargement  The  gray  substance  was  hyperasmic.  No  exuda- 
tion into  its  tissue,  nor  into  the  anterior  columns.  The  ventricle  of  the  cord  was 
<inlarged  and  distended  with  delicate  granular  nuclei.  The  affection  of  the  cord  ap- 
peared to  be  secondary  to  chronic  inflammation  of  its  membranes,  and  to  chronic 
changes  in  the  ependyma  of  its  ventricle  occurring  in  common  with  changes  in  the 
ependyma  of  the  fourth  and  lateral  ventricles  of  the  brain  Hypostatic  congestion  of 
both  lungs  ,  several  lobules  consolidated  from  recent  pneumonia,  some  grayish.  Other 
organs  healthy. 

The  phenomena  attributable  to  myelitis  which  presented  themselves  in  this 
case  were  rather  peculiar,  and  consisted  of  blunted  sensibility  (anaesthesia), 
paralysis  of  the  sphincters  with  obstinate  constipation,  diminished  motility 


«  Gruy's  Hospital  Reports,  1858,  j^p.  194,  195. 


470 


INJURIES  OF  THE  BACK. 


(voluntary-motor  paralysis),  and  muscular  atrophy.     The  hiccough  and  ^ 
vomiting,  which  were  frequently  observed  for  many  months  in  this  case,  were 
probably  dependent  upon  the  origin,  distribution,  and  connections  of  the 
phrenic  nerves,  and  arose  partly  from  disease  of  the  membranes,  and  partly 
from  disease  of  the  cord-substance,  in  the  cervical  region. 

In  regard  to  the  muscular  atrophy,  which  was  progressive  and  exceedingly 
well  marked,  it  also  must  be  looked  upon  as  one  of  the  remote  effects  of  spinal 
mjury,  resulting  directly,  however,  from  inflammatory  irritation  of  the  pos- 
terior columns  and  gray  substance  of  the  spinal  cord.  The  attentive  reader 
will  doubtless  have  already  observed  that,  in  the  case  just  related,  the  gray 
substance  was  found  to  be  hyper?emic  at  the  autopsy,  and  that  the  posterior 
columns,  but  especially  the  right  one,  exhibited  structural  changes  of  a  dis- 
tinctly inflammatory  character 

This  variety  of  muscular  atrophy  was  formerly  regarded  as  a  primary  affec- 
tion of  the  nmscles  themselves.  Its  origin,  however,  really  lies  in  certain 
morbid  alterations  which  have  taken  place  in  the  gray  substance  of  the  spinal 
cord,  particularly  the  anterior  cornua  thereof. 

I  shall  next  present  a  remarkable  example  which  will  prove  very  useful  in 
the  way  of  exhibiting  progressive  muscular  atroph}'  and  chronic  inflamma- 
tion of  the  rachidian  substance  as  remote  effects  of  spinal  injuries,  such,  for 
example,  as  concussions  of  the  spinal  cord  that  are  thought  nothing  of  at  the 
time  wdien  they  are  received ;  and,  wdiat  is  of  greater  importance,  it  will 
serve  to  show  how  difficult  it  sometimes  may  be  for  even  the  most  skilful 
observer  to  make  a  correct  diagnosis  as  to  the  essential  lesion  in  such  cases. 
In  this  example  an  erroneous  opinion  was  entertained  as  to  the  nature  of  the 
disease,  until  this  was  revealed,  by  the  autopsy. 

Sir  W.  Gull  has  related  the  following  very  instructive  case  of  chronic 
myelitis,  involving  first,  as  well  as  most  markedly,  the  cervical  portion  of 
the  cord,  and  arising  from  concussion  thereof  produced  by  a  blow  on  the 
neck: — ^ 

A  steamboat-stoker,  aged  23,  intemperate  but  healthy,  was  admitted  into  the  hos- 
pital, June  5,  1851.  Five  years  before,  he  had  been  struck  in  a  pugilistic  combat, 
unexpectedly  and  severely,  "  by  another  man's  fist  on  the  side  of  the  neck,  near  the 
articulation  of  the  skull  with  the  vertebral  column.  Since  that  he  has  occasionally  had 
difficulty  in  deglutition,  particularly  of  fluids,  which  would  be  expelled  through  the  nose. 
For  the  last  year  he  has  had  a  choking  sensation  ;  and,  at  times,  difficulty  in  passing 
water."  Meanwhile,  his  right  arm  became  weak  and  wasted,  from  the  shoulder  down- 
ward, which  he  ignorantly  attributed  to  an  injury  of  the  back  of  his  right  hand  by  the 
falling  of  a  piece  of  iron.  He  continued  to  work  with  his  left  arm  for  three  months 
longer;  but,  about  1850,  he  began  to  suffer  from  what  he  termed  "bile,"  that  is,  fre- 
quent vomiting,  unattended  by  any  pain  in  the  head,  or  giddiness.  These  attacks  of 
vomiting  continued  to  return  for  four  months  ;  and  then,  as  they  subsided,  there  was 
increased  difficulty  of  deglutition,  and  both  legs  became  weak,  the  left  first,  and  to  the 
greatest  degree.  In  the  autumn  he  improved,  and  was  able  to  walk  about,  but  the 
bladder  M^as  so  far  paralyzed  that  he  needed  the  catheter  to  be  passed  for  several  weeks. 
The  improvement,  however,  was  only  of  short  duration.  When  admitted  into  hospital, 
his  right  arm  was  completely  paralyzed  at  the  shoulder-joint,  and  there  was  great  wast- 
ing of  the  muscles ;  only  slight  power  of  moving  the  fingers  remained.  There  was 
anaesthesia,  increasing  toward  the  hand,  but  most  marked  in  the  branches  of  the  ulnar 
nerve  No  actual  paralysis  of  the  left  arm,  but  the  muscles  were  flaccid  and  weak.  He 
had  pains  running  over  the  back  of  his  head.  He  could  move  his  legs  slightly.  Sen- 
sation impaired  as  high  as  the  hips.  No  deformity  of  the  spine^  nor  tenderness  on  per- 
cussion. No  sense  of  constriction  at  any  part  of  the  trunk.  Vision  somewhat  impaired. 
Urine  and  feces  passed  involuntarily.    Pulse  90.    Tongue  clean  and  pale.    He  im- 


1  Ibid.,  185G,  pp.  181-185. 


REMOTE  EFFECTS  OF  SPINAL  INJURIES. 


471 


proved,  by  rest  and  by  the  use  of  electricity,  so  far  that,  in  October,  he  could  support 
himself  and  walk  without  help,  though  his  gate  was  very  vacillating,  from  want  of  power 
to  direct  the  muscles.  No  numbness  remained  in  the  legs.  The  riglit  arm  continued 
in  tlie  same  state  as  on  admission.  The  left  arm  was  weak,  and,  at  times,  he  had 
cramp  in  the  muscles,  and  involuntary  closure  of  tlie  hand.  The  spliincter  partially 
paralyzed.  Aspect  pale  and  emaciated  ;  the  wliole  muscular  system  much  atrophied. 
He  remained  in  the  hospital  until  June,  1852,  his  sym[)toms  fluctuating  between  im- 
provement and  relapse.  He  could  walk  about  the  ward  by  the  aid  of  a  stick,  with  a 
feeble  gait,  his  right  arm  hanging  loosely,  supported  only  by  the  ligaments  of  the  shoul- 
der-joint. In  October,  1852,  he  was  readmitted  to  tlie  hospital.  In  a  few  weeks  after- 
ward, the  left  arm  was  quite  paralyzed,  and  he  lost  the  little  remaining  power  over  the 
sphincters  and  legs,  and  became  universally  paraplegic.  He  often  complained  of  a  sharp 
pain  in  the  back  of  the  head,  and  in  the  upper  part  of  the  neck.  On  January  19,  1853, 
bronchitis  supervened,  from  exposure  in  moving  him  from  one  ward  to  another  ;  though 
trifling  in  degree,  the  distress  occasioned  by  it  was  inexpressible,  owing  to  paralysis  of 
the  intercostals  [and  inability  to  raise  the  phlegm  by  coughing].  A  remission  of  his 
chest-symptoms  occurred  until  March  14,  when  they  again  became  aggravated.  His 
distress  was  indescribable.  Ineffectual  efforts  to  expectorate  were  constantly  made ; 
pulse,  120  ;  respiration,  36  ;  face  congested.  There  was  complete  paralysis  of  the  walls 
of  the  chest,  as  well  as  of  the  extremities,  and  general  anaesthesia,  yet  great  pain  when 
the  body  or  limbs  were  roughly  handled  (hypersestliesia).  Frequent  spasms  in  the  legs  ; 
arms  not  so  affected.  Urine  constantly  dribbling.  The  integuments  over  the  sacrum 
became  slightly  abraded,  but  no  slough  formed.  This  patient's  miserable  existence  was 
protracted  until  April  12,  1853,  nearly  two  years  after  he  entered  the  hospital,  and 
seven  years  after  he  was  injured. 

Autopsy  Remarkable  atrophy  of  the  whole  muscular  system,  and  of  the  tissues  gen- 

eraily.  Pia  mater  (cranial)  and  brain-tissue  rather  watery.  On  removing  the  arches 
of  ihe  vertebrae,  the  whole  spinal  cord  appeared  to  be  large  and  swollen  ;  in  the  cervical 
region  the  theca  was  evidently  distended  by  it.  The  vertebrae  and  ligaments  were  not 
affected.  On  laying  open  the  theca,  there  was  exhibited  a  general  enlargement  of  the 
cervical  portion  of  the  cord,  which,  on  transverse  section,  had  an  unusual  appearance. 
The  columns  had  a  yellowish  tint,  and  were  distended  by  a  soft,  vascular,  translucent 
growth,  parts  of  which  were  firmer,  and  of  an  opaque-yellow  hue.  This  growth  was  not 
deflned,  but  passed  insensibly  into  the  degenerated  gray  substance,  which,  from  the  floor 
of  tlie  fourth  ventricle  to  the  filum  terminale,  was  pale  and  swollen,  and  had  much  the 
physical  character  aud  consistence  of  thick  boiled  starch.  This  soft  starch-like  sub- 
stance, under  the  microscope,  was  seen  to  consist  of  round,  oval,  and  elongated  granular 
nuclei,  imbedded  in  a  slimy  blastema.  At  the  filum  tei-minale,  where  the  more  normal 
characters  of  the  gray  substance  were  preserved,  tliese  nuclei  were  scattered  amongst 
the  softened  tubercles  with  exudation-cells.  The  vascular  growth  in  the  cervical  region 
consisted  of  degenerated  nerve-tissue,  nuclei  and  nucleated  cells,  as  in  the  fibro-plastic 
growths.  The  opaque  part  was  little  else  than  granular  matter  and  oil-globules.  There 
was  no  lesion  of  the  membranes  of  the  cord,  nor  was  the  continuity  of  the  columns 
destroyed,  though  in  the  cervical  region  they  were  spread  out,  and  slightly  softened  in 
parts.  The  nerves  arising  from  the  cord  in  the  cervical  and  lumbar  regions,  examined 
microscopically,  had  the  normal  structure. 

The  upper  lobes  of  both  lungs  contained  tubercular  masses  and  scattered  tubercles ; 
bronchial  tubes  dilated ;  their  lining  membranes  deeply  injected  and  contents  purulent. 
Hepatic  tissue  congested  and  fatty.    The  remaining  organs  were  all  healthy. 

In  this  ejcample  the  spinal  meninges  were  not  inflamed  (as  the  autopsy 
showed),  and  the  symptoms  developed  were  purely  those  of  chronic  traumatic 
myelitis,  commencing  in  the  cervical  portion  of  the  cord.  These  symptoms, 
in  general,  consisted  of  a  slowly  progressive,  though  somewhat  fluctuating, 
abolition  of  the  functions  of  the  spinal  cord.  There  was  progressive  sensory 
and  motor  paralysis,  which,  after  the  lapse  of  some  years,  terminated  in  com- 
plete paraplegia.  It  seems  that  there  was  no  pain  observed  until  the  end 
drew  near,  w^hen  "  complete  paralysis  of  the  walls  of  the  chest,  as  well  as  of 
the  extremities,  and  general  anaesthesia"  had  already  been  established,  "yet 


472 


INJURIES  OF  THE  BACK. 


^reat  pain"  was  felt  "when  the  body  or  limbs  were  roughly  handled."  This 
sort  of  pain,  especially  when  it  is  associated  with  general  anaesthesia  or  sensory 
paralysis  of  the  parts  in  which  it  is  perceived,  is  a  not  uncommon  form  of 
hyper^esthesia,  and  it  arose  in  the  case  under  consideration  either  from  the  in- 
flammatory changes  that  were  occurring  in  the  gray  substance  of  the  cord,  or 
from  the  excitation  of  the  sensory  filaments  in  the  adjacent  spinal  nerves 
that  was  caused  by  inliammation  of  the  cord-substance  itself,  but  probably 
from  the  former. 

The  general  atrophy  of  the  muscles  of  the  extremities,  observed  ni  the  pro- 
gress of  this  case  before  the  more  distinct  symptoms  of  paralysis  appeared, 
is  deserving  of  special  note,  as  bearing  upon  the  theory  of  progressive  mus- 
cular atrophy,  many  examples  of  which  have  no  doubt  had,  contrary  to  the 
opinion  of  those  who  have  recorded  them,  a  spinal  rather  than  a  muscular 
origin.  The  atrophy  of  the  muscles  of  the  right  shoulder,  whilst  those  of  the 
forearm  still  retained  some,  power,  elucidates  the  seat  of  the  paralyzing  lesion 
in  some  cases  of  infantile  paralysis  of  the  shoulder  occurring  during  dentition. 
It  has  been  doubted  whether  the  lesions  alluded  to  have  a  cerebral  or  a  spinal 
origin ;  but  their  occurrence  without  any  cerebral  symptoms,  the  occasional 
implication  of  both  arms,  or  of  all  the  extremities,  and  the  actual  observation 
of  a  limited  spot  of  ochrey  discoloration  in  the  cord,  as  in  one  case  examined 
by  Cruveilhier,  concur  with  the  collateral  evidence  here  afforded  in  proving 
a  spinal  origin  for  this  form  of  paralysis.  (Gull.) 

Again,  the  limitation  of  the  paralysis  at  its  commencement  to  the  right 
arm,\nd  the  preponderating  affection  of  the  muscles  of  the  shoulder-joint, 
are  points  in  the  clinical  history  of  this  case  of  great  interest  in  another  par- 
ticular. For,  taken  together  with  the  injury  of  his  right  hand,  to  which  the 
patient  attributed  his  symptoms,  they  led  to  an  opinion  that  the  case  was  one 
of  peripheral  paralysis.  But  such  an  inference  was  not  supported  by  the  history 
of  the  case,  nor  by  the  post-mortem  appearances  of  the  cord.  The  slight 
affection  of  the  muscles  of  deglutition  (paralysis),  the  sense  of  choking,  and 
the  occasional  loss  of  power  over  the  bladder,  which  appeared  early  m  the 
case,  established  a  causal  relation  between  the  blow  on  the  cervical  part  of 
the  spine  and  the  inflammatory  lesion  of  the  spinal  cord-substance,  whilst  the 
peripheral-origin  theory  of  the  malady  was  completely  refuted  by  the  normal 
microscopic  structure  of  the  nerve-trunks. 

There  is  nothing  more  fallacious  in  practical  medicine  than  hastily  interring 
a  neo-ative  from  negative  evidence,  as  was  clearly  shown  in  this  case.  The 
absence  of  pain  on  percussing  the  spine,  and  the  very  positive  statement  made 
by  the  patient,  that  his  paralytic  symptoms  had  resulted  from  an  injury  of 
his  hand,  led  to  the  belief  that  no  morbid  process  of  an  active  kind  was 
at  work  in  the  spinal  cord;  yet  it  cannot  be  doubted  that  the  reverse  was 
the  fact.  Moreover,  the  least  consideration  will  serve  to  show  that  if  the 
vertebral  ligaments,  and  bones,  and  joints  be  healthy,  no  amount  of  pres- 
sure or  percussion,  made  in  the  usual  way  during  a  clinical  examination, 
can  much  affect  the  substance  of  the  cord  itself,  and  that  we  should  base  no 
inference  upon  the  negative  evidence  thus  afforded.  Oftentimes  myelitis,^ 
whether  acute  or  chronic,  runs  its  whole  course  without  the  development  of 
any  pain  whatever,  excepting  cutaneous  hypersesthesia,  discernible,  it  may  be, 
only  by  a  very  careful  examination. 

The  impairment  of  vision,  which  was  observed  in  this  case,  although  a 
minor  symptom,  is  deserving  of  particular  notice.  It  may  be  associated, 
from  different  causes,  with  spinal  lesions.  Here  it  is  probably  referable  to 
anatomical  changes  in  the  cervical  portion  of  the  cord  itself,  inasmuch  as 
experiments  on  animals  have  clearly  shown  that  the  condition  of  the  eye  is 
at  once  affected  by  injuries  to  the  roots  of  the  cervical  nerves. 


REMOTE  EFFECTS  OF  SPINAL  INJURIES. 


478 


Yoniiting,  in  persistent,  recurring  attacks,  appeared  in  this  case,  as  an 
early  sign  that  the  cervical  portion  of  the  spinal  cord  was  diseased,  and 
was  probahly  dependent  upon  the  origin  and  connections  of  the  phrenic 
nerves.  In  another  case  seen  by  Gull,  that  belonged  to  the  same^  category, 
the  symptoms  set  in  with  an  irritating  cough ;  and  remember,"  says  the 
same  high  authority,  "an  obstinate  case  of  hiccough  which,  having  resisted 
other  treatment,  yielded  at  once  to  blisters  on  either  side  of  the  cervical  por- 
tion of  the  spine,  over  the  origin  of  the  phrenic  nerves."^ 

The  morbid  appearances  oflhe  gray  matter  of  the  cord  were  peculiar,  and 
probably  depended  in  part  upon  degeneration  of  the  normal  structure,  and  in 
part  upon  a  neoplastic  formation  of  the  simplest  kind.  In  the  cervical  region, 
where  the  disease  began,  the  morbid  process  had  proceeded  furthest,  making 
an  approach  to  the  development  of  a  tumor,  but  not  separated  by  any  line  of 
demarcation  from  the  other  parts  of  the  gray  matter,  which  had  undergone  a 
similar,  only  a  less  advanced,  change. 

More  recently,  however,  the  morbid  anatomy  of  progressive  muscular 
atrophy  has  been  studied  with  great  care  by  MM.  Ilayem,  Charcot,  and 
Joffroy.  In  M.  Hay  em's  case,  death  resulted  from  paralysis  of  the  diaphragm 
and  pneumonia.  The  lesions  revealed  by  the  post-mortem  examination  pointed 
to  the  existence  of  chronic  inflammation  of  the  gray  substance  of  the  cord._ 
MM.  Charcot  and  Joffroy  were  struck  in  examining  the  gray  substance^  of 
the  cervical  region  in  their  cases,  by  the  extreme  degree  of  atrophy  which 
the  cells  of  the  anterior  cornua  had  undergone ;  a  large  proportion  of  them 
had  disappeared  so  completely  as  to  leave  no  trace  behind.  The  posterior 
cornua  were  unaffected.  M.  Charcot  states  that  wdien  the  alterations  are  very 
well  marked,  the  anterior  horn  of  gray  matter,  which  is  the  seat  of  the  morbid 
process  or  the  essential  lesion,  may  become  considerably  reduced  in  size,  and 
may  present  a  shrunken  appearance  in  transverse  section. 

But  the  symptoms  of  progressive  muscular  atrophy,  when  it  arises  from 
concussion  of  the  spinal  cord,  may  come  on  with  great  rapidity,  as  was  ob- 
served in  the  following  instance,  which  was  also  reported  by  Sir  W.  Gull :  — ^ 

A  lad,  aged  15,  received  a  blow  with  the  fist,  between  the  shoulders,  from  a  boy  at 
play.  After  a  week  his  head  drooped,  and  from  that  time  the  muscles  of  his  upper  ex- 
tremities gradually  wasted ;  the  arms  dropped  and  hung  useless,  the  intercostals  lost 
their  power,  and  the  breathing  was  diaphragmatic ;  the  lower  two-thirds  of  the  trape- 
zii  and  the  erector  spinas  muscles  also  wasted  in  the  same  way. 

Fourteen  months  after  the  accident,  when  he  tried  to  stand  erect,  his  head  fell  for- 
ward, and  his  shoulders  were  thrown  backward  to  balance  it,  in  the  absence  of  muscular 
power.  He  was  able  to  walk,  but  his  gait  w^as  vacillating,  apparently  more  from  want 
of  muscular  power  to  fix  the  trunk  on  the  pelvis  than  from  defective  power  in  the  legs. 
He  could  not  sit  on  a  seat  without  a  support  to  his  back.  Sphincters  unaffected.  On 
testing  the  electro- contractility  of  the  wasted  muscles,  by  galvanism,  they  were  found 
to  contract  in  proportion  to  their  mass.  No  pain  attended  the  progress  of  the  disease ; 
no  tenderness  of  the  wasted  muscles  ;  no  flickering  contractions  of  their  fibres. 

We  now  proceed  to  mention  certain  joint-diseases  of  spinal  origin  which 
must  likewise  be  reckoned  among  the  remote  effects  of  spinal  injuries. 

(1)  M.  Charcot  has  called  attention  to  the  arthropathy  of  patients  having 
locomotor  ataxy. ^  Without  any  appreciable  cause  we  may  see,  occurring  in 
one  night,  the  development  of  a  general  and  often  enormous  tumefaction  of 
the  member,  most  commonly  without  any  pain  whatever,  or  any  febrile 
movement.  At  the  end  of  a  few  days,  the  general  tumefaction  disappears, 
but  a  more  or  less  considerable  swelling  of  the  joint  remains,  owing  to  the 


I  Ibid.,  p.  185.  «  Ibid.,  1858,  pp.  195,  196. 

•  Lectures  on  the  Diseases  of  the  Nervous  System,  pp.  79-82.    Am.  ed. 


474 


INJURIES  OF  THE  BACK. 


occurrence  of  hydrarthrosis ;  and  sometimes  to  the  collection  of  liquid  in  the 
periarticular  bursse  also.  On  making  a  puncture,  a  transparent,  lemon-colored 
liquid  has  frequently  been  withdrawn  from  such  joints.  Ataxic  arthropathy 
usually  occupies  the  l^ees,  shoulders,  and  elbows ;  it  may  also  afiect  the 
hip-joint.  This  disorder  generally  shows  itself  at  a  determinate  epoch  of  the 
ataxy,  and  its  appearance  coincides  in  many  cases  with  the  setting  in  of 
motor  incoordination. 

(2)  MM.  Patruban,  Remak,  and  Rosenthal  have  observed  in  jprogressive 
muscular  atrophy^  joint-diseases  w^hich  are  closely  allied  by  their  clinical 
features  to  the  arthropathies  of  ataxic  patients.  This  will  not  appear  sur- 
prising, if  we  remember  that  a  primary  or  secondary  irritative  lesion  of  the 
nerve-cells  of  the  anterior  cornua  of  the  spinal  gray  substance  is  the  starting 
point  of  progressive  muscular  atrophy.  (Charcot.) 

(3)  Sir  W.  Gull  relates  the  following  highly  instructive  case  of  rachidian 
concussion^  which  was  followed  by  incomplete  paraplegia,  with  redness  and 
swelling  of  the  wrists  and  ankles,  as  in  acute  rheumatism ;  and,  after  six 
months,  by  recovery: — ^ 

A  medical  man,  aged  38,  inadvertently  stepped  backward  into  a  hole,  a  few  feet  deep, 
and  received  a  concussion  of  the  spine,  on  January  22,  1855.  After  a  few  days  he 
became  partially  paraplegic,  with  weak  sphincters ;  and,  at  the  same  time,  there  came 
on  a  diffused  redness  and  swelling  of  the  ankles  and  wrists.  The  swelling  was  not 
from  effusion  into  the  joints,  but  from  oedema  of  the  surrounding  tissue.  The  joints 
were  very  painful.  The  redness  and  swelling  were  variable  in  degree.  When  most 
marked,  they  presented  the  usual  appearances  of  rheumatism,  or  rather  of  gout,  for  the 
erythema  was  brighter,  and  the  oedema  more  distinct,  than  in  rheumatism.  The  hands 
were  affected  equally  with  the  ankles,  though  there  w'as  no  obvious  want  of  muscular 
power,  nor  any  affection  of  sensation  in  the  upper  extremities  ;  tongue  clean  ;  pulse 
120  ;  no  acid  perspiration  ;  urine  high-colored,  free  from  sediment,  and  normal  in 
quantity.  The  cutaneous  nerves  generally  were  hypersesthetic  to  a  slight  touch,  but 
deep  pressure  gave  less  inconvenience. 

The  treatment  consisted  of  good  nourishment,  wine  and  brandy  freely  administered, 
and  opium  to  allay  pain  and  overcome  insomnia.  The  pulse  gradually  acquired  more 
power  and  sank  to  80. 

The  affection  of  the  joints  continued  in  varying  degree  through  March,  April,  May, 
and  June.  From  the  beginning  of  April  there  was  an  improvement  in  the  power  over 
the  legs.  The  same  treatment  was  continued  throughout,  without  the  use  of  mercurials, 
local  depletion,  or  counter-irritation.  In  June,  he  was  able  to  walk  without  assistance. 
During  sleep,  his  hands  and  feet,  wrists  and  ankles,  often  became  erythematous  and 
swollen.  Occasionally,  there  was  formication  in  the  lower  extremities.  Insomnia 
was  a  troublesome  symptom  from  the  beginning  until  the  end  of  the  case.  In  July,  he 
was  able  to  leave  the  hospital,  and  to  resume  his  duties  as  a  medical  practitioner  to 
some  extent. 

The  disorders,  however,  which  present  themselves  most  frequently  as  the 
remote  effects  of  spinal  injuries,  are  chronic  spinal  meningitis  and  chronic 
myelitis.  In  regard  to  the  symptoms  which  appear  in  cases  where  these  two 
affections  coincidently  occur,  it  should  be  stated  that  the  phenomena  which 
are  characteristic  of  meningeal  inflammation  will  be  less  and  less  apparent 
in  proportion  as  the  cord-substance  becomes  more  and  more  affected  by  the 
inflammatory  process,  and  the  syjnptoms  of  paraplegia,  or  arrested  rachidian 
functions,  will  correspondingly  predominate.  In  a  case  related  by  Sir  W. 
Gull,2  which  the  cord-substance  speedily  became  inflamed  as  Avell  as  the 
spinal  membranes,  "  the  patient  w^as  unable  to  leave  his  bed  on  account  of 
the  weakness  of  his  legs,"  "  within  thirty-six  hours  from  the  commencement 

1  Guy's  Hospital  Reports,  1858,  pp.  199,  200. 

2  Ibid.,  1856,  pp.  154,  155. 


REMOTE  EFFECTS  OF  SPINAL  INJURIES. 


475 


of  the  disease  ;"  and,  when  admitted  to  the  hospital,  "  on  the  ninth  day  from 
the  commencement  of  his  symptoms,"  there  was  complete  loss  of  motion 
and  sensation.  It  was  also  remarkable  how  entirely  the  functions  of  the 
brain  were  undisturbed  throughout,  contrasting  strongly  in  this  particular 
with  a  large  proportion  of  the  recorded  cases  of  acute  spinal  meningitis." 
These  differences  are  easily  explained  by  the  extent  of  the  injuries  or  by  the 
other  conditions  which  engender  the  disorder,  and  by  the  patient's  tempera- 
ment, the  extent  of  the  disease  itself,  and  the  actual  presence  of  disease  in 
the  brain  or  its  membranes. 

Treatment. — In  all  these  cases,  uninterrupted  rest  in  bed  is  a  remedial  mea- 
sure of  great  importance.  Ergot  should  be  perseveringly  administered  in  full 
doses,  with  a  view  to  control  the  congestion  of  the  spinal  cord  and  its  mem- 
branes which  is  present  in  almost  all  of  thenio  Potassium  iodide  and  the 
corrosive  chloride  of  mercury  should  be  given,  together  or  separately,  with  a 
view  to  dispose  of  the  inflammatory  products.  In  cases  tainted  with  syphilis, 
these  remedies  wdll  often  prove  singularly  useful,  as  I  know  from  experience. 
Counter-irritation  should  be  made  over  the  spinal  column  w^ith  dry-cupping, 
setons,  or  the  actual  cautery.  The  latter  especially  has  often  been  found  to 
do  much  good  in  such  cases.  Progressive  muscular  atrophy  requires  the 
eiuployment  of  the  primary  galvanic  current  to  the  sj^inal  cord  itself,  from 
above  downward,  and  of  the  faradic  current  to  each  of  the  w^asted  muscles.^ 

Railway-injuries  of  the  spine  are,  as  a  group,  characterized  by  the  coin- 
cident occurrence  of  sprains,  w^renches,  or  twists  of  the  vertebral  column, 
stretching  of  the  spinal  membranes — particularly  the  theca — corresponding 
thereto,  and  profound  concussion  of  the  rachidian  substance.  Hence,  in  such 
cases  there  may  coincidently  appear  inflammation  of  the  vertebral  joints, 
inflammation  of  the  spinal  membranes,  and  inflammation  of  the  rachidian 
substance.  Moreover,  in  these  cases  there  is  always  peculiar  difliculty 
experienced  in  determining  the  full  extent  of  the  damage — difficulty  w^hich  is 
often  increased  very  much  by  the  absence  of  all  external  evidence  of  physical 
injury,  by  the  obscurity  and  insidious  character  of  the  early  symptoms,  by 
the  slowly  progressive  development  of  the  secondary  organic  lesions,  as  well 
as  of  the  functional  derangements  produced  by  them,  and  by  the  uncertainty 
which  surrounds  the  ultimate  issue.  They  therefore  constitute  a  class  of 
injuries  which  often  severely  tax  the  surgeon's  diagnostic  skill  and  therapeu- 
tic resources. 

The  nature  and  peculiarities  of  railway-injuries  of  the  spine  can  be  most 
clearly  shown  by  presenting  an  example : — 

Mrs.  J.  C.  F.,  aged  31,  and  married,  consulted  me  on  March  11,  1881,  in  regard  to 
the  effects  of  injuries  which  she  had  received  in  a  railway-collision,  on  Christmas-eve, 
something  more  than  two  and  one-half  months  before.  While  seated  in  the  rear  por- 
tion of  a  railway  car,  she  suddenly  saw  that  a  collision  was  inevitable,  and  sprang  to  her 
feet,  and  was  therefore  standing  when  the  cars  collided.  She  was  terribly  shaken  up 
and  wrenched  in  the  loins,  as  well  as  thrown  about,  and  felt  stunned,  cold,  and  faint. 
There  was  so  much  depression  from  shock"  that  a  druggist  administered  ammonia  to 
excite  reaction.  She  was  in  perfect  health  when  tlie  accident  occurred,  but  has  not 
seen  a  well  moment  since  that  time.  Next  day,  she  felt  lame  and  sore  "  all  over,"  and 
had  severe  pain  in  tlie  lumbar  region,  which  was  increased  by  motion,  and  pain  in  the 
left  hip.  The  pain  in  the  loins  and  left  hip  continuing  eight  'days  after  the  accident, 
she  souglit  for  relief  at  the  Woman's  Dispensary,  when  tincture  of  iofline  appears  to 
have  been  applied  to  the  painful  hip,  but  without  doing  any  good  whatever.  At  this 
time  she  had  a  miscarriage,  being,  as  she  thinks,  about  two  months  advanced  in  preg- 
nancy. March  11.  She  says  that  she  has  not  been  free  from  the  pains  above  mentioned 

'  See  also  what  has  already  been  said  concerning  the  treatment  of  the  acute  and  subacuta 
forms  of  traumatic  spinal  meningitis  and  myelitis. 


476 


INJURIES  OF  THE  BACK. 


since  the  accident ;  has  now  much  distress  in  tlie  cervical  and  dorsal,  as  well  as  in  the 
lumbar  portion  of  the  spine  ;  the  pains  extend  from  the  left  loin  and  hip  downward 
into  the  left  thigh  and  knee  ;  has  also  much  pain  extending  from  the  spine  into  the 
left  arm,  and  numbness  in  the  parts  supplied  by  the  ulnar  nerve  (little  finger  and  adja- 
cent side  of  ring  finger) ;  has  lost  much  flesh  ;  is  very  weak  and  nervous,  and  has  been 
so  ever  since  the  accident ;  often  has  cardiac  palpitations  so  marked  that  she  is  afraid 
to  go  into  the  street  alone  ;  pulse  frequent  (about  100),  and  rather  weak  ;  countenance 
aneemic,  and  expressive  of  great  suffering ;  tongue  clean  ;  bowels  regular ;  appetite 
and  digestion  good,  but  her  food  does  not  seem  to  benefit  her  ;  she  suffers  much  from 
insomnia,  for  the  pains  in  her  spine,  left  hip,  and  left  extremities,  both  lower  and  upper, 
keep  her  awake ;  the  lumbar  part  of  the  spine,  especially  the  left  side  thereof,  exhibits 
tenderness  under  pressure.  I  prescribed  the  bromides  of  potassium,  sodium,"  and  iron, 
in  full  doses,  with  rest  as  nearly  absolute  as  possible,  and  counter-irritation  to  be  applied 
over  the  whole  spinal  column  ;  and  I  hoped  that,  as  the  inflammation  of  the  wrenched 
vertebral  articulations  should  subside  under  this  treatment,  the  symptoms  of  meningo- 
rachidian  irritation  would  likewise  disappear. 

July  21.  She  is  no  better;  is  much  emaciated  (weighing  but  103  lbs.,  while  her 
usual  weight  is  119  lbs.)  ;  is  pallid,  and  looks  wan,  wearied  and  prematurely  old ;  has 
much  distress  in  the  head,  with  a  sore  feeling  in  the  scalp,  and  rapid  falling  of  the  hair  ; 
pains  in  the  spine  and  left  hip  continue  severe,  and  involve  the  whole  of  the  left  upper 
extremity,  as  well  as  the  whole  of  the  left  lower  extremity  ;  pains  sometimes  shoot 
down  into  her  left  leg  and  foot ;  has  no  pain  in  the  right  extremities  ;  suffers  great  dis- 
tress at  the  bottom  of  her  back,  across  the  sacrum  (sacrodynia),  and  when  her  back  is 
worse  her  distress  in  the  head  is  more  severe  ;  she  also  has  formication,  a  "  pins  and 
needles"  feeling,  and  a  sensation  of  numbness  or  as  if  the  parts  were  asleep,  in  all  of 
her  left  side,  and  in  her  left  hip,  but  especially  in  the  left  foot  and  leg ;  has  likewise  a 
pins  and  needles"  feeling  in  the  left  hand  and  arm,  but  not  as  much  as  in  the  left  lower 
extremity  ;  has  a  constricted  or  "  tight-belt"  feeling  which  extends  around  her  body  ; 
the  muscles  of  her  left  leg  and  thigh  often  feel  stiff ;  her  pains  and  abnormal  sensations 
are  always  made  worse  by  getting  tired  ;  during  the  last  two  months,  exercise,  or  a 
sense  of  fatigue,  always  brings  on  nausea,  and  sometimes  vomiting;  feels  sick  at  the 
stomach  this  morning  in  consequence  of  walking  to  my  office  ;  lies  in  bed  on  her  left 
side,  because  she  gets  more  ease  in  that  position  ;  has  often  to  get  up  at  night  and  rub 
the  affected  parts  on  account  of  the  "  pins  and  needles"  feelings,  and  sensations  of 
numbness  ;  is  very  restless  at  night,  and  scarcely  ever  sleeps  more  than  two  hours  at  a 
time;  menstruation  irregular  and  deficient ;"  she  also  has  much  thirst  and  "inward 
fever  ;"  pulse  about  100,  and  feeble  ;  tongue  clear,  bowels  soluble.  Potassium  iodide, 
in  ten  grain  doses,  three  times  a  day,  was  ordered  as  a  remedy  against  the  spinal 
meningitis  and  myelitis  which  were  obviously  now  present,  with  syrup  of  the  hypo- 
phosphites  of  lime  and  sodium  as  a  tonic  ;  counter-irritation  over  the  left  hip  and  the 
whole  length  of  the  spinal  column,  to  be  continued,  with  rest  in  bed  ;  but  unfortunately 
her  circumstances  in  life  were  not  such  that  the  last-named  remedial  measure  could  be 
carried  out  as  thoroughly  as  was  desired. 

October  2.  Her  case  became  complicated  with  an  attack  of  malarial  fever,  which  was 
promptly  subdued  by  the  administration  of  quinine. 

March  21,  1882.  She  is  somewhat  better,  but  her  eyesight  is  impaired;  says  that 
after  resting  in  bed  for  a  time,  she  always  gets  better ;  but,  as  soon  as  she  begins  to  go 
around  again,  especially  if  she  tries  to  work,  she  again  gets  worse.  In  addition  to  potas- 
sium iodide,  syrup  of  the  iodide  of  iron,  gtt.  xv.,  three  times  a  day,  was  prescribed. 

June  12.  I  was  called,  and  found  her  suffering  very  much  from  coccygodynia  ;  the 
sacro-coccygeal  articulation  was  inflamed,  and  so  much  damaged  that  the  coccyx  was 
quite  movable,  as  well  as  bent  forward  at  nearly  a  right  angle  ;  her  general  symp- 
toms, however,  were  upon  the  whole  rather  better. 

June  15.  Professor  Wm.  A.  Hammond  saw  her  in  consultation.  Her  weight  is 
now  lbs. ;  it  used  to  be  119  lbs. ;  the  headache  continues,  and  her  eyesight  is  very 
much  impaired  ;  slie  has  difficulty  in  holding  her  urine,  which  is  normal  in  appearance  ; 
makes  it  too  often,  and  liias  to  run  in  order  to  avoid  wetting  herself  (vesical  hyperaes- 
thesia)  ;  has  pain  in  the  lumbar,  sacral,  and  coccygeal  regions  all  the  time,  and  it  is 
always  aggravated  by  exertion.    There  is  much  tenderness  under  pressure  along  the 


REMOTE  EFFECTS  OF  SPINAL  INJURIES. 


477 


left  side  of  the  dorsal  and  lumbar  vertebra?,  and  over  the  whole  of  thesacruiji ;  the  head 
of  the  coccyx  is  displaced  forward,  and  crepitus  can  be  felt  in  the  sacro-coccygeal  joint ; 
tenderness  about  the  lower  end  of  sacrum  and  coccyx  much  complained  of  by  the 
patient ;  besides  pain,  etc.,  she  says  she  has  a  "  stiff  feeling"  in  the  muscles  of  the  left 
thigh  and  leg,  which  is  worse  at  some  times  than  at  others  ;  says  she  also  feels  con- 
stricted around  her  bowels,  as  if  her  clothes  were  too  tight,  or  as  if  a  belt  were  tightly 
drawn  and  buckled  around  her  bowels,  and  has  had  this  feeling  for  a  long  time.  The 
sesthesiometer  showed  that  cutaneous  sensibility  in  the  left  thigh  was  less  than  normal. 
In  addition  to  syrup,  ferri  iodid.,  which  she  was  now  taking,  fluid  extract  of  ergot  in 
full  doses  was  prescribed,  with  strong  counter-irritation  over  the  sacrum. 

December  6.  Upon  the  whole  she  is  much  better.  The  sacro-coccygeal  pain  is 
greatly  lessened,  and  anchylosis  of  the  joint  appears  to  have  occurred,  with  the  coccyx 
bent  forward  and  somewhat  to  the  left  at  a  right  angle.  Her  eyesight,  however,  is 
very  much  impaired.  The  vesical  hypersesthesia,  too,  has  returned,  and  gives  much 
trouble,  for  she  has  to  make  water  every  few  minutes.  Ordered  extract  of  belladonna 
gr.  1,  ergotine,  gr.  liss.,  to  be  taken  in  pilular  form  three  times  a  day;  in  four  days 
the  vesical  reflex  became  normal.  Also  advised  the  belladonna  and  ergotine  to  be 
tal^en  for  a  fortnight  longer,  and  to  be  followed  by  potassium  iodide. 

The  internal  remedies  which  did  this  patient  most  good  were  ergot,  belladonna,  and 
potassium  iodide ;  and  the  benefit  derived  from  their  administration  was  very  evident. 

The  spinal  lesions  m  this  case  were  mostly  unilateral  and,  as  a  rule, 
involved  the  left  half  of  the  column  only.  The  spinal  articulations  which 
became  inflamed  were  certain  of  the  lumbar,  as  well  as  the  lumbo-sacral,  and 
the  sacro-coccygeal.  The  pain  felt  in  the  dorsal  and  cervical  parts  of  the 
spinal  column,  and  in  the  left  arm,  forearm,  and  hand,  was  due  entirely  to 
spinal  meningitis.  The  pain  in  the  head  and  the  impairment  of  vision,  which 
came  on  afterwards,  were  probably  due  to  extension  of  the  inflammatory  pro- 
cess from  the  spinal  to  the  cerebral  membranes.  The  pain  in  the  lumbar  verte- 
brae, sacrum,  and  left  lower  extremity,  was  caused  in  part  by  spinal  meningitis, 
and  in  part  by  inflammation  of  the  vertebral  joints.  The  sensations  of  numb- 
ness, or  as  if  the  limb  were  asleep,  of  formication,  of  "  pins  and  needles,"  of 
constriction  around  the  body  as  if  it  were  tightly  belted,  and  the  cutaneous 
anaisthesia,  arose  from  myelitis.  The  vesical  hyperaesthesia  probably  arose 
from  rachidian  hyperjemia  and  irritation,  whereby  the  urinary  bladder's  reflex 
centre  ^became  unduly  excited.  At  least,  such  was  my  diagnosis ;  and,  on 
administering  ergot  to  subdue  the  rachidian  hypereemia,  and  belladonna  to 
allay  the  vesical  reflex  excitation,  relief  was  promptly  obtained.  The  nausea 
and  vomiting  which  at  one  time  were  brought  on  by  any  slight  muscular 
eftbrt,  also  indicated  that  the  cervical  portion  of  the  spinal  cord-substance 
was  inflamed.  This  woman,  almost  two  years  after  the  accident,  although 
much  improved  in  health,  is  not  yet  well  again,  for  she  is  still  suftering  from 
inflammation  of  the  spinal  cord  and  its  membranes.  Moreover,  there  is  much 
doubt  as  to  whether  she  ever  will  entirely  recover. 

The  phenomena  which  present  themselves  in  cases  where  spinal  injuries, 
without  fracture,  are  caused  by  railway-collisions,  result,  as  already  intimated, 
from  the  severe  wrenches  and  twists  which  the  vertebral  joints  have  sus- 
tained, or  from  the  violent  stretching  and  hemorrhagic  infiltration  to  which 
the  spinal  membranes  have  been  subjected,  or  from  the  more  or  less  profound 
concussion,  and  perhaps  contusion,  of  the  substance  of  the  spinal  cord  itself, 
or  from  the  combined  influence  of  all  these  lesions.  We  shall  not  be  surprised 
to  find  that  such  grave  consequences  may  be  engendered  by  railway-collision?^, 
if  we  reflect  for  a  moment  upon  the  nature  of  these  accidents.  It  must,  I 
think,  be  evident  to  all  that,  in  no  ordinary  accidents  can  the  shock,  both 
physical  and  mental,  be  nearly  as  great  as  in  those  which  occur  in  the  colli- 
sions of  railway-cars  and  engines.  The  swiftness  of  the  movement,  and  the 
extraordinary  momentum  of  the  persons  injured,  as  well  as  of  the  vehicle 


478 


INJURIES  OF  THE  BACK. 


which  carries  them,  the  saddenness  of  its  arrest,  and  the  helplessness  of  the 
victims,  are  all  circumstances  which  of  necessity  greatly  augment  the  severity 
of  the  injuries  sustained  by  the  spinal  column  and  cerebro-spinal  axis.  But 
perhaps  there  is  one  circumstance  which  more  than  any  other  gives  a  pecu- 
liar character  to  railway-collisions,  namely,  the  thrill  or  jar,  the  ehranlemenf 
of  French  writers,  the  sharp  vibrations,  in  fact,  which  are  transmitted  to 
everything  that  is  subjected  to  the  force  of  such  collisions.  It  is  this  vibra- 
tory shock  or  jar,  which  by  some  is  compared  to  an  electric  shock,  by  others 
to  setting  the  teeth  on  edge  (Erichsen),  that  causes  railway  carriages  to  be 
shattered  into  splinters  on  colliding,  and  produces  the  sharp  tremulous  move- 
ment which  runs  through  every  structural  fibre  of  the  occupants,  whereby 
profound  concussion  or  contusion  of  their  spinal  cords  is  oftentimes  effected. 
Moreover,  the  body  of  the  passenger  is  simultaneously  pitched  about  or 
hurled  to  and  fro,  not  unfrequently  five  or  six  times,  without  there  being 
any  power  of  resistance  or  of  self-preservation,  and  thus  the  vertebral  articu- 
lations are  often  severely  wrenched,  as  well  as  the  spinal  membranes  severely 
stretched  and  irritated. 

Those  injured  by  railway-collisions  may  sustain  dislocations  and  frac- 
tures of  the  vertebrae,  lacerations  of  the  spinal  meninges  with  intra-vertebral 
hemorrhage,  and  lacerations  of  the  substance  of  the  spinal  cord  with  intra- 
rachidian  hemorrhage.  It  is  not,  however,  my  purpose  to  devote  now  any 
time  to  the  discussion  of  these  lesions,  for  they  differ  in  no  wise  from  those 
produced  by  falls  and  blows,  which  have  already  been  fully  considered  in  the 
foregoing  pages.  Likewise,  acute  inflammations  of  the  spinal  membranes 
and  spinal  cord  may  arise  from  the  injuries  occasioned  by  railway-collisions. 
These  disorders  have  also  been  so  fully  discussed  above,  that  it  is  now  unne- 
cessary to  take  them  up  again.  We  are  at  present  chiefly  concerned  with 
the  remote  effects  of  the  spinal  injuries  which  result  from  raihvay-collisions, 
such,  for  example,  as  chronic  inflammation  of  the  vertebral  joints,  chronic 
spinal  meningitis,  and  chronic  myelitis,  together  with  the  structural  changes, 
and  functional  disturbances,  or  phenomena,  by  which  these  affections  are 
severally  attended.  And,  inasmuch  as  chronic  vertebral  arthritis  with  caries 
and  necrosis,  chronic  spinal  meningitis,  and  chronic  myelitis,  when  they  pre- 
sent themselves  as  the  remote  eftects  of  spinal  injuries  caused  by  railway- 
collisions,  differ  in  no  essential  particular,  with  regard  to  anatomical  changes, 
functional  disturbances  or  symptoms,  and  therapeutic  indications,  from  the 
corresponding  affections  of  the  spine  which  are  not  unfrequently  produced  by 
blows  on  the  back  and  various  common  accidents,  the  discussion  of  which 
has  just  been  ended,  I  shall  not  occupy  much  space  in  any  further  discussion 
of  them. 

In  respect  to  the  symptoms  by  which  the  remote  effects  of  spinal  injuries 
caused  by  railway-collisions  are  characterized,  they  will  be  found  to  vary 
according  as  the  inflammatory  lesions  of  the  vertebral  articulations,  of  the 
spinal  membranes,  or  of  the  spinal  cord-substance,  may  predominate.  For 
instance,  in  cases  where  myelitis  constitutes  the  principal  secondary  lesion 
or  disorder,  cutaneous  ansesthesia  and  complete  paraplegia,  with  alkaline 
urine,  etc.,  often  combined  with  hypersesthesia,  will  probably  be  observed  at 
an  early  period ;  while  in  others,  where  meningeal  inflammation  constitutes 
the  main  affection,  there  will  be  marked  cutaneous  hypereesthesia  with  severe 
peripheral  pains,  as  well  as  intense  pain  in  the  spinal  column  itself,  combined 
■[)erhaps  with  tetanic  spasms  of  the  posterior  cervical,  abdominal,  and  other 
muscles,  but  without  any  paralysis  whatever  of  the  voluntary  muscular 
apparatus. 

As  Mr.  Erichsen  well  remarks,  one  of  the  most  remarkable  phenomena  of 
this  class  of  cases  is,  that,  at  the  time  of  the  accident,  the  victim  is  often  quite 


REMOTE  EFFECTS  OF  SPINAL  INJURIES. 


479 


unconscious  that  he  has  received  any  serious  damag*e.  lie  feels  that  lie  has 
been  violently  jolted,  and  shaken  ;  he  likewise  feels,  perhaps,  somewhat 
giddy  and  confused,  but  he  finds  no  bones  broken,  merely  some  superficial 
cuts  or  bruises,  and  possibly  even  no  external  evidence  whatever  of  injury. 
He  congratulates  himself  upon  his  escape  from  the  imminent  peril  to 
which  he  has  been  exposed,  and  gives  valuable  aid  to  his  less  fortunate 
fellow-passengers  for  several  hours.  JJut,  when  he  reaches  his  home,  the 
effects  of  the  injury  which  he  has  sustained  begin  to  manifest  themselves. 
He  bursts  perhaps  into  tears,  and  becomes  unusually  talkative,  as  w^ell  as 
excited.  He  cannot  sleep,  or,  if  he  does,  he  suddenly  wakes  with  a  vague 
sense  of  alarm.  ^N'ext  day  he  complains  of  feeling  shaken  or  bruised  all  over, 
or  as  if  he  had  been  beaten,  or  had  violently  strained  himself  by  exertion  of 
mi  unusual  kind.  This  stiff,  strained,  and  sore  feeling  chiefly  affects  the 
muscles  of  the  loins  and  neck,  but  sometimes  involves  also  those  of  the 
thighs  and  shoulders.  After  a  time,  which  varies  in  different  cases  from  a 
day  or  tw^o  to  a  week  or  more,  the  victim  finds  that  he  is  unfit  for  exertion 
and  unable  to  attend  to  business.  He  now  lays  up,  and  perhaps  for  the  flrst 
time  seeks  surgical  assistance.  (Erichsen.)  His  countenance  becomes  pallid, 
wrinkled,  and  acquires  a  care-worn  or  anxious  expression ;  and  he  genei^ally 
looks  much  older  than  he  really  is,  or  than  he  did  before  the  accident.  Some 
time  subsequently,  and  possibly  long  afterward,  the  symptoms  mentioned 
above,  of  spinal  meningitis  and  myelitis,  present  themselves  ;  and  these  grave 
disorders  run  their  destructive  course,  unless  they  are  fortunately  arrested  by 
timely  treatment. 

Pathological  Anatomy. — As  far  as  I  know,  there  is  but  one  case  on  record 
in  w^hich,  death  having  ensued  as  a  remote  consequence  of  spinal  lesions 
arising  from  a  railway-collision,  the  morbid  state  of  the  spinal  cord  and  its 
membranes  has  been  accurately  determined  by  a  thorough  post-mortem  exami- 
nation.   The  history  of  this  highly  important  case  is  briefly  as  follows : — 

A  man,  aged  52,  and  of  active  business  habits,  was  the  subject  of  a  railway-coflision. 
Immediately  after  it  he  walked  from  the  train  to  the  station  near  by.  He  received  no 
contusions,  nor  wounds,  nor  any  external  sign  of  injury  ;  but  he  did  complain  of  pain 
in  his  back.  He  strove  hard  to  keep  up,  and  at  his  business,  and  did  so  for  a  short  time 
after  the  accident,  although  with  much  distress.  Numbness  and  want  of  power  in  the 
muscles  of  his  lower  limbs  appeared,  and  gradually  but  steadily  increased  ;  thus  he  soon 
became  disabled.  His  gait  became  unsteady,  and  like  that  of  a  semi-intoxicated  per- 
son. There  was  also  extreme  sensitiveness  to  external  impressions,  so  that  a  shock 
against  a  table  or  chair  gave  him  great  distress.  The  paralytic  symptoms  came  on  in 
less  than  one  year  after  the  accident.  In  the  latter  part  of  his  illness,  some  weakness  of 
his  upper  extremities  became  apparent,  so  that,  when  he  was  off  his  guard,  a  cup  or  a 
glass  would  slip  from  his  fingers.  He  could  barely  walk  with  the  aid  of  two  sticks  ;  and 
at  last  he  was  confined  to  bed.  His  voice  became  thick,  and  his  articulation  imperfect. 
There  was  no  paralysis  of  the  bladder  until  about  two  years  after  the  accident,  when 
his  urine  became  pale  and  alkaline,  with  muco-purulent  deposit.  He  died  three  and 
one-half  years  after  the  accident.' 

Dr.  J.  Lockhart  Clarke  carefully  examined  the  spinal  cord  and  membranes, 
which  were  obtained  at  the  autopsy  of  this  case,  and  reported  upon  them  as 
follows : — 

"  I  found  that  the  membranes  at  some  parts  were  thickened,  and  adherent  at  others, 
to  the  surface  of  the  white  columns.  In  the  cord  itself,  one  of  the  most  striking  chanties 
consisted  in  a  diminution  of  the  antero-posterior  diameter,  which,  in  many  places,  was 
not  more  than  equal  to  half  the  transverse.  This  was  particularly  the  case  in  the 
upper  portion  of  the  cervical  enlargement,  where  the  cord  was  consequently  much  flat- 
tened from  behind  forward.    On  making  sections,  I  was  surprised  to  find  tliat  of  all  the 

•  Erichsen,  On  Concussion  of  the  Spine,  etc.,  pp.  178,  179.  1882. 


480 


INJURIES  OF  THE  BACK. 


white  columns,  the  posterior  were  exclusively  the  seat  of  disease.  These  columns  were 
darker,  browner,  denser,  and  more  opaque  than  the  anterolateral ;  and  when  they  were 
examined,  both  transversely  and  longitudinally,  in  their  preparations  under  the  micro- 
scope, this  appearance  was  found  to  be  due  to  a  multitude  of  compound  granular  cor- 
puscles, and  isolated  granules,  and  to  an  exuberance  of  wavy  fibrous  tissue  disposed  in. 
a  longitudinal  direction.  It  was  very  evident  that  many  of  the  nerve-fibres  had  been 
replaced  by  this  tissue,  and  that  at  certain  spots  or  tracts,  which  were  more  transparent 
than  others,  especially  along  the  sides  of  the  posterior  median  fissures,  they  had  wholly 
disappeared.  Corpora  amylacea  also  were  thickly  interspersed  through  the  same 
columns,  particularly  near  the  central  line.  The  extremities  of  the  posterior  horns 
contained  an  abundance  of  isolated  granules  like  those  in  the  columns,  and  in  some  sec- 
tions the  transverse  commissure  was  somewhat  damaged  by  disintegration.  The  anterior 
cornua  were  decidedly  smaller  than  natural,  and  altered  in  shape,  but  no  change  in 
structure  was  observed."^  Dr.  Clarke  remarked  that  the  alterations  in  appearance  pre- 
sented by  the  cord,  in  this  instance,  bore  a  striking  resemblance,  in  the  limitation  of  the 
principal  lesion's  to  the  posterior  columns,  to  what  is  met  with  in  locomotor  ataxy. 

The  post-mortem  examination  of  this  case  also  revealed  traces  of  chronic 
inflammation  in  the  cranial  arachnoid  membrane,  and  in  the  cortical  substance 

of  the  brain.  ... 

From  the  foregoing  account  of  this  case,  it  appears  that  the  injuries  caused 
by  the  railway-collision  eventuated  in  chronic  hypersemia  and  chronic  in- 
flammation of  the  spinal  arachnoid  membrane  and  spinal  cord-substance, 
especially  the  posterior  columns  thereof,  which  slowly  spread  upward  until 
Anally  the  morbid  process  involved  the  encephalic  arachnoid  membrane,  and 
the  cortical  substance  of  the  brain.  Moreover,  there  is  good  reason  to  believe 
that  when  the  inflammatory  process  attacks  other  portions  of  the  spinal  cord 
in  cases  belonging  to  this  category,  it  is  capable  of  producing  progressive 
muscular  atrophy,  and  other  important  consequences,  which  have  been  men- 
tioned above. 

'  Brief  mention  must  here  be  made  of  some  rather  important  complications 
which  present  themselves  with  great  frequency  in  cases  where  spinal  injuries 
have  been  produced  by  rail w^ay-collisions -without  luxation  or  fracture. 

(1)  Impairment  of  Vision. — One  of  the  most  frequent  and  troublesome  among 
the  remote  effects  arising  from  injuries  of  the  spine,  especially  those  received 
in  railway-collisions,  is  diminution  of  the  eye-sight.  As  a  rule,  this  compli- 
cation is  met  with  only  in  cases  where  there  is  traumatic  inflammation  ot 
the  spinal  cord  and  its  membranes,  which  pursues  a  chronic  course.  For  in- 
stance, it  presented  itself  some  considerable  time  after  the  accident  m  the  case 
of  Mrs.  J.  C.  F.,  which  has  been  related  above.  On  examination,  I  found 
her  eyeballs  sunken,  flattened,  watery,  and  dull  in  appearance,  and  looking 
like  the  eyeballs  of  a  much  older  person.  The  pupils  were  contracted  to  one- 
half  the  normal  size,  and  were  also  sluggish.  She  complained  that  her  eye- 
sight had  become  weak  and  dim.  There  was  no  diplopia,  but  objects  appeared 
to  her  to  be  enveloped  by  mist  or  fog.  At  one  time,  she  had  black  spots 
floating  in  the  field  of  vision.  The  veins  of  the  eyeballs  Were  dark-purple, 
and  distended  with  blood.  Her  vision  was  much  better  on  some  clays  than  on 
others  ;  for  example,  it  was  much  better  on  bright  than  on  dull  days,  fehe 
could  not  see  except  in  a  good  light. 

This  subject  has  been  carefully  investigated  by  Mr.  Wharton  Jones  and 
Dr.  Cliflbrd  Allbutt.  The  former  states  that  the  pupils  are  usually  hall- 
closed,  the  eyes  sunken,  dull,  and  watery,  and  the  veins  of  the  eyeball  con- 
crested,  which  abnormal  appearances  were  all  noted  in  the  case  recorded  by 
myself.    He  also  states  that  the  movements  of  the  pupils  are  sometimes 

1  Transactions  of  the  Pathological  Society  of  London,  vol.  xvii.  p.  21. 


REMOTE  EFFECTS  OF  SPINAL  INJURIES. 


481 


normal,  sometimes  sluggish,  and  sometimes  abnormally  active.  They  are 
sluggish  in  cases  of  asthenopia,  but  abnormally  active  in  cases  where  there 
is  intra-ocular  hypenemia  or  inflammation.^ 

The  ophthalmoscopical  appearances  presented  by  cases  of  spinal  disease  or 
Injury  have  been  described  by  Dr.  Alll)utt,  as  well  as  by  Mr.  AV^harton  Jones. 
Dr.  Allbutt  finds  that  they  may  all  be  classed  under  two  heads :  

"  1.  Simple  or  primary  atrophy  of  the  optic  nerve,  sometimes  accompanied  at  first  by 
tliat  slight  hyperaemia  and  inactive  proliferation  which  make  up  the  state  I  have  called 
chronic  neuritis.  This  sort  of  change  I  have  never  found  as  a  result  of  spinal  injuries, 
but  I  have  often  met  with  it  in  chronic  degeneration  of  the  cord  and  in  locomotor 
ataxy.  2.  A  somewhat  characteristic  hyperaimic  change,  wliich  I  have  not  seen  in 
chronic  degeneration,  nor  in  locomotor  ataxy,  but  in  cases  of  injury  to  the  spine  only. 
The  retinal  arteries  do  not  dilate,  but  become  indistinguishable ;  while  the  veins  begin  to 
swell,  and  become  somewhat  dark  and  tortuous.  The  disk  then  becomes  uniformly 
reddened,  and  its  borders  are  lost,  the  redness  or  pinkness  commencing  with  increased, 
fine  vascularity  at  the  inner  border,  which  then  invades  the  white  centre  and  the  rest,' 
so  that  the  disk  is  obscured,  or  its  situation  known  only  by  the  convergence  of  the 
vessels.  In  many  cases,  rather  than  redness,  I  have  observed  a  delicate° pink— pink 
which  sometimes  passes  into  a  daffodil  color.  In  one  case  in  particular—a  railway 
accident — ^^which  I  examined  in  consultation  with  my  friend  and  colleague,  Mr.  Teale, 
this  daffodil  color  of  the  whole  field  was  very  curious ;  no  disk  was  to  be  distinguislied,' 
but  tlie  dark  vessels  stood  out  in  beautiful  relief.  The  other  eye  presented  the  common 
appearances  of  hyperaemia  and  serous  effusion,  with  slight  swelling.  It  is  to  be  re- 
marked that  this  state  is  generally  or  always  of  long  duration  ;  it  passes  very  slowly  up 
to  its  full  development,  and  then  shows  a  disposition  to  end  in  resolution  rather  tlian  in 
atrophy.  In  those  cases  whicii  I  have  been  able  to  watch  diligently  for  many  months, 
the  pinkness  seems  slowly  to  have  receded,  leaving  an  indistinct  but  not  very  abnormal 
disk  behind.  Sometimes  the  sight  suffers  a  good  deal  in  these  cases,  sometimes  but  little 
or  scarcely  at  all.  I  have  never  seen  true  optic  neuritis,  with  active  proliferation,  as  a 
sequel  of  spinal  disease."^ 

Dr.  Allbutt  states  that  in  thirteen  cases  of  chronic  spinal  disease  followino- 
accideiits,  he  found  disturbance  of  the  optic  disk  and  its  neighborhood  in 
eight  instances,  and  that  the  disturbance  of  the  eye  "  is  seen  to  follow  dis- 
turbance of  the  spine  with  sufficient  frequency  and  uniformity  to  establish 
the  probability  of  a  causal  relation  between  the  two  events."  But,  in  the 
more  severe  forms  of  spinal  injury,  those,  for  example,  which  prove  fatal  in 
a  few  weeks,  these  evidences  of  ophthalmic  disease  are  not  met  with  ;  for,  in 
seventeen  cases  of  this  sort,  Dr.  Allbutt  found  no  evidence  of  ophthalmic 
disease  in  any  instance. 

To  w-hat  should  the  impairment  of  vision  in  question  be  ascribed  ?  The 
same  eminent  authority  holds  "  that  hyperaemia  of  the  back  of  the  eye,  fol- 
lowing injury  to  the  spine,  is  probably  dependent  upon  a  greater  or' less 
extensioji  of  the  meningeal  irritation  up  to  the  base  of  the  brain.  Xow,  have 
we  any  reason  to  suppose  that  spinal  meningitis  does  creep  up  into  the  ence- 
phalon?  We  have:  For,  setting  aside  tbe  curious  head-symptoms  such 
patients  often  present,  here  the  actual  demonstration  of  autopsy  comes  to 
our  aid.  ^  It  is  tolerably  w^ell  known  to  careful  jDathologists  that  encephalic 
memngitis  is  a  very  common  accompaniment  of  spinal  menino;itis."  More- 
over, in  a  number  of  instances  presented  in  the  foregoing  pa2:es,  the  post- 
mortem examination  revealed  the  tact  that  inflammation  of  the  spinal 
membranes  had  extended  upward  until  it  likewise  involved  the  encephalic 
membranes.  I  have  no  doubt  that  the  ophthalmic  lesions  above  mentioned 
are  solely  due  to  the  creeping  upward  of  a  chronic  meningitis  which  orio-inally 
is  spinal,  but  in  the  end  becomes  cerebral  also.  ^ 

1  On  Failure  of  Sight  after  Railway  and  other  Injuries,  p.  44. 

2  Lancet,  1870,  vol,  i.  pp.  76,  77. 
VOL.  IV.— 31 


482  INJURIES  OF  THE  BACK. 

(2)  Impotency.—Mv.  Erichsen  states  that  priapism  does  not  occur  in  cases 
of  siDinal  concussion  resulting  from  railway-collisions,  and  that,  as  a  rule,  the 
genitals  are  quite  flaccid  in  such  cases.^  This  statement,  however,  does  not 
hold  good  in  those  concussions  of  the  spinal  cord  which  are  attended  with 
contusions  of  the  rachidian  substance,  or  with  intra-rachidian  extravasations 
of  blood  ;  for  there  was  well-marked  priapism  in  several  instances  of  this  sort 
which  have  been  mentioned  in  the  preceding  pages.  - 

Mr  Erichsen  likewise  states  that  sexual  desire  and  sexual  power  are  usually 
greatly  impaired,  and  often  entirely  and  permanently  lost,  in  consequence  of 
spinal  injuries  arising  from  railway-collisions,  and  Mr.  Humphry  has  seen  a 
case  of  complete  impotence  consequent  on  a  jar  to  the  spine  thus  caused. 
This,  however,  is  not  invariably  the  case;  for  the  wife  of  one  of  Mr.  Erich- 
sen's  patients  miscarried  twice  during  the  year  succeeding  her  husband  s  in- 
iuries^  There  'is,  however,  no  doubt,  I  think,  that  the  spinal  injuries  pro- 
duced' by  railway-collisions  usually  inhibit  for  a  time,  and  often  completely 
and  permanently  destroy,  the  sexual  reflex  centre  m  the  spmal  cord,  in 
this  manner,  such  iniuries  frequently  give  rise  to  impotency.  ... 

(3)  Sacrodynia.— The  group  of  symptoms  arising  from  spinal  injuries 
received  in  railway-collisions,  to  which  Mr.  Erichsen  with  much  propriety 
has  given  the  name  oi  sacrodyjiia,  consists  of  the  following:  Soon,  but  not  ot 
necessity  at  once,  after  the  accident,  the  patient  feels  a  diffused  pam  over  the 
entire  sacral  and  sacro-lumbar  regions.    It  is  usually  most  intense  over  the 
sacrum,  and  especially  over  the  sacro-iliac  synchondrosis    It  is,  however 
not  confined  to  this  part ;  for  it  extends  upward  as  high  as  the  fourth  or  third 
lumbar  vertebra,  and  laterally,  perhaps,  almost  to  the  trochanters.    .But  the 
sacrum  is  the  focus  of  its  greatest  intensity.    When  the  sacro-iliac  junction 
also  is  the  seat  of  suffering,  it  is  the  left  that  is  aff'ected  m  a  large  majority  ot 
instances.    Over  the  whole  of  this  region  there  is  tenderness  under  pressure, 
and  the  pain  is  greatly  increased  by  movements  of  all  kinds.  ^  There  is  no 
nocturnal  exacerbation.    There  is  no  external  sign  of  injury  in  the  way  ot 
swelling,  heat,  or  discoloration.    The  patient  cannot  stand  erect  without  in- 
creasing the  pain;  hence,  a  tendency  to  stoop  slightly  forward,  and  perhaps  to 
incline  to  one  side,  is  exhibited.    Advancing  the  lower  extremities  greatly 
increases  the  pain;  the  patient,  therefore,  walks  with  difliculty,  takes  short 
steps,  leans  on  a  stick,  and,  when  one  side  is  more  pamfu  than  the  other  drags 
the  leg  on  that  side.    As  already  stated,  the  left  is  much  more  frequently  the 
painful  side  than  the  right,  and  hence  it  is  that  the  left  leg  is  so  frequently 
"  dragged  "  in  these  cases.    The  greater  frequency  and  the  greater  severity  ot 
sacrodynia  on  the  left  side,  than  on  the  right,  and  the  consequent  dragging  ot 
the  left  leg,  are  very  notable  circumstances.    They  occur  m  at  least  three- 
fourths  of  all  the  cases.    My  patient,  whose  case  has  been  related  above  with 
some  particularity,  suffered  dreadfully  in  this  way.    The  great  preponderance 
of  left-sided  cases  of  sacrodynia,  is  probably  to  be  explained  by  the  fact  that 
most  people  are  right-handed,  and  that  in  consequence  thereof  they  ii?stinc- 
tively  put  forth  their  right  hands  for  self-protection  when  they  are  pitched 
about  the  cars  in  railway-collisions,  and  at  the  same  time  correspondingly 
advance  the  right  side  of  their  bodies,  which  of  course  places  their  left  but- 
tocks and  the  left  side  of  their  sacral  bones  in  a  position  to  bear  the  brunt  ot 
blows  received  from  behhid.    At  all  events,  I  believe  this  to  be  the  trae  ex- 
planation of  the  left-sided  sacrodynia  with  which  my  patient  was  afllicted 
In  her  case,  too,  there  was  so  much  traumatic  inflammation  /acral 
ligaments,  that  the  sacro-coccygeal  articulation  was  destroyed  by  it,  ana 
anchylosis  of  that  joint  with  the  coccyx  in  an  abnormal  position  ensued. 

1  Op.  cit.,  p.  64.  2  Holmes's  System  of  Surgery,  vol.  v.  p.  161,  foot  note. 

>  Op.  cit.,  p.  172. 


REMOTE  EFFECTS  OF  SPINAL  INJURIES. 


483 


The  symptoms-  of  sacrodynia  often  continue  for  a  long  time.  When  once 
they  have  fairly  set  in,  they  will  last  for  many  months,  and  not  unfrequently 
for  a  year  or  two.  Moreover,  the  pain  does  not  follow  the  anatomical  course 
of  any  nerve,  and,  therefore,  it  cannot  be  classified  with  the  neuralgias.  It 
appears  to  arise  directly  from  bruising  and  spraining  of  the  ligamentous 
structures.  The  sacro- vertebral,  the  ilio-lumbar,  the  sacro-iliac,  and  the  sacro- 
ischiatic  ligaments  may  all  be  more  or  less  strained  in  the  bumps,  twists,  and 
wrenches  to  which  the  pelvis  and  lower  part  of  the  spine  are  subjected  in  the 
accidents  under  consideration.  And,  according  as  the  violence  falls  more  or 
less  directly  on  one  or  other  of  these  ligaments,  so  the  patient  will  suffer  more 
or  less  in  the  part  where  it  is  situated.  (Erichsen.)  The  long  continuance  of 
pain  in  cases  of  sacrodynia  is  exactly  what  we  find  in  cases  where  the  liga- 
ments are  strained  in  other  parts  of  the  body. 

(4)  yomiting. — It  will  be  remembered  by  some  that  about  twenty-five  years 
ago  Sir  W.  Gull,  in  Guy's  Hospital  Reports,  called  attention  to  vomiting  as 
a  symptom  or  effect  of  hypersemia  or  inflammatory  irritation  of  the  rachi- 
dian  substance  in  the  cervical  region,  and  recorded  an  example  in  which  the 
existence  of  myelitis  in  the  cervical  region  (caused  by  a  blow  on  the  neck) 
was  proved  by  post-mortem  examination.  This  case  I  have  used  above  to 
illustrate  the  remote  effects  of  spinal  injuries.  It  will  likewise  be  remem- 
bered that  any  slight  muscular  effort  on  the  part  of  my  own  patient  who 
suffered  from  railway-injury  of  the  spine,  and  whose  case  I  have  so  often 
referred  to,  always  produced  nausea,  and  sometimes  caused  vomiting,  and 
that  these  symptoms  of  cervical  myelitis  lasted  for  several  months.  Mr.  Erich- 
sen,i  too,  relates  a  very  instructive  case  in  which  concussion  of  the  spinal 
€ord  caused  by  a  blow  on  the  nape  of  the  neck  received  in  a  railway-collision, 
and  the  rachidian  inflammation  which  ensued,  were  attended  by  vomiting  as 
a  prominent  and  a  very  persistent  symptom.  It  is  obvious  that  medication 
for  the  relief  of  this  symptom,  in  such  cases,  should  be  directed  tow^ards  the 
removal  of  its  cause,  namely,  the  rachidian  hypersemia  and  irritation  in  the 
•cervical  region,  upon  which  its  existence  depends. 

Treatment — Inasmuch  as  the  spinal  injuries  arising  from  railway-collisions 
may  be  followed  by  inflammation  of  the  vertebral  articulations,  inflammation 
of  the  spinal  membranes — but  particularly  of  the  spinal  arachnoid  and  pia 
mater — and  inflammation  of  the  rachidian  substance,  the  first  step  consists  in 
making,  as  far  as  practicable,  a  differential  diagnosis.     Almost  always,  in 
such  cases,  spinal  meningitis  and  myelitis  will  be'found  creeping  up  the  cord 
together  into  the  cranium ;  and,  not  unfrequently,  all  three  disorders  will' 
siniultaneously  present  themselves.    The  principles  upon  which  the  treatment 
of  each  of  these  inflammatory  affections  of  the  spine,  whether  acute  or  chronic, 
should  be  conducted,  have  already  been  laid  down,  and  the  several  remedial 
measures  which  experience  has  shown  to  be  the  most  useful  in  such  cases, 
have  already  been  mentioned  ;  it  does  not  seem  necessary  to  restate  them 
here.^  One  thing,  however,  I  will  say,  namely :  The  importance  of  rest  in 
bed,  in  these  cases,  caimot  be  overestimated.  "^Furthermore,  insomnia  occur- 
ring per  se,  that  is,  without  pain,  should  be  overcome  by  administering  the 
bromides  or  chloral  hydi-ate  rathei-  than  opium  or  morphia ;  but  pains  m  the 
spinal  membranes,  lig^aments,  or  joints  must  be  subdued  by  exhibiting  the 
last-named  drugs.    When  the  morbid  process  in  the  rachidian  substance  has 
reached  the  stage  of  atrophy,  the  primary  galvanic  current  passed  downward 
through  the  cord  may  prove  very  useful.    But  whatever  the  treatment  may 
be,  no  speedy  benefit  can,  as  a  rule,  be  expected. 


I  Op.  cit.,  pp.  216-219. 


484 


INJURIES  OF  THE  BACK. 


[Additional  Remarks  on  Railway-Injuries  of  the  Spine. 

Mr.  Gore's  case,  quoted  from  Mr.  Erichsen,  on  page  479,  lias  been  much 
relied  upon  by  surgeons  called  as  expert  witnesses  for  the  plamtift,  m  suits 
for  damages  against  railway  companies,  as  showing  the  grave  and  well-de- 
lined  lesiSns  of  the  spinal  cord,  which  may  follow  m  instances  of  what  is 
ordinarily  called  "  spinal  concussion;"  and  it  has,  on  the  other  hand,  been 
subiected  to  sharp  criticism  by  experts  for  the  defense,  m  such  suits,  on  the 
oTound  that  it  stands  alone,  and  that  the  lesions  observed  were  Pfsibly  due 
to  ordinary  locomotor  ataxia,  and  not  really  caused  by  the  accident  which 
preceded  their  development.    It  is  to  be  observed,  however,  as  pointed  out 
by  Mr.  Jacobsoi;  in  the  third  edition  of  the  "  System  ot  Surgery,  edited  by 
Messrs.  Holmes  and  Hulke,  that  unmistakable  cord-lesions,  only  recogniza- 
ble by  the  microscope,  have  also  been  observed  in  cases  ot  spmal  concus- 
sion "  due  to  other  than  railway-injuries.    Thus,  in  the  case  reported  by  Dr. 
Bastian  in  the  50th  volume  of  the  Medico-Chirurgical  Transactions,  and 
quoted  bv  both  Jacobson  and  Page  (by  the  former  incorrectly  attributed  to 
Dr  Gowers),  the  patient  lived  nearly  six  months  after  falling,  while  asleep, 
twenty-live  feet  from  the  top  of  a  hay-rick;  at  the  post-mortem  examina- 
tion, the  vertebrae  were  found  uninjured,  and  to  the  naked  eye  the  spmal 
cord  appeared  perfectly  healthy.    Under  the  microscope  however,  ruptures 
of  varyins:  size  were  found  in  the  right  and  left  halves  of  the  grey  matter  ot 
the  cervical  cord,  and  distinct  areas  of  degeneration  in  the  anterior  columns 
of  the  cervical,  dorsal  and  lumbar  cord,  best  marked  above,    feimilar,  but 
less  extensive,  areas  were  also  found  in  the  left  lateral  column.    Beside  the 
descendino'  lesions  of  the  anterior  and  lateral  columns,  there  was  ascending 
degeneratfon  in  the  posterior  columns  of  the  upper  cervical  cord  and 

"^ms^case  is  reported  by  its  observer,  and  accepted  by  Mr.  Jacobson,  as 
one  exhibiting  tvpical    concussion-lesions,"  but  Mr.  Page  (whose  excellent 
work     Iniuries  of  the  Spine  and  Spinal  Cord  without  apparent  Mechanical 
Lesion,"  etc.,  appeared  after  Dr.  Lidell's  article  had  been  completed)  objects 
to  the  term  "  concussion  "  as  applied  to  injuries  of  the  spmal  cord,  and  points 
out  that  thouo-h  Dr.  Bastian  referred  to  the  case  as  one  of  concussion-lesion, 
such  as  mio-hf  be  met  with  after  railway-collisions,  no  record  ot  any  case  at 
all  comparable  with  it  has  been  published  since.    Mr.  Page  maintains,  and 
my  own  exi  )erience  disposes  me  to  agree  with  him,  that  m  certainly  the  very 
•  laro-e  maiority  of  severe  spinal  injuries  received  in  railway-collisions  or  by 
similar  accidents,  there  is  found  some  tangible  lesion,  recognizable  during 
life  such  as  a  twist  or  sprain  of  the  vertebral  articulations,  or  a  rupture, 
partial  or  complete,  of  the  spinal  nerves ;  and  he  believes,  with  Le  Gros 
Clark,  that  the  milder  cases,  in  which  recovery  often  follows  after  some 
months  or  vears,  are  attributable  to  general  ^'  shock  to  the  nervous  system 
rather  than  to  any  condition  peculiar  to  the  spinal  cord     I  see  myselt  no 
obiection  to  the  term    spinal  concussion,"  and  believe  that  the  spinal  cord 
may  as  the  result  of  severe  shaking  and  knocking  about,  as  well  as  trom 
falls 'or  other  forms  of  diffused  violence,  be  the  seat  of  such  lesions  .as  are 
acknowledged  to  be  i)resent  in  the  brain  in  cases  of  cerebral  concussion- 
slight  and  qui(;kly  recovered  from  in  most  instances,  but  under  other  cir- 
cumstances more  severe,  and  followed  by  inflammatory  or  degenerative 
changes  which  may  cause  prolonged  disability  or  even  death.    At  the  same 
time  there  can  be  no  doubt  that  in  many  cases  of  so-called  railway-spme, 
the  condition  is  a  general  one,  affecting  the  whole  nervous  system,  and  more 


REMOTE  EFFECTS  OF  SPIxXAL  INJURIES. 


485 


analogous  to  certain  examples  of  Avhat,  for  \\'ant  of  a  better  name,  we  call 
hysteria,  than  to  any  local  aftectiom  The  suffering  in  these  cases  maybe 
really  quite  as  severe  as  in  more  dangerous  conditions,  and  tliough  the  prog- 
nosis may  be  more  favorable,  the  patient's  disability  is,  for  the  time  at  least, 
indisputable.  "  It  is  all  very  well  to  say,"  remarks  Mr.  Page—"  and  it  is  an 
easy  enough  diagnosis  to  make— that  so-and-so,  who  recovered  as  soon  as  his 
claim  was  settled,  was  '  shamming,'  and  that  his  sym[)toms  were  altogether 
untrue  or  wilfully  exaggerated  •^'"but  this  will  hardly  sufK.ce,  nor  can  we 
accept  It,  to  explain  the  symptoms  which  have  caused  so  nnrch  anxiety  and 
trouble,  and  have  been  so  little  amenable  to  treatment.  The  man  recovers 
quickly  because  the  goal,  whose  prospect  unsettled  him,  has  at  leno;th  been 
reached,  and  because  it  no  longer  stands  in  the  way  of  his  making  tlie 
requisite  and  successful  effort  to  resume  his  work." 

Mr.  Page  refers  to  some  interesting  cases  reported  by  Mr.  Bruce-Clarke  in 
the  sixteenth  volume  of  St.  Bartholomew's  nosi)ital  Reports,  which  show 
that  not  only  do  well-marked  changes  in  the  optic  disc  often  accompany 
injuries  in  the  upper  part  of  the  spinal  cord,  but  that,  in  cases  which  end  in 
recovery,  these  changes— hypersemia  and  oedema— may  be  only  transient ; 
and  the  inference  is  therefore  reasonable  that  similar  changes  may  exist  at 
some  period  in  many  cases  of  minor  spinal  injury,  and  are  not  detected  sim- 
ply because  they  are  not  looked  for  at  the  right  time. 


Resection  of  the  Spine. 

On  page  379,  reference  has  been  made  to  the  statistics  of  spinal  trephin- 
ing or  resection  collected  by  the  Editor.  To  the  41  cases  there  mentioned, 
nine  examples  of  the  operation  have  been  recently  added  bv  Stemen  (two 
cases),  Pinkerton,  Halsted,  Macewen,  Lucke,  Albert,  Lauenstein  and  R.  T. 
Morris,  so  that  the  figures  now  stand  as  follows : — 

Whole  luiinber  of  cases        ....  50 

33  or  6G  per  cent. 
7  "  14   "  " 
4  c.    8   "  " 
2  "    4   "  " 

In  ^Vfacewen's  case,  which,  with  the  exception  of  Lauenstein's,  is  the  only 
one  in  which  the  operation  can  be  said  to  have  been  follo^ved  bv  recoverv, 
the  fracture  involved  the  vertebral  laniin«i  only,  the  injury  being,  therefore, 
soniewhat  analogous  to  that  of  Louis's  patieiit  (see  pao:e  379),  and  the  prog- 
nosis being  exceptionally  favorable. 

The  following  table  includes  the  50  cases  referred  to: — 


Patients  died  . 
Patients  not  benefited 
Patients  relieved 
Patients  recovered  . 
Resnlt  unknown 


486  injuries  of  the  back. 

Table  of  Cases  of  Resection  of  the  Spinal  Column  for  Injury. 


No. 

Result. 

Operator's  name. 

1 

Died 

Cline 

2 

(( 

Wickham 

3 

<( 

Oldknow 

4 

(( 

Tyrrell 

5 

Id. 

6 

(( 

Barton 

7 

(( 

Boyer 

8 

(( 

Rogers 

9 

(( 

Attenburrow 

10 

(( 

Laugier 

11 

(( 

Uolsclier 

12 

Relieved 

A.  G.  Smith 

13 

Died 

Mayer 

14 

(( 

South 

15 

Blackman 

16 

Not  known 

Edwards 

17 

(( 

Blair 

18 

(C 

Goldsmith 

19 

Died 

Stephen  Smith 

20 

Hutchison 

21 

Jones 

22 

<( 

Potter 

23 

<( 

Id. 

24 

Not  benefited 

Id. 

25 

Died 

McDonnell 

26 

Relieved 

Gordon 

27 

Died 

Tillaux 

28 

u 

Willett 

29 

Not  known 

H.  J.  Tyrrell 

30 

Died 

Maunder 

31 

Not  "benefited 

Eve 

32 

Died 

Cheever 

33 

<  ( 

Id. 

34 

(I 

35 

(( 

Nunneley 

36 

(( 

Id. 

37 

<( 

Id. 

38 

Relieved 

Id. 

39 

Died 

Willard 

40 

Relieved 

Stemen 

41 

Not  benefited 

Id. 

42 

Died 

Id. 

AO 

Not  benefited 

44 

a 

Id. 

45 

Died 

Pinkerton 

46 

Halsted 

47 

Recovered 

Macewen 

48 

Lauenstein 

49 

Not  benefited 

Albert 

50 

R.  T.  Morris 

Chelius's  Surgery,  ed.  by  South,  vol.  i.  p.  590. 
Lancet,  1827. 

Hutchison,  Am.  Med.  Times,  1861. 
Malgaigne,  Fract.  et  Luxations,  tome  i.  p.  425. 
Ibid. 

Malgaigne  (Packard's  translation),  p.  343. 
Heyfelder,  Traite  des  Resections  (trad,  par  Boeckel), 
p.  244. 

Am.  Journ.  Med.  Sciences,  0.  S.,  vol.  xvi. 
Chelius  and  Heyfelder,  op.  cit. 
Malgaigne,  op.  cit. 

Brown-Sequard,  Diseases  of  the  Central  Nervous  System, 
p.  256. 

N.  A.  Med.  and  Surg.  Journal,  vol.  vm.  p.  94. 
Heyfelder,  op.  cit. 

Notes  to  Chelius's  Surgery,  vol.  i.  p.  591,  etc. 
Hutchison,  loc.  cit. 
Brit,  and  Foreign  Med.  Review,  1838. 
Ballingall,  apud  Hutchison,  loc.  cit. 
Gross,  System  of  Surgery,  2d  ed.,  vol.  i. 
Hutchison,  loc.  cit. 
Ibid. 

Brown-Sequard,  op.  cit.,  p.  255. 
Hurd,  N.  Y.  Journ.  of  Med.,  1845. 
Am.  Journ.  Med.  Sciences,  N.  S.,  vol.  xlv. 
Ibid. 

Ibid.,  vol.  1. 
Med.-Chir.  Trans.,  vol  xlix.  p.  21. 
Brit,  and  For.  Med.-Chirurgical  Review,  1866. 
Med.  Times  and  Gazette,  Feb.  2,  1867,  and  St.  Barthol. 

Hosp.  Rep.,  vol.  ii.  p.  242. 
Dub.  Quart.  Journ.  Med.  Sci.,  Aug.  1866. 
Med.  Times  and  Gazette,  Feb.  23,  1867. 
Am.  Journ.  Med.  Sci.,  N.S.,  vol.  Ivi. 
Boston  City  Hosp.  Reports,  p.  577,  1870. 

Ibid.,  p.  580. 
St.  Barth.  Hosp.  Reports,  vol.  vi. 
Med.  Times  and  Gaz.,  Aug.  7,  1869. 

Ibid. 

Ibid. 

Ibid. 

Am.  Journ.  Med.  Sci.,  N.  S.,  vol.  Ixiii. 

Fort  Wayne  Journ.  of  the  Med.  Sciences,  April,  1883. 

Ibid.  V 

Ibid.,  Oct.  1883. 
Revue  des  Sciences  Medicales,'  Avril,  1880. 
London  Medical  Record,  March  15.  1887. 
Medical  News,  Jan.  3,  1885. 

Ibid. 

Glasgow  Med.  Journal,  March,  1886. 
London  Medical  Record,  March  15,  1887. 
Ibid. 

Annals  of  Surgery,  June,  1886.] 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


FREDERICK  TREVES,  F.R.C.S., 

ASSISTANT  SURGEON  TO,  AND  SENIOR  DEMONSTRATOR  OF  ANATOMY  AT,  THE  LONDON  HOSPITAL. 


Spina  Bifida. 

The  term  "  spina  bifida"  is  applied  essentially  to  a  hernia  of  the  mem- 
branes of  the  cord  through  a  congenital  fissure  in  some  portion  of  the  bones 
forming  the  spinal  column. 

Pathological  Anatomy.— Speaking  generally,  the  congenital  deficiency 
that  leads  to  spina  bifida  is  in  the  posterior  segments  of  the  column,  and  is 
at  the  expense  of  the  laminae  and  spinous  proce'sses.  Through  the  bony  gap 
the  spinal  membranes  protrude,  distended  by  an  abnormal  amount  of  cerebro- 
spinal fluid.  Often  the  cord  itself,  or  some  part  of  it,  takes  a  share  in  the 
protrusion.  The  spina  bifida,  therefore,  appears  as  a  tumor  of  variable  size, 
situated  in  the  middle  line,  covered  w^ith  normal  or  more  or  less  modified 
integuments,  and  presenting  the  essential  features  of  a  simple  cyst. 

Causes.— As  to  the  causes  of  spina  bifida  nothing  definite  can  be  said,  and 
the  etiology  of  the  afiection  n?ust  for  the  present  be  hidden  under  the  general 
term,  "arrest  of  development."  A  vast  number  of  theories  have  been  pro- 
pounded upon  the  subject,  supported  for  the  most  part  by  a  minimum  of 
facts;  and  it  must  be  confessed,  that  in  spite  of  long  argument  and  a  multi- 
tude of  opinions,  little  real  addition  has  been  made  to  our  knowledge  of  the 
causes  of  this  and  like  deformities.  Perhaps  the  most  essential  question  that 
requires  to  be  answered  is  this:  Which  is  the  primary  defect,  the  arrest  of 
development  in  the  bones,  or  the  dropsy  of  the  membranes  ?  Does  the  defici- 
ency in  the  bony  canal  encourage  a  protrusion  of  the  membranes,  or  has  the 
protrusion  prevented  the  proper  formation  of  the  osseous  canal  ?  Those  who 
are  interested  in  this  discussion  will  find  the  matter  fully  argued  out  by 
Follin  and  Duplay,  in  their  Traite  de  Pathologic  Extcrne. 

Site.— The  common  situation  for  spina  bifida  is  in  the  lumbo-sacral  region. ' 
Indeed,  it  may  be  said  that  the  deformity  is  rare  elsewhere,    i^ext  in  fre- 
quency to  the  lumbo-sacral  region  comes  the  upper  cervical  region,  and  then 
the  rest  of  the  cervical  spine,  while  the  least  frequent  spot  for  a  spina  bifida 
is  the  mid-dorsal  res-ion. 

KuMBER.— The  spina  bifida  is  usually  single.  In  rare  cases,  however,  there 
may  be  two  examples  of  the  deformity  in  the  same  person.  Thus  there  may 
be  a  spina  bifida  in  the  lumbo-sacral  region,  and  another  in  the  neck.  Bryant 

(487) 


488  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

figures  a  case  where  there  was  one  tumor  in  the  lumbar  region  and  another 
in  the  sacral.' 

Condition  of  the  Bone.— An  examination  of  the  vertebra  at  the  site  of  the 
spina  bifida  will  show  that  the  spinous  process  is  absent,  and  that  the  corres- 
pondincr  laminae  are  also  entirely  absent,  or  more  or  less  defective,  i he  re- 
mainder of  the  bone  is  usually  perfect  and  well  developed.  The  osseous  detect 
is  rarely  limited  to  one  vertebra.  It  usually  involves  two  or  three  or  more. 
In  some  few  instances,  in  monsters,  all  the  vertebrse  have  been  found  involved 
—a  condition  not  compatible  with  existence.  Follin  and  Duplay^  cite  some 
instances  where  the  defect  in  the  bone  extended  as  a  cleft  through  the  entire 
body  of  the  afiected  vertebra  ;  and  Bryant^  has  reported  the  case  of  a  woman, 
a2:ed  25  who  died  from  accident,  and  who  presented  an  anterior  spina  bifida. 
Dr  John  Ogle,  has  recorded  a  remarkable  case  of  spina  bifida  opposite  the  upper 
lumbar  vertebra,  where  the  body  of  the  second  lumbar  vertebra  was  deficient, 
and  was  so  pushed  backward  that  the  first  and  third  vertebrse  came  almost 
in  contact.  The  defect  was  associated  with  a  very  marked  and  abrupt  cur- 
vature of  the  spine  backwards  at  the  seat  of  the  spina  bifida.* 

The  Tumor.— The  tumor  varies  greatly  in  size,  and  may  range  from  a  pro- 
trusion the  size  of  a  walnut  to  a  mass  larger  than  an  infant's  head.   Broca  ex- 
hibited a  case  in  an  adult  man,  where  the  circumference  of  the  tumor  was  45 
centimetres  (17.5  inches).   The  usual  size  of  the  tumor  at  birth  is  from  that  ot  a 
bantam's  egg  to  that  of  a  small  orange.  According  to  Follin  and  Duplay,  there 
mav  be  no  tumor  at  all,  but  merely  a  cordiform  or  oval  patch  on  the  skin,  asso- 
ciated with  no  elevation  of  anv  kind.    It  is  asserted  that  this  condition  may 
occur  with  division  of  many  vertebrse.    The  tumor  is  usually  round,  or  oval, 
with  its  greatest  axis  longitudinal,  and  is  of  regular  outline.    The  wall  of  the 
sac  is  thin  and  ultimately  adherent  to  the  skin  or  its  representative   In  cases 
that  have  existed  for  some  years,  the  sac  wall  may  become  great! thickened, 
and  may  present  some  calcareous  change.  In  certain  large  tumors  the  outline  ot 
the  mass  may  be  bossy  and  irregular,  probably  from  unequal  resistance  of  the 
envelopes.  The  tumor  may  be  sessile,  but  it  is  usually  peduncu  ated.   Ihe  size 
of  the  pedicle  depends  upon  the  size  of  the  hole  in  the  vertebral  canal.  In 
process  of  time  the  pedicle  tends  to  become  lengthened,  a  condition  that 
depends  much  upon  the  weight  of  the  tumor,  the  size  of  the  opening  into  the 
spinal  canal,  and  the  maintenance  of  the  vertical  position.^  The  skm  covering 
the  spina  bifida  is  rarely  normal.    It  is  usually  thinned  and  deficient,  often 
shining  and  purple,  and  not  unfrequently  inflamed.    In  other  cases  the  skm 
mav  be  hard  and  coriaceous ;  it  may  be  hairy,  or  in  a  condition  of  ichthyosis. 
Sometimes  it  is  found  to  be  hypertrophied,  although  more  commonly  it  is 
deficient,  and  may  be  entirely  absent.    In  the  latter  case  the  spinal  dura 
mater  is  exposed  as  a  bluish-red  and  vascular  membrane.    Ihe  defective  skm, 
moreover,  may  be  represented  by  a  scanty  fibrous  material,  not  un  ike  cicatri- 
cial tissue,  or  the  integuments  may  be  hypertrophied  at  the  periphery  ot  tfie 
*  tumor  and  atrophied  at  its  centre.    The  deficiency  m  the  integuments  may 
depend  upon  congenital  defect  in  those  parts,  or  may  be  due  to  a  wasting 
of  the  coverings  of  the  tumor,  consequent  upon  increasing  pressure  from 
within.    In  many  cases  the  coverings  of  the  spina  bifida  are  curiously  in- 
flamed and  appear  very  vascular  and  rugose ;  or  they  may  be  sloughing,  or 

1  Manual  for  the  Practice  of  Surgery,  2d  ed.,  vol.  i.  page  256. 

2  Traits  de  Path.  Externe,  tome  iii.  p.  709.  '  Medical  ^razette,  1838. 

:      a  •      "•l^&.'^d  Surg.  Joum.,  July,  1862,  page  4.6,  the  pedicle  is 

said  to  have  been  "about  a  foot  m  length." 


SPINA  BIFIDA. 


489 


the  seat  of  more  or  less  considerable  ulceration.  A  nse void  condition  of  the 
skin  is  by  no  means  uncommon,  either  over  or  about  a  spina  bifida.  ^  When  the 
skhi  is  dissected  off,  the  true  sac  of  the  tumor  is  met  with.  This  is  formed 
from  the  membranes  of  the  cord  matted  together.  X()  layers,  however,  can 
usually  be  made  out,  nor  can  the  integuments  be  distinctly  separated  from 
the  protruded  membranes.  In  cases  where  the  skin  is  quite  normal,  however, 
a  layer  of  loose  comiective  tissue  often  exists  between  the  membranes  and  the 
most  external  coverings  of  the  protrusion.  Mr.  Thomas  Smith  has  recorded 
a  remarkable  case  where  the  tumor  contained  two  distinct  sacs.  The  tumor, 
in  this  instance,  was  large  and  pendulous^  and  opened  from  the  lower  lumbar 
region.  It  was  translucent,  but  presented  no  impulse  on  crying.  The  child 
was  14  months  old,  and,  apart  from  the  tumor,  in  perfect  health.  The  mass 
was  tapped,  and  8  ounces  of  clear  fluid  drawn  off.  The  patient  died  in  ten 
days  from  spinal  meningitis.  At  the  autopsy,  a  second  and  smaller  cyst  was 
found  at  the  upper  part  of  the  mass,  that  had  not  been  punctured.  Between 
the  two  cysts  was  a  strong  membrane,  and  in  this  position  also  ran  the  cauda 
equina.  The  bony  opening  was  at  the  last  lumbar  vertebra.  The  larger  or 
lower  cyst  communicated  with  the  spinal  canal  and  contained  a  few  nerves. 
The  smaller  cyst  led  by  a  funnel-like  process  to  the  centre  of  the  cauda  equina 
and  subarachnoid  space.^  Sir  James  Paget  has  also  recorded  a  case  of  two 
sacs  in  a  spina  bifida,  one  inclosing  the  meninges  and  cord,  and  the  other 
occupied  by  fibrous  and  fatty  tissue. 

Contents  of  the  Tumor. — The  sac  of  a  spina  bifida  contains  more  or  less  • 
fluid,  which  is  identical  in  composition  with  the  cerebro-spinal  fluid.  There 
is  no  doubt,  moreover,  that  this  fluid  and  the  fluid  in  the  sac  of  the  tumor 
are  one.  The  fluid  may  be  found  either  between  the  cord  and  its  membranes 
(hydro rachis  externa  or  hydro-meningocele),  or  may  be  found  in  the  central 
canal  of  the  cord  (hydrorachis  interna  or  hydro-myelocele).  In  the  latter  case, 
the  cord  is  usually  found  spread  out  so  as  to  form  a  thin  covering  over  the 
wall  of  the  sac,^nd  its  condition  may  be  compared  to  that  of  the  brain  in  severe 
hydrocephalus.  Follin  and  Duplay  believe  that  in  at  least  three-fourths  of 
all  cases  the  fluid  is  formed  within  the  centre  of  the  cord.  In  all  cases  where 
the  fluid  has  apparently  accumulated  in  the  central  canal,  an  extensive  spread- 
ino-  out  of  the  substance  of  the  cord  is  not  necessary.  In  mau}^  instances  the 
cavity  of  the  sac  has  been  found  to  communicate  by  a  funnel-shaped  opening 
with  the  central  canal  of  the  cord,  while  yet  the  thinning  or  expansion  of  the 
cord  was  very  slight.^  In  all  these  cases  the  communication  has  been  at  the 
lower  part  of  the  medulla  spinalis ;  and  while  it  is  probable  that  in  these 
instances  the  fluid  originally  accumulated  in  the  central  canal,  it  is  equally 
probable  that  the  collection  communicated  at  an  early  period  with  the  sub- 
arachoid  space.  In  some  cases  cerebro-spinal  fluid  may  form  the  sole  contents 
of  the  sac  in  spina  bifida  ;  but  such  cases  are  exceptional.  As  a  rule,  the 
spinal  cord,  or  some  part  of  it,  and  a  certain  number  of  the  spinal  nerves,  are 
included  in  the  protrusion.  Follin  'M\d  Duplay  state  that  some  nerve-tissue 
is  found  in  the  sac  in  five-sixths  of  all  cases.  Out  of  twenty  cases  of  spina 
bifida,  reported  by  Sir  Prescott  Hewlett,  in  one  instance  only  was  the  sac  free 
from  nerve-structures.^  The  relation  of  the  cord  or  of  the  spinal  nerves  to 
the  sac  varies  greatly.  In  some  cases  the  cord  may  bend  into  the  sac,  and, 
having  possibly  contracted  some  adhesions  there,  may  re-enter  the  spinal  canal ; 
or  the  cauda  equina,  with  more  or  less  of  the  lower  end  of  the  cord,  may 

1  Trans.  Path.  Soc,  vol.  xxi.  page  1.  1869. 

2  See  drawing  of  a  dissection  in  Bryant's  Surgery,  vol.  i,  p.  255. 
s  London  Medical  Gazette,  vol.  xxxiv.  1844. 


490 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


pass  through  the  bony  opeiniig,  and,  enteriDg  the  sac,  become  adherent  to  its 
inner  wall."  In  such  cases  th"e  termination  of  the  medulla  spinalis  is  often 
indicated  by  the  point  of  its  adhesion  to  the  protruded  sac;  and  this  adhesion 
is,  in  some  cases,  marked  by  a  depression  on  the  outer  surface  of  the  cyst. 

Sometimes  the  cord-structure  is  found  spread  out  as  a  thin  coating  of  nerve- 
tissue  over  the  inner  surface  of  the  cyst,  a  condition  depending  upon  great 
accumulation  of  fluid  in  the  central  canal  of  the  cord.  In  other  instances  the 
cord  may  be  fairly  sound,  and  the  cauda  equina  may  be  spread  out  as  a  lining 
to  the  cyst  wall ;  or  the  extremity  of  the  cord  may  be,  as  it  were,  dissected  up 
into  bundles,  and  thus  be  made  to  represent  an  unduly  large  and  coarse  cauda 
equina.  Sometimes  only  a  few  nerves  are  to  be  found  in  the  sac,  scattered 
about  its  posterior  wall,  or  hanging  loosely  in  the  fluid  with  which  it  is 
tilled.  Speaking  generally,  the  nerve-structures,  when  they  occupy  the  sac, 
tend  to  observe,  for  the  most  part,  the  middle  line  and  the  posterior  aspect 
of  the  tumor ;  and  it  may  be  said  that  the  larger  the  opening  in  the  bones, 
the  more  probable  is  it  that  a  large  amount  of  nerve-tissue  will  be  found  in  the 
cyst,  and  vice  versa.  In  spina  bifida  not  only  may  the  cord  be  defective,  or  its 
parts  disturbed  in  the  manner  just  indicated,  but  the  great  nerves  concerned  in 
the  deformity  may  also  show  certain  deficiencies.  Thus,  Dr.  Fisher^  found  in 
two  cases  of  spina  bifida  that  he  examined,  a  fusion  of  two  or  more  of  the 
sacral  ganglia,  and  observed  that  the  corresponding  nerves  passed  through  the 
spinal  membranes  in  one  bundle.  South,^  commenting  upon  this  observation, 
says  that  he  has  himself  verified  it  in  a  case  which  he  examined  after  death 
following  puncture.  Some  few,  rare  instances  have  been  recorded  where  the 
sac  contained,  in  addition  to  cerebro-spinal  fluid  and  some  cord  or  nerve-struc- 
tures, a  certain  amount  of  fibrous  and  fatty  tissue.^    [See  page  560.] 

Symptoms  and  Diagnosis. — The  tumor  in  spina  -bifida  is  congenital,  is 
always  in  the  middle  line,  and  always  closely  and  distinctly  connected  to  the 
subjacent  bone.  In  many  cases  the  defect  in  the  bone  can  be  felt  when  the 
tumor  is  drawn  away  from  its  attachments.  The  tumor  is  round  or  oval,  and 
usually  of  regular  outline.  It  feels  tense  and  elastic,  and,  as  a  rule,  presents 
very  distinct  fluctuation.  If  the  coverings  of  the  cyst  be  thin,  the  mass  may 
be  as  translucent  as  a  hydrocele.  The  Integument  over  the  tumor  may  be 
normal,  or  may  present  any  of  the  conditions  that  have  already  been  described. 
The  mass  is  generally  constricted  at  its  .  base,  if  not  distinctly  pedunculated. 
Careful  attention  must  be  paid  to  those  symptoms  that  mark  the  connection 
of  the  cyst  with  the  interior  of  the  spinal  canal.  Chief  among  these  symp- 
toms are  the  following :  The  size  and  tenseness  of  the  mass  can  be  diminished 
by  pressure.  Such  pressure  will  often  cause  evident  pain  or  convulsions,  or 
limited  muscular  spasms,  and  if  continued  may  induce  a  state  of  coma  in 
many  instances.  When  hydrocephalus  exists  at  the  same  time,  pressure 
upon  the  tumor  causes  increased  tension  at  the  anterior  fontanelle;  and,  in  like 
manner,  pressure  at  the  anterior  fontanelle  produces  some  increase  in  the  sac 
of  the  spina  bifida.  These  mutual  pressure-effects  cannot  be  seen  unless  the 
head  is  hydrocephalic.  If  the  pelvis  be  raised  above  the  bead,^  the  tumor 
becomes  softer,  while  its  tension  is  increased  during  the  act  of  crying.  These 
evidences  of  a  communication  between  the  sac  and  the  spinal  canal  are  more 
marked  in  large  tumors  than  in  small,  and  in  those  without  a  pedicle  than  in 
those  possessed  of  one.  It  will  be  obvious  that  the  smaller  the  orifice  between 
the  sac  and  the  canal,  the  less  marked  will  be  the  evidences  of  the  communi- 

1  London  and  Edinburgh  Philospli.  Mag.,  vol.  x.  p.  316.  1837. 

2  Chelius's  System  of  Surgery,  voL  ii.  p.  466.  1847. 
«  Holmes's  System  of  Surgery,  2d  ed.,  vol  v.  p.  804. 


SPINA  BIFIDA. 


491 


cation.  The  complication  of  hydrocephalus  tends  to  render  the  symptoms  of 
communication  much  more  distinct. 

Spina  bitida  is  very  commonly  associated  with  some  gross  nerve  disturbance, 
due  to  injury  or  defect  in  the  cord  or  great  nerves  at  the  seat  of  the  deform- 
ity. Thus  talipes  is  very  frequent,  and  especially  talipes  equino-varus.  There 
may  be  a  loss  of  power  in  the  lower  limbs  that  may  present  any  grade  from« 
mere  muscular  weakness  to  absolute  paraplegia.  With  this  paraplegia  there 
may  be  paralysis  of  the  sphincters,  although  this  latter  symptom  may  exist 
independently  of  paraplegia.  With  the  loss  of  movement  in  the  lower  limbs, 
more  or  less  loss  of  sensation  may  be  associated,  and,  as  a  rule,  both  move- 
ment and  sensation  are  impaired  together,  the  impairment  of  motion,  how- 
ever, being  the  more  marked  of  the  two.  According  to  Follin  and  Duplay, 
there  may  be  loss  of  sensation  only  in  the  lower  limbs,  but  such  a  condition 
must  be  quite  uncommon.  In  some  equally  rare  histances  the  affected  limbs 
are  hyptsrsesthetic.  Launay^  has  recorded  a  case  where  there  was  loss  of  both 
motion  and  sensation  in  the  right  lower  limb,  with  loss  of  movement  only  in 
the  left.  Hydrocephalus  is  commonly  associated  with  spina  bitida,  and  in. 
the  course  of  any  case  convulsions  are  not  infrequent.  It  is  difficult  to  say 
positively,  in  all  cases,  whether  the  cord  is  or  is  not  in  the  sac  of  the  spina 
bitida.  It  may  be  safe  to  suspect  its  presence  in  the  tumor,  unless  there  are 
indications  to  the  contrary.  The  larger  the  opening  into  the  spinal  canal,  the 
more  probably  will  the  cord  be  found  in  the  sac,  whereas  such  a  complication 
is  but  little  to  be  suspected  when  the  bony  opening  is  small  and  the  pedicle, 
long  and  narrow.  In  those  cases  that  are  associated  with  hydrocephalus,  the 
cord,  or  at  least  some  part  of  it  or  of  its  main  nerves,  are  very  usually  to  be 
found  in  the  cyst  of  the  spina  bifida.  The  existence  of  talipes,  or  of  paralysis, 
the  occurrence  of  convulsions,  the  readiness  with  which  nerve  symptoms  are 
produced  by  pressure,  are  all  in  favor  of  cord  tissue  being  associated  with  the 
protrusion. 

Follin  and  Duplay  have  pointed  out  that  when  the  termination  of  the  cord 
is  adherent  to  the  posterioi*  wall  of  the  sac,  the  site  of  the  adhesion  is  often 
indicated  by  a  depression  on  the  surface  of  the  tumor  in  the  middle  line.  In 
man}'  cases  also  where  the  cord  is  adherent  to  the  sac,  its  position  is  indicated 
by  undue  thickness  of  the  cyst  wall  at  one  part,  and  possibly  also  by  some 
loss  of  translucency.  A  vascular  and  reddened  condition  of  the  skin  is  said 
by  some  to  indicate  adhesion  to  the  parts  beneath. 

It  is  probable  that  complete  paraplegia  will  in  all  cases  depend  upon 
hydrorachis  interna. 

The  diagnosis  of  spina  bifida  is  rarely  a  matter  of  difiiculty.  The  disease  has 
been  confused  with  certain  tumors  that  have  occupied  the  middle  line,  and  have 
been  congenital ;  but  in  such  growths  the  laminae  and  spinous  processes  of  the 
vertebrae  have  been  felt  intact  beneath  the  tumor,  and  it  has  been  possible  to 
demonstrate  the  absence  of  any  adhesion  between  the  tumor  and  the  bone. 
In  such  cases,  moreover,  there  has  been  an  absence  of  those  symptoms  that 
indicate  a  communication  between  the  tumor  and  the  spinal  canal.  Some- 
times the  sac  of  a  spina  bifida  becomes  cut  ofi'  from  all  communication  with 
the  vertebral  canal,  and  then  the  diagnosis  between  such  a  cyst  and  a  con- 
genital cystic  growth  in  the  middle  line  is  practically  impossible.  Xot  only 
is  the  diagnosis  often  impossible  in  such  cases,  but  it  is  also  quite  unim- 
portant, inasmuch  as  the  treatment  in  the  two  affections  is  identical.  The 
points  of  difference  between  spina  bifida  and  certain  congenital  growths  in 
the  regions  common  to  spina  bifida,  will  be  dealt  with  hereafter. 


1  Bull,  de  la  Soc.  Anat.,  1859,  page  342. 


492 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


Progress  and  Prognosis. — The  commoD  tendency  of  spina  bifida  is  towards 
rupture  of  the  sac.  The  tunnor  usually  increases  steadily,  and  in  time  reaches 
such  dimensions  that  the  skin  or  coverings  of  the  protrusion  give  way.  The 
contained  cerebro-spinal  fluid  is  then  discharged,  and  death  very  commonly 
follows  from  convulsions,  or  less  frequently  from  inflammation  of  the  spinal 
membranes.  The  rate  at  which  the  tumor  increases  varies  greatly,  and  can 
hardly  be  definitely  laid  down.  In  several  instances  the  sac  has  ruptured  in 
liter 0^  and  the  infant  has  either  been  born  dead,  or  has  survived  its  birth  but 
a  few  hours  or  days.  Often  the  tumor  has  given  way  during  birth,  and  its 
contents  have  been  discharged  with  a  more  or  less  rapidly  fatal  result.  Some- 
times the  rupture  is  represented  by  but  a  small  hole  in  the  skin ;  this  heals 
and  the  sac  refills.  In  such  a  case,  a  second  rupture  of  the  sac  may  end  in 
death,  or  the  opening  caused  by  the  rupture  may  remain  patent  and  a  fistula 
be  established  that  is,  however,  soon  attended  by  a  fatal  termination.  In  cer- 
tain instances  the  contained  fluid  may  escape  through  the  greatly  thinned  skin 
without  any  opening  being  apparent.  In  the  minority  of  all  cases  spontaneous 
cure  takes  place.  Such  a  cure  is  most  likely  to  occur  in  cases  where  the  tumor 
is  small,  possessed  of  a  small  and  narrow  pedicle,  and  occupied  by  no  part  of 
the  cord,  or  of  the  great  spinal  nerves.  In  such  a  tumor  the  abnormal  opening 
may  gradually  close,  the  fluid  in  the  sac  may  be  absorbed,  and  the  mass  may 
shrink  and  almost  disappear ;  or  this  end  may  be  brought  about  by  some  ad- 
hesive inflammation  at  the  root  of  the  tumor,  whereby  the  obnoxious  orifice 
is  closed  and  a  good  result  follows.  Many  cases  are  recorded  where  a  com- 
plete cure  has  followed  upon  the  spontaneous  rupture  of  the  sac,  and  Holmes 
cites  a  case  where  a  like  fortunate  result  followed  upon  the  suppuration  and 
bursting  of  the  cyst  in  a  child  aged  six  months.^ 

The  tumor  may  increase  in  size  for  years,  and  then  suddenly  cease  to  grow, 
and  begin  to  exibit  a  retrograde  movement  that  in  time  will  end  in  a  cure  of 
the  deformity.'^ 

In  the  Transactions  of  the  Pathological  Society^  is  an  account  of  a  case 
where  a  spina  bifida,  the  size  of  the  patient's  head  at  birth,  was  rapidly 
undergoing  spontaneous  cure  at  the  age  of  twelve  months.  Patients  with 
spina  bifid'a  have  reached  the  ages  of  28,  37,  43,  and  50  years.^ 

Treatment. — The  treatment  of  spina  bifida  may  be  classed  as  'palliative  and 
curative. 

Palliative  treatment  consists  simply  in  protecting  the  part  from  friction  or 
injurious  pressure,  and  in  retaining  in  as  healthy  a  condition  as  possible  the 
coverings  of  the  protruded  mass.  These  ends  can  be  best  eftected  by 
enveloping  the  mass  in  a  pad  of  cotton-wool  smeared  with  vaseline,  and 
secured  to  the  part  by  means  of  a  circular  bandage  so  applied  as  to  exer- 
cise some  pressure  upon  the  tumor.  By  these  simple  means  the  growth  of 
the  tumor  has  been  arrested  or  greatly  modified,  the  amount  of  inflanmiation 
in  the  skin  has  been  lessened,  and  any  progressive  thinning  of  the  cyst- wall 
has  been  considerably  retarded.  I  believe  that  this  very  rudimentary  plan 
of  treatment  is  better  than  that  of  keeping  the  part  constantly  painted  with 
collodion.  The  pressure  exercised  by  the  contracting  colk)dion  is  slight  and 
superflcial,  the  application  itself  often  increases  rather  than  diminishes 
the  inflammation  of  the  skin  when  it  exists,  and  wdien  that  inflammation 

1  Surgical  Treatment  of  Children's  Diseases,  page  82. 

2  a  case  in  Med.-Chir.  Trans.,  vol.  xl,  page  19,  where  the  tunior  continued  to  grow  steadily 
for  three  years  and  then  began  to  decrease. 

3  Vol.  xvi.  page  13. 

4  Case  by  Behrend,  Journ.  fiir  Kinderkrankheiten,  13d.  xxxi.  S.  350, 


SPINA  BIFIDA. 


4^3 


has  proceeded  to  actual  ulceration,  I  presume  that  the  use  of  collodion  would 
be  very  generally  considered  as  inapplicable,  even  if  possible. 

Before  any  more  active  measures  are  proposed,  it  is  well  to  consider  the 
relations  and  surroundings  of  the  tumor.  The  true  spina  bitida  communi- 
cates with  the  cavity  of  the  spinal  membranes,  aiid  usually  contains  either 
the  cord  or  some  part  of  it,  or  a  certain  number  of  tlie  lowest  spinal  nerves. 
Any  operation,  therefore,  upon  such  a  tumor  must  involve  the  spinal  mem- 
branes, and  probably  the  medulla  spinalis  itself,  and  it  is  unnecessary  to 
point  out  that  an  operation  with  such  incidents  must  be  among  the  most 
serious  that  can  be  entertained  in  the  practice  of  surgery. 

lu  the  face  of  these  serious  features  in  any  operative  proceedings  for  the 
relief  of  spina  bitida,  it  has  been  pointed  out  that  the  cases  most  suitable  for 
operation  are  tho^e  where  the  bony  defect  is  trilling,  the  tumor  well  pedun- 
culated, and  the  cord  and  its  nerves  free  from  any  participation  in  tlie  pro- 
trusion. This  is  obvious  ;  but  these  very  cases  that  are  considered  the  best 
suited  for  operation,  are  the  very  cases  that  are  the  most  prone  to  undergo 
spontaneous  cure.  I  would  venture  to  urge  that  the  possibility  of  sponta- 
neous cure  in  spina  bifida  has  been  a  little  too  lightly  estimated,  and  thtit, 
while  perhaps  harm  may  be  done  by  temporizing  with  a  case,  that  harm  is 
not  so  very  unevenly  balanced  by  the  mischief  that  has  followed  upon  hasty, 
premature,  and  ill-conceived  operations.  There  are  not  a  few  cases  on  record 
that,  like  the  following  example,  would  urge  a  greater  tolerance  of  the  possi- 
bility of  spontaneous  cure.  A  man,  aged  twenty,  had  a  spina  bifida  that 
had  of  course  existed  from  birth.  It  was  of  great  size,  but,  apart  from  the 
inconvenience  attending  its  large  bulk,  it  gave  him  no  trouble.  For  twenty 
years,  then,  it  had  caused  no  serious  or  even  very  troublesome  symptoms. 
At  the  age  of  twenty,  the  tumor  was  tapped.  With  wdiat  result  ?  AVithin 
six  days  of  the  second  tapping  the  man  w^as  dead.^ 

Looking  over  the  records  of  the  treatment  of  this  deformity,  one  is  struck 
with  the  nninense  number  of  cases  of  spina  bifida  that  have  been  subjected 
to  operation  within  a  few  days— nay  some  even  within  a  few  hours— of  the 
birth  of  the  victim.  In  such  cases,  the  possibility  of  spontaneous  cure  can 
hardly  have  been  considered,  and  it  remains  with  those  who  have  undertaken 
such  operations  to  show  upon  what  grounds  these  apparently  premature  and 
hasty  measures  have  been  adopted.  I  would  then  urge  a  little  patience  as  the 
first  factor  in  the  treatment  of  spina  bifida.  Let  the  first  measures  be  pal- 
liative, and  let  operative  measures  be  considered  when  some  definite  indica- 
tions for  further  treatment  arise.  These  indications  may  be  aftbrded  by  the 
rapid  growth  of  the  tumor,  by  the  probability  of  its  speedy  rupture,^  by 
the  onset  of  convulsions  or  other  nerve  disturbance,  or  by  the  increase  in  a 
paralysis  that  has  perhaps  always  existed  to  some  extent. 

The  principal  curative  measures  (so  called)  may  be  considered  under  the 
head  of  (1)  Puncture,  (2)  Injection,  (3)  Ligature,  and  (4)  Excision. 

(1)  Puncture. — There  are  many  cases  where  the  only  symptom  that  requires 
to  be  immediately  dealt  with  is  the  rapid  increase  in  the  size  of  the  tumor,  or 
in  the  degree  of  its  tenseness.  I  think  that  such  cases  can — for  a  while  at 
least — be  very  well  treated  by  puncture.  I  might  best  illustrate  the  matter 
by  reference  to  two  cases  at  present  under  my  care  at  the  London  Hospital. 
One  patient  is  aged  nine,  and  the  other  six  months.  Both  tumors  are  in  the 
lumbo-sacral  region  ;  they  are  both  large,  and  have  but  thin  coverings.  In 
each  case  the  skin  inflamed  about  the  summit  of  the  cyst,  and  has  been 
many  times  ulcerated.  There  is  reason  to  believe  that  the  cord,  or  some  part 
of  it,  has  a  share  in  the  protrusion  in  each  instance.    For  some  weeks  after 


1  Trans.  Path.  Soc.  vol.  viii.  page  10. 


494 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


birth,  the  tumors  were  simply  kept  covered  up  with  cotton-wool  smeared 
with  vaseline,  and  some  slight  pressure  was  maintained  over  the  part  by  means 
of  a  banda2:e.  The  history  and  progress  of  the  two  cases  are  so  similar  that 
they  may  be  treated  as  one.  In  time  the  tumor  increased  in  size  and  in  tense- 
ness, the  child  became  restless  and  convulsed,  and  the  undue  tension  in  the 
cyst  appeared  to  be  the  cause  of  these  fresh  symptoms.  The  tumor  was  then 
tapped  as  far  from  the  middle  line  as  possible,  with  the  finest  trocar,  and 
enough  fluid  (about  1}  drachms)  let  out  to  relieve  the  tension.  The  wool 
was  then  reapplied,  and  the  pressure  of  the  bandage  again  maintained.  Im- 
mediate relief  followed.  In  the  child  aged  nine  months  I  have  thus  punc- 
tured the  cyst,  I  dare  say,  a  dozen  times,  but  the  necessity  for  such  punctures 
has  become  less  and  less  frequent,  and  the  operation  has  not  been  performed 
for  the  last  three  months.  The  tumor  is  now  apparently  stationary.  The 
€hild  is  still — as  it  always  has  been — partially  paralyzed  in  its  lower  limbs ; 
but  it  has  had  no  convulsions  for  months,  and  it  is  in  fair  health.  As  far  as  I 
€an  judge,  there  is  in  this  case  a  large  defect  in  the  bone,  and  the  cord  is  in 
the  sac.  But  what  operation  can  be  done — as  far  as  our  present  knowledge 
goes — to  close  this  defect  and  restore  the  cord  to  its  proper  place  ? 

To  ligature  or  to  excise  the  mass  would  probably  be  to  ligature  or  excise 
the  cord  or  some  part  of  it,  and  I  can  hardly  believe  that  iodine  injection 
could  loosen  any  adhesions  that  may  exist  between  the  cord  and  the  sac,  restore 
the  cord  to  its  proper  canal,  and  close  the  defect  in  the  bone.  In  the  child 
aged  six  months,  the  tumor  is  increasing,  but  is  kept  within  bounds  by  fre- 
quent tapping — sometimes  once  a  week,  or  once  a  fortnight^ — and  the  child 
appears,  apart  from  the  tumor,  to  be  well.  I  think,  then,  that  in  certain 
cases,  the  treatment  by  puncture  and  gentle  pressure  may  be  advised,  not, 
perhaps,  so  much  as  a  means  of  cure,  but  as  a  measure  for  prolonging  life 
and  rendering;  the  existence  of  the  patient  less  distressing  than  it  might  be. 
I  can,  however,  well  believe  that  it  may  in  some  cases  lead  to  a  cure,  although 
a  paraplegia  or  other  gross  nerve-lesion  may  persist.  It  would  appear  that . 
the  smallest  possible  puncture  is  the  best,  and  that  it  should  always  be  made, 
when  available,  through  healthy  skin.  The  less  fluid  drawn  oft'  at  each 
operation  the  better.  It  is  m^erely  required  to  lessen  the  tension.  The  sub- 
sequent pressure  should  be  slight  and  evenly  applied.  I  believe  that  this 
treatment  ori2;inated  with  Sir  Astley  Cooper.  That  surgeon  at  least  reported 
two  cases  where  he  had  adopted  this  measure  and  with  very  good  success.^ 
The  practice  of  simple  puncture,  with  evacuation  of  the  entire  amount  of 
the  contained  fluid,  is  strongly  to  be  condemned.  It  would  appear  to  have 
led  in  most  cases  to  severe  and  fatal  convulsions,  and  in  certain  instances  to 
almost'  sudden  death.  It  must  be  remembered  that  puncture  under  any  cir- 
cumstances may  be  followed  by  inflammation  of  the  sac. 

(2)  Injection. — This  mode  of  treatment  has  so  far  been  the  most  successful 
that  has  been  made  use  of  in  this  deformity.  Many  fluids  have  been  used 
for  injection,  but  the  only  one  that  has  proved  of  any  practical  use  is  iodine. 
The  tumors  best  suited  for  this  method  of  treatment  are  those  that  present 
the  condition  most  favorable  for  spontaneous  cure,  and  it  is  in  such  cases 
that  successful  results  have,  for  the  most  part,  been  obtained.  When  there 
is  a  free  communication  between  the  sac  and  the  spinal  canal,  and  when  the 
cord  or  the  large  nerves  enter  into  the  protrusion,  the  success  of  the  operation, 
and  indeed  its  very  advisability,  are  matters  of  considerable  doubt.  There 
are  many  who  maintain  that  the  treatment  by  injection  is  not  justifiable 
when  the  hole  leading  from  the  sac  to  the  cavity  of  the  spinal  membranes  is 

1  Med.  Chir.  Trans.,  vol.  ii.  page  324.  Bryant,  in  his  "Surgery,"  2d  ed.,  vol.  i.  page  257, 
gives  an  account  and  a  drawing  of  a  case  cured  by  repeated  puncture  with  a  needle. 


SPINA  BIFIDA. 


495 


large  and  free,  or  when  the  contents  of  the  cyst  are  other  than  simple  fluid. 
If  then  only  selected  cases  are  considered  suitable  for  this  measure,  its  success 
must  be  estimated  at  a  proper  value.  I  am  aware  of  no  case  of  cure  from 
iodine  injection  where  it  was  distinctly  proved  that  a  free  communication 
existed  between  the  interior  of  the  sac  and  the  spinal  canal,  that  could  not 
be  even  temporarily  cut  otf,  and  where  at  the  same  time  the  cyst  contained 
the  cord  or  some  considerable  portion  of  it.  The  methods  of  using  this 
iodine  treatment  vary. 

Brainard,  c>f  Chicago,  adopted  the  following  plan  :  Six  ounces  of  the  fluid 
in  the  cyst  were  drawn  ofl:*,  and  half  an  ounce  of  an  iodine  solution  was  then 
injected.  This,  after  a  few  seconds,  was  allowed  to  flow  out,  the  sac  was 
then  washed  out  with  water,  and  the  operation  was  completed  by  the  injec- 
tion of  two  ounces  of  the  original  cerebro-spinal  fluid  that  had  been  kept 
in  the  meanwhile  at  the  temperature  of  the  body.  After  the  operation,  pres- 
sure was  applied.  Brainard's  solution  consisted  of  iodine,  5  grs.,  potassium 
iodide,  15  grs.,  and  water,  one  fluidounce.^  Velpeau  withdrew  all  the  fluid  in 
the  cyst,  and  then  injected  a  solution  of  tincture  of  iodine  and  water,  after  the 
manner  adopted  in  the  treatment  of  hj'drocele.  Morton's  method  appears  to 
have  the  advantage  over  both  these  plans,  and  is  probably  the  most  successful 
method  of  using  iodine  that  has  been  proposed.  Morton  uses  a  solution  of 
tec  grains  of  iodine  and  thirty  grains  of  iodide  of  potassium  in  one  ounce  of 
glycerine.  The  operation  is  not  advised  until  the  child  has  passed  over  the 
accidents  of  birth,"  unless  a  speedy  bursting  of  the  tumor  is  threatening. 
A  little  of  the  cerebro-spinal  fluid  is  drawn  oft',  and  then  from  half  a  drachm 
to  one  drachm  or  more  of  the  "  iodo-glycerine  solution"  is  injected.  This  is 
allowed  to  remain  in  the  cyst.  The  puncture  is  then  painted  with  collodion. 
The  operation  may  need  to  be  repeated  several  times  at  intervals  of  a  week 
or  ten  days,  or  longer.  Some  little  inflammation  commonly  follows  each 
injection,  but  it  usually  remains  limited.^  If  a  good  result  follows,  the  mass 
shrinks,  and  soon  ceases  to  give  trouble.  In  a  recent  communication,  Dr. 
^Morton^  states  that,  as  far  as  he  knows,  29  cases  have  now  been  treated  by 
this  method.  Out  of  this  number  failure  has  occurred  in  six  instances  only, 
and  from  this  Dr.  Morton  argues  that  the  iodo-glycerine  solution  treatment 
has  brought  about  a  saving  of  life  to  the  extent" of  79.31  percent.  Before, 
however,  this  very  pleasuig  conclusion  is  accepted,  it  would  be  desirable  to 
have  more  full  details  as  to  the  exact  condition  of  the  various  cases  operated 
upon,  and  especially  as  to  the  anatomical  relations  of  the  parts  concerned  in 
the  tumor. 

The  failures  from  the  injection  treatment  have  depended  upon  inflammation 
involving  the  spinal  membranes  and  cord,  upon  convulsions  independent  of 
such  inflammation,  or  upon  suppuration  and  premature  bursting  of  the  sac. 

(3)  Ligature  and  (4)  Excision. — These  operations  can  only  be  undertaken  in 
those  comparatively  infrequent  cases  where  the  sac  is  quite  free  from  either  the 
cord  or  any  of  the  spinal  nerves.  The  smaller  the  tumor,  the  smaller  the  bony 
hole,  and  the  narrower  the  pedicle,  the  greater  is  the  chance  of  success.  The 
real  danger  is,  that  the  inflammation  incident  upon  healing  and  upon  the 
closure  of  the  aperture  in  the  bony  canal,  may  extend  inwards  and  extensively 
involve  the  spinal  membranes.  It  would  be  of  no  avail  to  detail  the  many 
modes  in  which  these  operations  have  been  carried  out.  The  ligature  has 
been  applied  gradually,  and  it  has  been  applied  suddenly.  The  mass  has  been 
allowed  to  fall  oft',  and  it  has  been  taken  oft*  at  once  with  the  kraseur,  Ex- 

J  Am.  Journ.  Med.  Sciences,  vol.  xlii.  page  65.  1861. 

2  See  Lancet,  vol.  ii.  1876,  pages  776  and  881. 

3  Glasgow  Medical  Journal,  1881,  page  401. 


496 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


cision  has  been  preceded  by  ligature ;  excision  has  been  performed  with  or 
without  the  preliminary  use  of  a  clamp.  It  has  been  executed  in  a  great 
variety  of  w^ays:  by  excising  the  whole,  or  by  excising  a  part;  by  invaginating 
the  collapsed  membranes,  or  by  cutting  them  off  close  to  the  bone.  It  has 
been  followed  by  the  use  of  the  cautery,  and  b}'  the  application  of  divers  kinds 
of  suture.  It  has,  indeed,  been  practised  wdth  all  the  ingenuity  that  is  a 
feature  in  the  history  of  so  many  surgical  procedures. 

The  modus  ojmrtndi  is  of  little  moment.  If  the  sac  contain  cord-elements, 
the  result  w^ill  prove  fatal ;  if  not,  success  may  possibly  follow.  The  opera- 
tions are,  as  far  as  surgical  science  at  present  goes,  restricted  to  cases  that 
present  in  a  marked  degree  the  elements  necessary  for  spontaneous  cure,  and 
to  cases  where  that  cure  has  so  far  advanced  that  the  opening  in  the  bones 
has  become  closed,  and  the  tumor  gives  trouble  only  by  its  bulk.  If  the  liga- 
ture be  used,  a  superficial  cut  should  be  made  in  the  skin  at  the  base  of  the 
mass,  and  a  silk  ligature  should  then  be  applied  and  drawn  sufiiciently  tight 
to  strangle  the  mass.  In  excising  the  cyst,  it  should  be  removed  by  an  oval 
incision  at  its  base,  so  planned  that  after  removal  the  edges  of  the  wound  may 
come  together  in  a  clean,  straight  line.  The  operation  should  be  done  antisep- 
tically,  and  firm  pressure  should  be  maintained  until  the  wound  has  healed. 

An  account  of  the  chief  operations  alluded  to  under  this  heading  will  be 
found  in  Mr.  Holmes's  monograph  in  his  "  System  of  Surgery,"  2d  ed.,  vol. 
V.  p.  807.    [See  page  560.] 

False  Spina  Bifida. 

This  term  has  been  applied  to  many  difi:erent  tumors  that  have,  however, 
for  their  common  characters  a  congenital  origin  and  a  communication  with 
the  spinal  canal,  but  not  with  the  spinal  membranes.  Some  of  these  tumors 
are  solid,  some  are  multilocular  cysts,  and  some  are  simple  cysts.  Both 
pathologically  and  clinically,  they  present  striking  points  of  difference,  and 
as  there"  appears  to  be  no  great  advantage  in  classing  these  various  growths 
under  a  common  head,  I  would  venture  to  question  the  value  of  this  term  in 
its  present  extended  sense.  The  term  false  spina  bifida  should  be  applied  to 
one  tumor  onl}- ,  namely,  to  a  spina  bifida  whose  communication  with  the 
spinal  membranes,  and,  perhaps,  with  the  spinal  canal  itself,  has  been  cut  oft'. 
Such  a  tnmor  is  the  result  of  the  process  of  natural  cure  in  cleft  spine,  and  of 
it  many  examples  have  been  furnished.  The  false  spina  bifida  will  be  found 
in  some  region  common  to  this  deformity — most  probably  in  the  lumbo-sacral 
region — will  be  of  congenital  origin,  cystic  in  structure,  and  situated  accu- 
rately in  the  middle  line.  It  will  present  no  evidence  of  communication  with 
the  spinal  membranes ;  will  be,  in  almost  every  instance,  pedunculated  and 
will  probably  have  been  of  some  duration.  There  may  possibly  be  a  history 
to  show  that  such  a  mass  did  at  one  time  present  all  the  features  of  a  true 
spina  bifida. 

Lacking  this  fact  in  the  history  of  the  case,  the  diagnosis  of  false  spina 
bifida  is  by  no  means  eo^sy.  There  are  certain  congenital  tumors  of  a  cystic 
character  that  may  appear  in  the  middle  line  in  regions  common  to  spina 
bifida,  and  that  may  furthermore  have  an  intimate  connection  with  the 
column.  These  tumors  may  closely  resemble  false  spina  bifida,  but  the  resem- 
blance will,  in  most  instances,  not  be  of  long  duration.  The  cystic  tumor  is 
usually  multilocular ;  the  false  spina  bifida  a  simple  cyst.  The  cystic  tumor 
is  apt  to  grow  rapidly,  is  usually  not  very  distinctly  peduuculat^ed,  often  con- 
tains more  solid  masses  in  its  interior,  and  is  nearly  always  irregular  and 
bossy  in  outline.  The  false  spina  bifida,  on  the  other  hand,  tends  to  diminish 
rather  than  to  increase  in  size ;  its  pedunculation  is  nearly  always  very  dis- 


CONGENITAL  SACRO-COCCYGEAL  TUMORS. 


497 


tinct ;  it  contains  no  separate,  solid  masses,  altlioiigh  it  may  present  a  uniform 
thickening  of  its  sac ;  and  lastly,  its  outline  is  nearly  always  quite  smooth 
and  regular. 

The  diagnosis,  however,  is  of  no  great  moment,  as  it  would  suggest  no  plan 
of  treatment  that,  while  applicable  to  a  false  spina  bifida,  would  not  be 
equally  applicable  to  such  a  cystic  tumor  as  would  closely  resemble  the  simple 
cyst. 

Excision  is  probably  the  most  suitable  mode  of  treating  these  cases,  and  is 
the  method  that  has  been  attended  with  the  greatest  success.  Injection  with 
iodine  has  been  proposed,  but  would  appear  to  have  no  great  claim  to  atten- 
tion, for  the  sac  of  the  false  spina  bifida  is  often  thick,  and,  even  if  the  sac 
should  become  obliterated  as  a  result  of  the  injection,  the  cyst-wall  would 
still  remain  with  probably  a  considerable  pedicle.  If  the  case  should  prove 
to  be  a  multilocular  growth,  the  injection  would  then  be  obviously  useless. 
On  the  whole,  therefore,  considering  possible  errors  in  diagnosis,  a  cautious 
excision  of  the  mass  is  probably  the  most  certain  and  the  safest  procedure. 

Certain  of  the  following  tumors  may  be— and  have  been— mistaken  for 
spina  bifida. 

Congenital  Sacro-coccygeal  Tumors. 

The  sacro-coccygeal  region  is  peculiarly  liable  to  be  the  seat  of  certain  con- 
genital tumors.  Some  of  these  grow  from  the  sacrum  alone,  and  others  from 
both  the  sacrum  and  the  coccyx,  but  the  majority  would  appear  to  have  their 
primary  origin  from  the  coccyx  alone. 

As  to  the  reason  w-hy  this  region  is  so  frequently  the  seat  of  congenital 
growth,  nothing  definite  can  be  said.  It  is  a  problem  that  still  requires  to  be 
worked  out.  It  is  remarkable  that  the  congenital  tumors  about  the  sacrum 
and  coccyx  should  be  much  more  frequent  in  the  female  than  in  the  male. 
Molk  gives  58  cases  in  which  the  sex  was  noted,  and  of  this  number  44 
were  in  females,  and  14  in  males. 

These  tumors  are  very  varied  in  their  external  characters,  and  are,  I  think, 
best  classed  in  the  following  manner :  (1)  Attached  foetuses,  (2)  Cono-enital 
tumors  with  foetal  remains,  (3)  Congenital  cystic  tumors  of  various  Tvinds, 
(4)  Congenital  fatty,  fibrous  or  fibro-cellular  tumors,  and  (5)  Caudal  ex- 
crescences. 

Attached  F(ETUS.1— The  most  common  example  of  this  condition  is  afibrded 
by  a  third  lower  limb  that  is  attached  to  the  sacral  region,  and  that  hangs  down 
between  the  normal  legs  of  the  patient.    The  condition  has  been  known  as 
"  human  tripodism."    The  superfluous  limb  consists  usually  of  the  two  leo-s 
of  another  foetus  blended  into  one.    The  size  and  development  of  this  addi- 
tional member  vary.    It  is  usually  dwarfed,  and  often  contracted  at  the  knee, 
and  the  foot,  or  feet,  commonly  much  deformed.    It  may,  however,  appear 
wxll  developed,  and  may  even  exceed  the  natural  limbs  in  the  de2:ree  of  its 
development.    In  some  instances,  one  of  the  natural  lower  extremUies  of  the 
patient  may  be  wasted  and  deformed,  and  in  a  condition  but  little  better 
than  that  of  the  additional  member.    This  abnormality  is  associated  with 
certain  alterations  in  the  anatomy  of  the  pelvis,  and  some  variation  is  shown 
in  the  manner  in  wdiich  the  additional  limb  is  attached  to  the  trunk.  In 
certain  less  frequent  instances,  the  attached  foetus  has  been  represented  by 
a  confused,  pendulous  mass  that  exhibits  the  rudiments  of  several  limbs. 

*  Representations  of  the  principal  varieties  of  attached  foetus  are  given  in  Dr  W  Braune's 
Die  Doppelbildungen  und  angeboren  Geschwulste  der  Kreuzbeingegend.    Leipzig  186*2 
VOL.  IV. — 32 


498 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


Such  an  instance  is  represented  by  Braune  in  his  well-known  monograph 
(Plate  3,  Figure  7).  Usually  the  superfluous  limb  is  obvious  at  birth,  but  it 
may  be  concealed  for  some  time  within  a  fibrous  sac,  and  may  thus  resemble 
the  cystic  tumor  with  foetal  contents  to  be  next  dealt  with.  In  two  or  three 
recorded  instances  of  this  condition,  the  child  was  born  with  a  sacral  tumor 
that  continued  for  some  time  to  increase,  and  then  gave  way,  allowing  a  foot 
and  les;  to  come  out.  ^  _ 

The^  treatment  of  these  supernumerary  limbs  is  by  amputation.  The  chief 
difiiculty  in  any  such  operation  is  the  connection  of  the  member  to  the  pelvis. 
But  in  these  cases  a  disarticulation  is  not  necessary  in  all  instances,  nor  is  it 
of  course  desirable  to  in  any  way  interfere  with  any  pelvic  abnormality. 
It  is  sLifiicient  to  remove  the  projecting  part  of  the  additional  meniber,  and 
this  operation  would  appear  from  recorded  cases  to  be  both  fairly  simple  and 
more  than  fairly  successful.^ 

Congenital  Tumors  with  Fcetal  Remains. — These  tumors  present  them- 
selves under  a  2:reat  variety  of  aspects.  Usually  they  appear  as  roundish  or 
irregular  tumors,  pendulous  from  the  sacro-coccygeal  region,  and  covered 
with  a  thin  and  often  purplish  skin.  Beneath  the  skin  is  a  sac,  lined  with  a 
smooth  membrane,  and  within  this  sac  is  a  certain  amount  of  fluid,  and  fcetal 
remains  of  the  most  variable  nature  and  aspect.  These  foetal  i-emains  usually 
present  themselves  in  the  form  of  an  irregular,  solid  mass,  bony,  pendulous, 
and  imperfectly  pedunculated,  This  mass  is  composed  of  fatty  and  fibrous 
tissue,  and  presents  usually  a  number  of  multilocular  cysts,  variously  disposed. 
Some  part  of  the  mass  may  present  fingers  or  toes,  or  rudimentary  limbs. 
In  other  cases  the  tumor  may  contain  portions  of  bone,  most  usually  portions 
of  the  vertebrge,  or  fragments  of  cartilage,  with  here  and  there  some  ill-formed 
and  indefinitely  arranged  muscular  tissue.  In  other  instances  the  mass  has 
presented  a  knuckle  of  gut,  that  has  sometimes  contained  a  material  like 
meconium.  Some  few  of  these  masses  would  appear  to  have  been  dermoid, 
and  have  contained  hair,  teeth,  and  fragments  of  bone. 

These  tumors  may  occupy  the  subcutaneous  tissue,  but  usually  they  are  more 
deeply  seated,  and  they  are,  as  a  rule,  closely  adherent  to  the  bone.  They  may 
communicate  with  the  spinal  canal,  but  such  communication  is  quite  rare. 
Sometimes  they  extend  deeply  into  the  pelvis,  and  a  large  congenital  tumor 
may  in  addition  be  found  in  that  region  ;  their  size  varies  greatly  ;  they  are 
apt  to  be  pendulous,  but  are  seldom  well  pedunculated.  Stanley  has  reported 
a  case  where  the  tumor  reached  almost  to  the  feet.^  Braune  has  detailed  the 
case  of  a  girl,  who  presented  a  congenital  mass  of  this  nature  that  w^as  pendu- 
lous and  attached  to  the  buttock  by  a  stout  pedicle.  The  tumor  contained 
the  rudiments  of  limbs.  It  increased  in  size,  and  at  the  age  of  16  was  26 
inches  lono-,  and  weighed  20  lbs.  It  was  then  successfully  amputated.  These 
tumors  usually  grow  after  birth,  and,  as  a  rule,  their  growth  is  rapid.  The 
skin  covering  the  mass  may  give  way,  and  the  foetal  remains  contained  within 
may  protrude.  This  may  or  may  not  be  preceded  by  more  or  less  inflamma- 
tion or  slouo-hirig  of  the  excrescence.  In  one  or  two  instances  these  tumors 
have  been  associated  with  a  spina  bifida  in  the  sacral  region. 

Sometimes  the  foetal  remains  are  not  contained  within  a  sac,  but  are  freely 
exposed.  Such  a  condition  rather  approaches  that  alluded  to  under  the  term 
"  attached  fcBtus."  Such  tumors  are  very  irregular  in  outline,  and  still  more 
irregular  in  composition.    They  may  present,  in  addition  to  much  fatty  and 

'  For  an  account  of  the  cases  operated  upon,  see  Braune's  work,  and  also  an  excellent  article 
by  Mr.  Holmes,  in  his  System  of  Surgery,  2d  ed.,  vol.  v.  page  801. 
2  Med.-Chir.  Trans.,  vol.  xxiv.  page  235. 


CONGENITAL  SACRO-COCCYGEAL  TUMORS.  499 

cjstie  tissue,  the  rudiments  of  limbs,  portions  of  bone  or  cartilao-e,  or  repre- 
sentatives of  the  head  and  of  the  intestinal  traet.  A  complex  variety  of  such 
a  tumor  I  have  described  in  Vol.  XXXIII.  of  the  Patholocrical  Society's 
Transactions. 

Treatment—These  tumors  have  been  subjected  to  many  operations  for  the 
purpose  of  ejecting  their  removal,  but  the  most  successful  measure  of  this 
kind  that  has  been  proposed  is  excision.    If  the  mass  is  considered  suitable 
for  removal,  there  is  no  better  plan  of  accomplishing  this  than  by  the  knife 
The  ligature  is  strongly  to  be  condemned,  and  the  galvanic  cautery  has  no 
ijx  vantages  over  the  knife,  while  it  entails  certain  grave  additional  risks 
ihese  tumors  are  not  extremely  vascular,  and  such  hemorrhao;e  as  has  occur- 
red during  their  removal  appears  to  have  always  been  readily  Shocked.  Exci- 
sion  of  the  mass  is  only  to  be  advised  in  those  cases  where  the  tumor  can  be 
entirely  removed  without  great  difficulty,  and  without  damage  to  neio-hboriuir 
important  structures.    These  tumors  are  usually  well  defined  at  the?r  origin 
and  show  less  inclination  to  invade  the  pelvis  than  do  those  which  are  treated 
ot  in  the  next  section.    They  sometimes  communicate  with  the  spinal  canal, 
.and,  unfortunately,  the  existence  of  that  communication  cannot  always  be 
foretold     lu  c^ses,  therefore,  where  the  mass  is  well  limited  as  to  its  oridn, 
where  the  pelvis  is  quite  free,  and  where  no  communication  with  the  spinal 
€anal  is  expected,  the  tumor  may  be  excised,  provided  that  the  genei^al  condi- 
tion of  the  patient  afford  no  counter-indications.    Molk  notes  eight  examples 
ot  removal  of  these  masses,  and  of  this  number  seven  were  successful  The 
statistics  given  by  Holmes  show  a  like  good  result.    If  the  tumor  be  left,  it 
will  probably  in  time  bring  about  a  fatal  result,  the  patient  dying  of  maras- 
mus,  or  of  the  etfects  of  inflammation,  suppuration,  or  sloughing  of  the  mass. 
A  great  number  of  the  subjects  of  these  growths  are  born  dead.  . 

Congenital  Cystic  TuMORs.-These  constitute  the  2:reater  number  of  the 

Sn^P    ZT"   if  '^]'^'  ^^'^^y  ^'''^  considerable 

diffeience^,  both  in  their  external  appearance  and  in  their  internal  structure, 
^ome  few  are  single  cysts,  but  the  bulk  are  multilocular  growths.   The  single 

Z^il^eSl^  ^-'^  "'"''"''^  ""''"^  ^^^'^  'P'"^  ^^^^^ 

It  is  well^  known  that  spina  bifida  in  the  sacral  region  alone  is  rare,  and 

L  nnrLo      ;  '^^^^'^^  ^^'""^  coccygeal  spina  bifida  does 

not,  and  cannot,  exist.  Into  the  features  of  spina  bificfa  of  the  sacral  region 
it  IS  unnecessaiy  to  enter,  after  what  has  been  already  said.  With  re-ard  to 
false  spina  bifida,  it  is  probable  that  it  constitutes  the  sole  form  of  simple  cyst 
2,^±'lf^^^^  sole  form  of  deep-seated 

simple  cy.t.    In  a  number  of  instances,  these  simple  cysts  in  the  sacro-coccy- 

iltlV^lf'l^^r  ^^^^^  time  directly  connected 

cyst  in  this  part  do  not  appear  to  oppose  the  idea  that  they  also  are  to  be 
regarded  as  examples  of  false  spina  bifida.  ^ 
^J^'''  '/'''^f^^^^  form  the  most  important  series  of  tumors 

encountered  m  this  region  They  arise  usually  from  the  anterior  surfa^of 
both  of To'J  r'^^'^'  ^re^^enaj  from  the  posterior  surface  of  one  or 

wii    .1         ^""T'  ^'^^  ^^a^'ies  greatly.    It  may  be  no 

&  i  l"^"^  ^^^^^  '""''''^  '^'^  dimensions  of  the  childl  head? 

rSvS  ^""^^        ^'''^'^  ^^'^^^^^  tumors  tends  to 

XSh  vpvv  7''^^'  dimensions.  In  outline  they  are  roundish  or  oval, 
My\  d^?^.T^'"J^'l  f^™"^^^  pendulous  masses.    T-here  is 

4W  in  tL  ne^^^^^  those  growths  that  have  no  extensive  ramifi- 

<Jation.  in  the  pehis.    The  skm  covering  them  is  thin  and  transparent,  and 


500  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

presents  lar2;e  and  distinct  superficial  veins.  The  mass  is  usually  of  very 
unequal  density,  some  parts  being  elastic  or  fluctuating,  while  others  are 
firmer  and  more  solid.  The  growth  may  communicate  with  the  spinal  canal, 
but  such  communication  is  quite  exceptional. 

When  the  mass  grows  from  the  front  of  the  sacrum  or  coccyx,  the  latter 
bone  is  usually  pushed  backwards  as  the  tumor  develops,  and  may  be  so  tar 
turned  back  as  to  project  beneath  the  skin.  In  other  cases  the  coccyx  is 
quite  buried  in  the  tumor, or  it  may  be  rudimentary,  or  even  entirely  absent. 
If  the  mass  is  of  any  great  size,  the  anus  and  genita  s  are  pushed  forwards, 
and  the  rectum  is  sometimes  found  enveloped  by  the  growth.  The  tumor 
mav  still  further  invade  the  pelvis,  and  its  development  within  that  cavity 
may  be  such  that  the  pelvis  may  be  filled,  and  the  mass  may  then  be  found 
to  occupy  some  part  of  the  abdomen.  i  . 

In  structure,  these  tumors  are,  for  the  most  part,  composed  of  a  mimber  ot 
cysts,  varying  in  size  from  that  of  a  pea  to  that  of  a  horse-chestnut,  and  com- 
municating more  or  less  freely  the  one  with  the  other.  These  cysts  contain  a 
fluid  that  resembles  that  of  hydrocele,  or  they  may  be  occupied  by  a  gelati- 
nous material  very  much  like  boiled  sago-grains  These  cysts  are  held  to- 
g-ether by  a  varying  amount  of  firm,  young,  fibrous  tissue  Some  of  the 
tumors  maybe  composed  solely  of  this  cystic  structure,^  whi  e  others,  and 
these  are  the  majority,  contain  more  or  less  solid  tissue  m  addition. 

This  solid  tissue  may  be  fatty  or  fibrous,  or  it  may  contain  some  particles 
of  cartilao-e,  or  even  of  bone.    Sometimes  it  preponderates  m  amount  oyer 
the  cysts,  and  the  mass  is  rather  a  mass  of  fatty  or  fibrous  tissue  associated 
with  some  multilocular  cysts  than  a  tumor  that  can  be  fairly  called  cystic. 
As  to  the  real  nature  of  these  tumors,  little  that  is  definite  can  at  present 

^""On  Microscopical  examination,  the  cysts  are  found  to  be  lined  with  cubical 
or  columnar  epithelium,  and  to  be  supported  by  a  very  cellular  coimective 
^  tissue  3  This  connective  tissue,  which  would  appear  to  be  no  other  than 
embryonic  connective  tissue,  has  been  considered  by  some  to  be  sarcomatous 
in  its  nature,  and  upon  these  grounds  a  number  of  these  tumors  have  been 
classed  as  sarcomata  or  cystic  sarcomata.  .     ^  ^i.        +  n 

Others  payinp;  2:reater  heed  to  the  epithelial  growth  about  the  cyst-wall^, 
have  maintained  that  these  tumors  are  to  be  rega,rded  as  cylindrical-celled 
epitheliomata,  and  are  therefore  to  be  classed  with  the  cancers.    I  do  not 
think  however,  that  either  of  these  accounts  of  the  nature  of  these  growths 
has  been  by  any  means  well  established,  and  it  still  remains  more  than  prob- 
able that  these  remarkable  tumors  must  be  regarded  as  the  results  of  some 
abnormal  and  unknown  phase  in  the  tissue-formation  of  the  fcetus  feome 
pathologists  have  endeavored  to  maintain  that  these  growths  are  due  to  a 
de^enerltive  process  involving  Luschka's  gland.    It  is  true  that  a  vast  num- 
ber of  these  tumors  take  origin  from  the  front  of  the  sacrum  and  coccyx, 
and  it  is  al^o  true  that  no  trace  of  Luschka's  gland  is  to  be  found  m  these 
instances ;  but  here  the  main  facts  end.   It  has  never  been  distmctly  proved 
that  the  tumor  has  actually  had  origin  ^om  this  little  body,  ^  ^^^^^^^^^^^^^ 
structure  between  the  two  has  never  been  fully  established,  and  the  loss  of  the 
crland  by  its  becoming  embedded  in  the  growing  tumor     not  hard  to^under- 
stand.    In  spite,  therefore,  of  the  eminent  names  associated  with  this  theory, 
it  must  still  be  regarded  as  not  proven.* 

1  See  case  by  Mr.  Shattock,  Path.  Soc  Trans.,  vol  xxxii.  page  l^J.  1882. 

2  Hntcliinson,  Illustrations  of  Clinical  Surgery  vol.  ii.  page  36.  1879. 

Diet.  Encyclop.  des  Sc.  Med.,  1878. 


CONGENITAL  SACRO-COCCYGEAL  TUMORS. 


501 


Such  of  these  tumors  as  contain  foetal  remains,  serve  to  connect  this  series 
of  tumors  with  those  dealt  with  in  the  previous  paragraph. 

Progi^ess^etc. — In  many  instances  the  children  presenting  these  growths  are 
born  dead.  A  large  number  die  within  a  (,lay  or  so  of  birth.  In  those  who 
survive,  th<3  tumor  generally  grows  ra[)idly,  and  often  very  rapidly.  The  skin 
may  give  way  in  places,  and  the  contents  of  the  subjacent  cysts  be  discharged. 
After  such  discharge  the  aperture  may  close,  or  further  destructive  changes 
may  take  place  in  the  part.  Bryant  records  a  case  where  spontaneous  cure 
followed  ui)on  the  bursting  of  a  cyst  in  this  region.^  As  the  growth  advances, 
death  may  follow  from  marasmus,  or  from  inflammation  and  sloughing  of  tlie 
mass,  or  from  extension  of  the  intlannnatory  process  to  the  cord  or  pelvic 
viscera. 

Treatment. — In  the  treatment  of  these  tumors  all  partial  measures  are  to  be 
condemned.  The  practice  of  incising  the  mass  is  meaningless,  useless,  and 
pernicious.  The  tapping  of  a  few  of  the  cysts  is  equally  futile.  The  excision 
of  a  part  of  the  tumor  oidy,  leaves  an  iiiflamed  and,  perhaps,  sloughing  stump, 
from  which  fresli  tumor-tissue  will  be  produced  should  the  child  survive.  In 
like  manner,  to  ligature  a  portion  only  of  the  mass,  is  to  do  more  harm  than 
good,  and  the  same  criticism  must  apply  to  all  attempts  to  destroy  the  tumor 
with  caustics  or  the  actual  cautery.  The  mass  should  be  removed  entire,  or 
left  alone;  and  the  most  serious  question  involved  in  this  matter  of  treatment 
is  that  concerned  in  the  selection  of  proper  cases  for  operation.  The  tumors 
best  suited  for  operation  are  those  in  which  a  good  pedicle  exists,  in  which  the 
base  of  the  mass  is  comparatively  narrow,  and  in  which  the  tumor  has  neither 
extended  into  the  pelvis  nor  is  in  communication  with  the  spinal  canal.  Such 
cases  are  unfortunately  quite  the  exception.  Mr.  Holmes  has  shown,  how- 
ever, that  tumors  of  this  nature  can  be  removed  even  when  they  involve  the 
pelvis,  and  extend  into  that  cavity  for  no  little  distance.^  The  question  there- 
fore for  the  surgeon  to  decide  is  whether  he  can  remove  the  entire  mass 
without  inflicting  such  an  injury  upon  the  pelvic  structures  and  viscera  as  no 
operation  would  justify.^  It  is  impossible  to  give  definite  data  for  the  deci- 
sion of  this  question.  Each  case  must  be  judged  upon  its  own  merits.  It  is 
very  often  difficult  to  make  out  the  limits  of  the  entire  pelvic  grow^th,  although 
much  may  be  learnt  by  a  rectal  examination.  Apart  from  this  matter  of  the 
pelvis,  the  possibility  of  the  mass  communicating  Avith  the  spinal  canal  must 
be  considered,  although  the  evidence  that  will  point  to  such  communication 
is  usually  of  tlie  scantiest. 

Of  ^  the  various  methods  available  for  the  removal  of  these  tumors,  that  of 
excision  is  undoubtedly  the  best,  and  is  the  operation  that  has  given  the  most 
favorable  results.^  • 

Congenital  Fatty,  Fibrous,  and  Fibrocellular  Tumors.— These  growths 
are  not  common  in  this  situation,  although  several  examples  of  each  kind 
have  been  recorded.  They  resemble  in  cliaracter  the  congenital  tumors  met 
with  elsewhere,  that  are  composed  of  fatty,  fibrous,  or  fibrocellular  tissue, 
and  present  the  same  features  with  regard  to  diagnosis,  prognosis,  and  treat- 
ment. They  may  be  tolerably  superficial,  but  as  a  rule  have  a  deep  origin. 
Molk  cites  five  cases  of  lipomata  arising  from  the  front  or  tip  of  the  coccyx. 
Sometimes  these  congenital  fatty  tumors  may  be  very  large,  and  one  case  is 
recorded  where  such  a  tumor  formed  a  pendulous  mass  that  reached  the 
calves.  In  another  instance  the  flitty  growth  involved  the  pelvis,  and 
reached  such  dimensions  as  to  almost  fill  that  cavity. 

»  Manual  for  the  Practice  of  Surgery,  2d  ed.,  vol.  i.  page  259. 

«  British  Med.  Jonru.,  March  23,  1867. 

*  See  Holmes's  System  of  Surgery,  vol.  v.  p.  802. 


502  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

The  most  interesting  examples,  however,  of  lipomata  in  this  region  are 
afforded  bv  those  that  have  communicated  with  the  spinal  canal,  a  comp  ica- 
tion  of  great  rarity.  Mr.  Athol  Johnson  has  reported  the  case  ot  a  child 
aged  10  months,  from  whose  sacral  region  he  excised  a  fatty  tumor  that  was 
increasing,  and  becoming  ulcerated  on  its  surface  The  mass  was  found  to 
extend  iSto  the  spinal  canal  through  a  hole  in  the  sacrum  large  enough  to 
admit  a  foretinger.  Within  the  canal  the  mass  was  found  adherent  to  the 
membi^nesTfrom  which  it  had,  indeed,  to  be  disseUed  off.  The  child  recov- 
ered  from  the  operation.  The  only  evidence  of  cord  complication  previous 
to  the  operation  was  an  occasional  convulsive  movement  m  the  right  leg. 

Mr.  Thomas  Smith  has  recorded  a  case  of  congenital  liponia  growing  from 
the  coccyx,  that  is  said  to  have  closely  resembled  a  spina  bifida.  J- he  mass 
was  at  birth  the  size  of  a  small  egg,  but  in  four  months  it  had  reached  the 
size  of  a  foetal  head.    It  was  successfully  excised  by  Mr.  bmith. 

These  tumors,  except  in  those  rare  instances  where  they  encroach  con- 
siderably upon  the  pelvic  cavity,  should  be  removed  at  as  early  a  period 
as  convenient,  and  no  better  means  is  afforded  for  such  removal  than  by 
excision. 

Caudal  Excrescences.— These  are  of  two  kinds:  (1)  bony  appendages  com- 
posed of  supplementary  coccygeal  vertebrae;  and  (2)  certain  tbrocellular 
lumors  that  assume  the  form  of  a  tail.  Of  the  former  kind  Molk  gives  two 
examples  Of  the  latter  several  instances  have  been  furnished,  ihe  tumoi 
in  these  cases  grows  from  the  coccygeal  region,  and  is  «"'"P<>««^^  usuaUy  of 
fibrocellular  tilsue.  It  contains  no  bone,  and  springs  from  the  subcutaneous 
connective  tissue.  Being  long,  narrow,  and  perhaps  pointed,  it  lesemb  es 
the  tail  of  some  animals"  Gosselin^  quotes  a  case  where  the  appendage  was 
five  centimetres  (two  inches)  in  length,  and  was  curled  forwards  a  ong  the 
perineum.  Chauvel'  also  gives  a  case  where  the  excrescence  was  of  the  same 
fength,  and  of  the  thickness  of  a  little  finger.  These  tumors  are  all  readily 
removed  with  the  knife. 

In  addition  to  the  works  of  Braune,  Holmes,  Hutchinson  and  others  already  alM^^^^ 
to  reference  maybe  made  to  the  following  monographs  dealing  wth  the  subject  o 
lo'n'enital  sacro-coccygeal  tumors:   Molk,  Des  tumeurs  congemtales  de  I'extremite 
•n^r^uir/u  tronc,  s'?asburg,  1868,  These,  Se  serie,  No.  106^    ^uplay   Des  tumeurs 
congenitales  de  la  region  sacro-coccyg.enne  Arch.  Gen  de  Med.,  1868  tome  xn.  Wag 
staffe,  St.  Thomas's  Hospital  Reports,  N.  S.  vol.  iv.  (1873),  page  213. 

Antbro-postertor  Curvatures  of  the  Spine. 

Under  this  term  are  included  two  precisely  opposite  conditions,  viz  cyphosis, 
or  a  curving  of  the  spine  backwards,  and  lordosis,  or  a  curving  of  the  column 
forwards. 

Cyphosis  —In  this  condition  there  is  abnormal  curvature  of  the  column,  or 
of  some  part  of  it,  directly  backwards ;  and  as  the  term  "  curving  backwards 
of  the  sp  ne"  is  open  to  some  varied  interpretation,  it  is  necessary  to  add  that, 
in  all  cases,  the  abnormal  curve  has  its  convexity  directed  posteriorly.  Cy- 
phosis maf  involve  the  whole  of  the  column,  although,  as  a  rule,  but  a 
por^i^on  of  H  is  implicated.  In  the  majority  of  instances,  indeed,  ?t  consists 
mereiV  in  an  exaggeration  of  the  posterior  curve  that  normally  exists  m  the 
dorsal  region.    Cyphosis  may  be  temporary  or  permanent. 

.  Path.  Soc.  Trans.,  vol.  viii.  page  16  '  i'if  i^KerWopfts  Sci.  I,Kdicales. 

»  Cllnique  Chirurgioale,  tome  n.  p.  665.  Art.  m  Liici.  Jincyo  op 


ANTERO-POSTERIOR  CURVATURES  OF  THE  SPINE. 


503 


Etiology. — In  dealing  with  the  etiology  of  cyphosis,  it  will  he  most  con- 
venient to  classify  the  causes  of  the  aft'ection  according  to  the  period  of  life 
at  which  it  has  commenced. 

The  cyphosis  of  infaids  and  of  quite  young  children  depends  for  the  most 
part  upon  rickets,  and  consists  of  a  very  general  and  equable  curving  back- 
wards of  the  whole  column.  This  rachitic  curvature  will  be  treated  of  here- 
after. Quite  independent  of  rickets,  however,  cyphosis  may  be  developed  at 
this  period  of  life,  and  under  such  circumstances  will  depend  upon  a  normal 
muscular  weakness,  if  such  a  term  can  be  allowed.  It  is  well  known  that 
the  spine  at  birth  is  straight,  and  that  the  curves  that  normally  mark  the  adult 
spine  are  the  result  of  a  subsequent  development,  and  are  dependent  upon 
the  establishing  of  a  proper  equilibrium  in  the  erect  posture.  For  a  consider- 
able time  after  birth  the  erect  position  is  not  required.  The  normal  posture 
of  an  infant,  indeed,  is  the  posture  of  lying  flat  upon  its  back.  Thus  it 
happens  that  the  spinal  muscles  long  remain'but  imperfectly  developed,  and 
it  will  be  seen  that  the  spinal  column  in  infancy  may  readily  be  induced  to 
assume  almost  any  species  of  curvature.  In  cases  of  general  muscular  debility, 
some  cyphosis  naturally  develops  when  the  erect  posture  is  attempted,  and 
that  cyphosis  is,  indeed,  but  the  outward  sign  of  an  inability  on  the  part  of 
the  muscles  to  properly  support  the  spinal  c'olunm. 

A  cyphosis  from  a  like  cause,  will  commonly  develop  in  the  backs  of  in- 
fants who  are  continually  being  nursed  in  the  sitting  posture.  Such  a  position 
is  unnatural,  and  the  spinal  muscles  are  usually  unable  to  retain  the  colunm 
erect;  the  child's  spine  yields  to  the  pressure  of  the  superincumbent  weight, 
and  a  more  or  less  extensive  posterior  curvature  is  the  result.  Besides  "the 
pernicious  habit  of  nursing  infants  in  the  sitting  posture,  some  mothers  take 
particular  pleasure  in  making  their  children  sit  upright  at  as  early  a  period 
as  possible.  They  appear  to  consider  that  an  ability  to  assume  this  position 
is  an  evidence  of  precocity  and  rapid  development,  and  is  an  accomplishment  to 
be  fostered  as  tending  to  strengthen  the  back.  The  result,  however,  is  often 
a  very  definite  cyphosis,  that  may  become  more  or  less  permanent.  It  must 
be  allowed,  however,  that  the  posterior  cui-vature  that  may  develop  in  the 
spines  of  infants  and  young  children  shows  some  tendency  to  more  or  less 
correct  itself  when  the  child  begins  to  walk,  and  begins  in  consequence  to  de- 
velop those  curvatures  that  are  normal  to  the  adult  spine. 

A  cyphosis  may  develop  about  pi/^er^?/— especially  in  weakly  girls— either,  it 
would  appear,  from  debility  of  the  spinal  muscles  in  common  with  the  other 
muscles  of  the  body,  or  from  an  undue  or  disproportionate  use  of  those  struc- 
tures. The  causes  of  cyphosis  at  this  period  are,  probably,  very  nearly  iden- 
tical with  those  that  tend  to  produce  a  lateral  curvature  of  the  spine.  The 
child,  perhaps,  is  engaged  for  a  long  time  in  a  sitting  posture  without  proper 
support  to^  the  back.  In  learning  the  pianoforte,  or  in  the  ordinary  routine 
of  school  life,  this  position  is  often  assumed  for  hours  at  a  time.  The  nuiscles, 
either  from  inherent  weakness  or  from  undue  use,  become  wearied,  the  back 
aches,  and  the  child  throws  the  burden  of  supporting  the  column  upon  the 
hganients  that  are  not  susceptible  to  a  sense  of  weariness.  To  effect  this  the 
back  IS  arched  backwards,  and  a  temporary  cyphosis  produced  ;  but  in  time 
the  over-stretched  ligaments  yield,  the  elements  of  the  column  undero-o  slight 
structural  changes,  and  the  curve  becomes  permanent.  Cyphosis  is  the  posi- 
tion often  assumed  by  the  tired  child  who  is  compelled  to  still  retain  the 
upright  posture,  and  it  requires  merely  a  frequent  repetition  of  the  malposition 
to  render  it  definite  and  permanent.  As  active  causes  therefore  in  producincr 
this  form  of  cyphosis,  one  must  recognize  any  debilitating  infiuences,prolono;ed 
sitting  or  standing  without  support  to  the  back,  too  earlv  study,  laclJof 
proper  muscular  exercise,  and,  as  some  would  urge,  the  early  and  continued 


504  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

use  of  rio-id  corsets,  that,  ^vhile  mechanically  supporting  the  spine,  tend  to 
discoura-n!  a  proper  development  of  the  spinal  muscles.  u  •  ^  a 

The  c3Tho  is  of  adults  may  depend  upon  mam'  causes  It  may  be  induced 
bv  an  employment  that  involves  prolonged  arching  of  the  back,  or  prolonged 
stoop  n",  or ^bendiug  forwards  of  the  head,  or  it  may  depend  upon  chronic 
rhe?mat  c  arthritis^f  the  spine  (spondylitis  deformans  .  In  most  cases, 
h"er,  the  cyphosis  of  adults  is  secondary  to  some  previous  morbid  condi- 
tion, and  is  therefore  "  symptomatic,"  rather  than  "  essential. 

Thus,  any  disease  inwlving  frequent  or  prolonged  dyspnoea  may  lead  to 
some  cvphosis  as  the  result  of  an  attempt  to  increase  the  chest  capacity  by  an 
aiXino-  If  the  dorsal  vertebra.  Asthma  and  emphysema  are  not  infrequently 
associated  with  this  form  of  curvature.  Chronic  pamful  affections  of  the  ab- 
domen may  lead  to  cyphosis  as  to  a  means  of  relieving  pam  by  avoiding 
preiure  upon  tender  parts.  Thus  FoUin  and  Duplay'  enumerate  metritis 
and  chronic  peritonitis  among  the  causes  of  cyphosis.  .  ^v.   a    ^  . 

Muscular  Jlieumatism,  either  by  directly  causing  ««"^raction  of  the  flexor 
of  the  spine,  or  by  rendering  the  extensors  painful  and  thereby  to  some  extent 
useless  may  lead  to  this  posterior  curvature  of  the  column.  Jacques  Del- 
;  ch'  iSsIhe  case  of  2  man,  aged  25,  whose  back  be^Be  so  arche^^^^^^^^^ 
Lid  from  rheumatism  that  he  could  not  support  himself  without  crutches. 
Gymnastic  exercise  was  advised,  and  in  time  a  complete  cure  followed  _ 

Cyphosis  is  very  common  in  the  aged,  and  especially  among  the  laboring 
classes.  It  depends  in  many  instances  upon  a  general  enfeeb  mgot  the  mus- 
cuTar  System,  with  probably- some  loss  of  elasticity  in  the  elastic  tissues  Not 
intently  t  is  the  result  of  chronic  rheumatic  arthritis,  and  the  case  figured 
by  r.f  Agnew,'  of  an  old  woman  with  general  cyphosis  so  severe  that  when 
in  the  sitting  posture  her  chin  touched  the  knees,  was  probably  of  this  natur^ 
in  otheHnstances  the  arching  of  the  back  has  been  determmed  by  the  patient  s 
employment,  or  by  some  of  the  causes  just  detailed. 

Lastly,  it  must  be  remembered  that  cyphosis  may  be  hereditary,  and  this 
remark-especially  applies  to  a  limited  cyphosis  of  the  "PP^r  clorsal  region 

Pathological  J««tomj/.-Cyphosis  may  be  general  or  partial.    If  gen^nal, 
thfwhole^of  the  spinal  column  is  involved,  including  even  the  lunibar  region 
but  Ih  s  form  of  the  disease  is  quite  rare.    The  great  majority  of  the  cases  ot 
cypho  is  aJe  of'limited  extent,  and  are  restricted  to  the  dorsal  region.  Such 
instances  of  limited  cyphosis  consist  indeed  merely  of  an  increase  in  the 
natural  curve  of  the  dorsal  spine.    The  curvature  is  most  usually  about  the 
(Centre  of  the  dorsal  region,  the  summit  of  the  curve  being  represented  by  one 
vertebra  alng  the  A  6th,  7th,  or  8th;  and  of  these  it  would  appear  tfia 
Ihe  6th  dorsal  .-ertebra  is  the  one  that  most  commonly  marks  the  greatest 
TOint  in  the  curvature.^    The  curve,  however,  may  involve  the  upper  doi-sal 
reSalone,  or  the  dorso-lumbar  region  alone,  or  all  the  vertebm  from  the 
cefvical  to  the  lumbar  may  be  implicated  in  the  deformity.    It  is  also  to  be 
remarked  that  cyphosis  may  coexist  with  lateral  curvature  of  the  spine  or 
seSiosis    In  the  slighter  firms  of  the  disease,  there  is  merely  some  relaxa- 
ion  of  ihe  vertebral^ligaments,  with  a  separation  of  the  laminse  and  spmou 
processes  but  without  any  gross  alteration  in  the  bones  _  themselves.  In 
Sed  and  confirmed  exaun^les  of  this  deformity,  the  anterior  <Jommon  iga- 
ment  is  found  to  be  contracted,  while  the  posterior  ligaments  of  the  column 
Tre  relaxed    The  individual  bones  have  become  altered  so  that  the  bodies  of 


ANTERO-POSTERIOR  CURVATURES  OF  THE  SPINE. 


505 


the  vertebra  are  somewhat  wedge-shaped,  being  thin  in  front  and  thiek  behind. 
This  latter  change  is  due  not  to  hypertrophy  of  the  posterior  segments  of  the 
bodies,  but  to  absorption  of  their  anterior  parts,  and  involves  a  diminution  in 
the  proper  height  of  the  colunm.  In  cases  of  limited  cyphosis,  those  vertebme 
alone  are  altered  in  shape  that  form  the  summit  of  the  curve,  but  in  the  more 
extensive  examples  of  the  deformity  a  number  of  the  vertebral  segments  may 

be  involved.  t     x-         x-  xi 

It  is  commonly  asserted  that,  in  extensive  and  long-standing  torms  ot  the 
disease,  the  spine  may  become  fixed  in  its  false  position  by  anchylosis. 

I -believe  that  all  such  cases  of  cyphosis,  attended  with  bony  outgrowths 
and  anchylosis,  are  dependent  upon  chronic  rheumatic  arthritis,  and  are  more 
properly  to  be  considered  under  the  head  of  spondylitis  deformans. 

In  confirmed  and  well-marked  cyphosis,  from  whatever  cause,^there  is 
usually  some  corresponding  deformity  in  the  thorax.  The  ribs,  while  some- 
what separated  behind,  tend  to  come  more  and  more  in  contact  in  front,  and 
the  whole  thorax  tends  to  increase  in  its  antero-posterior  diameter  at  the 
expense  of  its  transverse  dimensions.  If  the  curve  be  in  the  dorsal  or  dorso- 
lumbar  region,  the  thorax  may  incline  towards  the  pelvis,  and  the  ribs  be- 
come more%ertical  in  direction.  The  sternum,  being  compressed  in  its  vertical 
axis,  becomes  bent,  and  usually  this  bend  is  of  such  a  nature  as  to  present  a 
concavity  forwards.  The  pelvis  may  follow  the  spine,  and  become  so  vertical 
as  to  almost  efface  the  sacro-vertebral  angle,  but  more  commonly  it  tends  to 
assume  rather  the  horizontal  direction  for  compensatory  purposes,  and  thus 
to  increase  rather  than  diminish  the  angle  at  its  junction  with  the  spine.  ^ 

Diagnosis.  The  recognition  of  this  deformity  is  attended  with  no  diffi- 
culty. In  the  common,  dorsal  cyphosis  the  back  is  arched,  the  head  poked 
forwards,  and  the  chin  turned  towards  the  sternum.  The  shoulders  are  com- 
monly  raised  and  unduly  prominent,  a  prominence  that  depends  mainly  upon 
the  removal  from  the  chest  wall  of  the  inferior  angles  and  posterior  borders 
of  the  scapulae.  In  severer  cases,  the  entire  back  may  be  Arched,  and  pro- 
gression and  even  standing  may  be  impossible  without  some  kind  of  arti- 
ficial support.  In  any  case,  backache  is  frequently  complained  of,  and  the 
constant  false  position  may  lead  to  or  at  least  augment  certain  visceral 
troubles.  . 

Mr.  Adams*  remarks  that,  in  many  instances,  he  has  observed  the  cyphosis 
of  young  children  to  end  in  vertebral  caries  with  angular  projection  of  the 
spine.  The  diagnosis  of  this  deformity  from  that  due  to  Pott's  disease  is,  as 
a  rule,  a  matter  of  simplicity.  In  cyphosis  the  curve  is  truly  a  curve,  and 
not  an  angular  prominence  of  one  part  of  the  spine.  The  curvature,  more- 
over, is  extensive  and  uniform.  There  is  no  muscular  rigidity  of  the  spine, 
but  rather  all  the  vertebral  muscles  are  flabby,  wasted,  and  relaxed.  There 
is  no  tenderness  about  the  part,  no  sign  of  abscess,  no  evidence  of  cord  impli- 
cation. Cyphosis,  moreover,  is  most  common  among  the  aged,  at  a  period 
of  life  when  Pott's  disease  is  comparatively  unknown.^ 

Treatment,— Qy'^ho^i^  in  the  young  is,  for  the  most  part,  readily  cured,  but 
in  the  old  it  depends,  in  nearly  every  instance,  upon  causes  that  are  scarcely 
to  be  influenced  by  any  treatment.  In  dealing  with  the  spontaneous  cyphosis 
of  the  young,  it  is  necessary  to  remove,  in  the  first  place,  the  cause  of  the 
malady.  Prolonged  sitting  or  standing,  or  prolonged  poring  over  books  or 
work,  must  be  forbidden.  The  general  health  should  be,  if  possible,  improved, 
and  especial  attention  paid  to  the  development  of  the  muscular  system.  Out- 
door exercise  should  be  enforced  under  certain  restrictions,  and  gymnastic 


1  Lectures  on  Curvature  of  tlie  Spine. 
*  See  under  Pott's  disease,  infra. 


London,  1865,  page  83. 


506 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


movements,  calculated  to  call  into  moderate  and  varied  use  the  vertebral 
muscles,  are  to  be  strongly  advised.  The  great  point,  indeed,  to  be  aimed  at, 
is  the  more  efficient  development  of  the  muscles  that  should  support  the 
spinal  column  erect.  It  may  be  of  some  use  to  stimulate  these  muscles  by 
baths,  friction,  or  electricity,  although  properly  directed  exercise  is,  without 
doubt,  the  more  important  feature  in  treatment.  The  patient  should  sleep 
upon  a  flat,  horse-hair  mattress,  and  during  the  day  should  assume  for  a  cer- 
tain time  the  dorsal  decubitus.  The  practice  of  lying  for  an  hour  or  so 
daily  prone  upon  the  face  will  also  be  of  service.  Instruments  and  supports 
of  all  kinds  should  be  avoided  as  calculated  to  do  harm  by  inducing  still 
less  activity  of  the  spinal  muscles.  In  very  severe  cases,  however,  Vhere 
the  deformity  is  considerable,  the  use  of  instruments  may  be  sometimes 
advised  as  a  preliminary  measure,  and  the  circumstances  requiring  their  use 
are  identical  with  those  that  point  to  instrumental  treatment  in  cases  of  lateral 
curvature,  which  is  considered  in  another  article.  Upon  the  treatment  of  non- 
essential or  symptomatic  cyphosis,  it  is  unnecessary  to  comment. 

Lordosis. — This  term  is  applied  to  a  curving  of  the  spinal  column  ante- 
riorly, of  such  a  nature  that  the  convexity  of  the  curve  projects  forwards. 

With  the  exception  of  certain  cases  of  congenital  deformity,  lordosis  in- 
volves only  a  portion  of  the  spine,  and  is  therefore  always  "  partial." 

It  is  usually  met  with  in  the  lumbar  region,  and  in  that  position  consists 
merely  in  an  increase  of  the  natural  vertebral  curve. 

Mtiology. — Lordosis  may  depend  upon  many  causes.  A  certain  amount  of 
lumbar  lordosis  may  be  hereditary.  "  Congenital  lordosis"  is  a  condition 
met  with  in  certain  rnonsters,  and  is  accompanied  by  deformities  that  are 
usually  incompatible  with  any  but  the  briefest  existence.  It  may  be  met 
with  in  any  part  of  the  spine.  If  in  the  cervical  region,  it  usually  depends 
upon  some  cranial  deformity  ;  if  in  the  dorsal  or  lumbar  regions,  upon  some 
thoracic  or  abdominal  defect.  The  curve  in  these  cases  is  usually  abrupt  and 
extreme,  and  in  some  instances  the  lordosis  may  so  involve  the  entire  spine 
that  the  head  rests  upon  the  sacrum.  Some  lumbar  lordosis,  more  or  less  of 
a  temporary  character,  may  depend  upon  position,  in  cases  where  undue  weight 
is  thrown  in  advance  of  the  line  of  gravity  of  the  body.  Thus  it  may  be 
seen  in  cases  of  peddlers  and  others  who  continually  carry  trays  in  front  of 
them,  and  in  ascites,  in  pregnancy,  in  ovarian  disease,  and,  as  a  somew^hat  more 
permanent  condition,  in  great  obesity.^  The  great  majority  of  the  cases  of 
lordosis  are  compensatory  to  some  other  deformity  elsewhere  that  deflects  the 
line  of  gravity  of  the  body.  Thus  arises  a  lumbar  lordosis  to  compensate 
a  forced  flexion  of  the  thigh,  in  instances  of  hip-disease.  For  like  reasons 
is  lordosis  met  with  in  congenital  or  unreduced  dislocation  of  the  head  of 
the  femur,  in  rickety  deformities  of  the  pelvis,  and  in  rickety  curvatures  of 
the  lower  limbs.  A  lordosis  may  occur  at  almost  any  part  of  the  spine  to 
compensate  an  angular  projection  of  the  column  developed  at  some  other  part. 
Cervical  lordosis  may  depend  upon  the  contraction  of  the  scar  after  burns 
about  the  posterior  part  of  the  neck. 

Mr.  William  Adams  figures  a  case  of  lordosis  associated  with  a  lateral 
curvature  of  the  column,  and  like  cases  are  referred  to  by  others.^  Then 
again  this  deformity  may  depend  upon  paralysis.  The  paralysis  that  leads 
to  lordosis  may  involve  either  the  flexors  of  the  spine  (the  abdominal  mus- 
cles), or  the  extensors  of  the  spine.    In  the  former  instance,  the  column  is 

'  Maisoiiabe  (Journ.  des  diflformites,  No.  2,  1825)  gives  two  cases  where  the  lordosis  of  preg- 
nancy persisted  after  confinement. 
2  Op.  cit.,  page  74,  fig.  10. 


ANTERO-POSTERIOR  CURVATURES  OF  THE  SPINE. 


507 


drawn  backwards  by  the  unresisted  sacro-vertebral  muscles,  and  in  the  latter 
instance  the  body  is  thrown  back  to  enable  the  i)atient  to  walk  whik'  the 
abdominal  muscles  prevent  the  backward  movement  from  being  extreme. 
There  is  a  form  of  lordosis  that  depends  upon  rickets,  and  that  constitutes  a 
chief  feature  of  the  rachitic  spine.  It  will  be  alluded  to  in  a  subsequent 
paragraph. 

Cases  of  lordosis  are  sometimes  met  with  that  are  open  to  considerable 
conjecture  as  to  their  nature.  A  case  of  this  kind  was  lately  under  the  care 
of  my  colleague,  Dr.  Warner,  at  the  London  Hospital.  The  patient  was  a 
little  2:irl,  aged  nine,  with  a  considerable  amount  of  lumbar  lordosis.  She 
was  a  deaf-mute,  but  was  otherwise  in  all  respects  well  developed.^  There 
was  no  evidence  of  rickets  nor  of  syphilis.  She  walked  with  a  curious  and 
unsteady  gait,  like  a  doddering  old  man,  placing  the  sole  at  each  step  Hat 
upon  the"2:round  at  once.  There  was  no  definite  paralysis  of  any  muscles, 
and  the  child  would  run  and  play  about  all  day  without  becoming  unduly 
tired.  She  was  very  intelligent.  The  hip-joints,  and  all  the  muscles  of  the 
lower  limbs  and  back,  appeared  normal.  It  was  asserted  that  the  lordosis 
had  been  noticed  since  the  child  had  learned  to  walk.  The  greater  part  of 
the  spinal  deformity  disappeared  on  suspension,  or  when  the  child  was  i)laced 
in  the  recumbent  posture.  The  condition  remained  unaltered  during  the 
year  or  so  that  the  child  was  under  observation.  In  this  case,  the  defect 
would  appear  to  have  been  in  the  motor  nerve  system,  and  whatever  the 
defect  might  be,  it  was  probably  congenital,  or  developed  soon  after  birth. 

Pathological  Anatomy. — In  marked  cases  of  long  duration,  the  posterior 
spinal  ligaments  are  found  contracted,  and  the  anterior  common  ligament 
stretched.  The  spines  and  transverse  processes  of  the  affected  part  may 
touch,  or  be  crowded  together.  The  intervertebral  disks  may  be  increased  in 
thickness  in  front,  but  it  does  not  appear  that  any  absorption  of  the  posterior 
segments  of  the  bodies  is  usual,  or  even  common.  The  sacro-vertebral  mass 
of"  muscles  is  often  found  contracted  and  rigid ;  and  the  psoas  muscle,  on  the 
other  hand,  in  a  state  of  fatty  degeneration  from  disuse.  In  lordosis  of  the 
lower  portions  of  the  spine,  the  pelvis  tends  to  become  more  vertical,  and  the 
sacro-lumbar  angle  more  prominent.  If  the  dorsal  region  be  much  involved, 
the  thorax  may  become  deformed  by  a  diminution  in  its  antero-posterior 
diameter.  In  some  cases  the  spinal  column  may  be  rigidly  fixed  in  the 
abnormal  position  by  a  bony  anchylosis  of  its  parts,  although  such  a  circum- 
stance is  of  much  less  frequency  in  lordosis  than  it  is  in  the  opposite  deformity 
before  treated  of. 

This  anchylosis  may  take  the  form  of  stalactitic  outgrowths  from  the  trans- 
verse processes  and  spines,  of  such  a  character  as  to  bind  adjacent  vertebrae 
together.  In  other  cases  the  articular  processes  may  be  anchylosed,  and  in 
another  set  of  instances  bony  outgrowths  from  the  margins  of  the  bodies 
themselves  may  serve  to  immobilize  the  affected  portion  of  the  spine.  Du 
Yerney*  records  a  case  of  extensive  lordosis  of  the  dorsal  and  lumbar  regions  of 
the  spinal  column,  where  the  intervertebral  disks  Avere  ossified,  and  the  whole 
spine  thereby  rendered  rigid.  The  account  given  of  this  case,  however,  is 
very  meagre.  It  is  probable  that  in  some  of  the  instances  of  lordosis,  char- 
acterized by  the  outgrowth  of  stalactitic  processes,  a  chronic  rheumatic 
arthritis  of  the  part  is  the  cause  of  the  condition. 

The  diagnosis  of  this  curvature  is  extremely  simple.  It  is  impossible  to  be 
mistaken,  if  in  any  degree  well  developed.  The  in-curved  back,  the  erect 
carriage,  the  prominent  belly,  are  all  very  familiar  as  usual  concomitants  of 
lordosis  in  its  most  common  position — the  lumbar  spine.    A  more  difficult 


1  Traite  des  Maladies  des  Os,  tome  ii.  p.  117.    Paris,  1751. 


508 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


matter  is  to  determine  the  cause  of  the  deformity  ;  but  as  this  subject  would 
involve  a  discussion  of  the  symptoms  of  many  very  difficult  diseases,  it  can 
hardly  be  dealt  with  in  this  place. 

The  treatment^  in  perhaps  the  majority  of  instances,  is  simply  negative.  In 
many  cases  the  lordosis  is  compensatory  to  some  permanent  and  incurable  de- 
formity, and  is  an  advantage  rather  than  a  detriment  to  the  patient.  In  few 
cases,  indeed,  is  it  of  itself  a  cause  of  any  great  trouble  to  the  individual  who 
presents  it.  It  would  be  obviously  absurd  to  attempt  to  treat  the  lordosis 
depending  upon  abdominal  tumor  or  pregnane}^,  although  the  curvature  some- 
times due  to  obesity  may  perhaps  be  lessened  by  supporting  the  pendulous 
abdomen  with  a  proper  belt.  Cases  due  to  prolonged  false  position  of  the 
spine  in  connection  with  some  special  employment,  may  obviously  be  relieved 
by  discontinuing  .that  emplojmient.  Lordosis  depending  upon  muscular 
weakness  may  be  treated  on  the  general  plan  advised  in  speaking  of  cyphosis. 
In  no  cases — except,  perhaps,  in  tliose  of  confirmed  paralytic  lordosis — are 
instruments  of  any  kind  desirable,  and  even  in  these  cases  they  can  do  little 
more  than  help  to  retain  the  spinal  column  erect. 

The  Rachitic  Spine. — Before  leaving  the  subject  of  antero-posterior  curva- 
tures, some  slight  notice  may  be  taken  of  the  common  changes  in  the  spinal 
column  in  rickets. 

For  a  full  account  of  the  pathology  of  this  disease,  and  of  the  various  defor- 
mities which  it  causes,  the  reader  is  referred  to  the  article  on  Eachitis,^ 
and  to  that  on  Orthopaedic  Surgery.  The  spine  in  rickets  may  become 
the  seat  of  certain  curvatures  that  are  nearly  always  in  the  antero-posterior 
direction.  The  nature  of  the  curve  is,  to  a  great  extent,  influenced  by  the 
age  of  the  patient  at  the  time  of  its  commencement.  It  must  be  remem- 
bered that  at  birth  the  vertebral  column  is  without  curve.  The  natural 
curve,  such  as  it  is,  of  infancy,  is  a  general  curving  of  the  back,  a  slight 
cyphosis.  This  curve  is  seen  when  the  infant  is  placed  in  the  sitting  posi- 
tion, and  is  the  natural  effect  upon  the  column  of  the  superincumbent 
w^eight.  The  earliest  deformity  of  the  spine  in  rickets,  the  deformity  that 
appears  at  a  time  before  the  child  begins  to  walk,  is  simi:)ly  an  exaggeration 
of  the  natural  infantile  curve,  ^hen  the  rickety  child  assumes  the  sitting 
posture,  the  whole  back  becomes  curved  from  the  neck  to  the  loins.  This 
curve  is  by  no  means  permanent,  and,  indeed,  at  once  disappears  if  the  patient 
be  suspended  by  the  arms.  It  is  due  simply  to  a  disproportion  between  the 
weight  the  column  has  to  support,  and  the  means  it  possesses  to  effect  that 
support.  The  essential  and  primary  defects  in  the  column  itself  depend 
upon  certain  changes  in  the  bodies  of  the  vertebrae,  upon  certain  defects  in 
their  growth  and  method  of  development,  in  the  yieldings  of  enfeebled  liga- 
ments'^ in  the  failure  of  still  more  enfeebled  muscles,  and,  as  some  would  add,^ 
in  an  abnormal  softness  of  the  intervertebral  disks.  The  cyphosis  of  rickets  is 
most  marked  in  the  lower  dorsal  region,  is  seldom  severe,  and  is  not  very  apt 
to  become  permanent  and  irremediable.  Indeed,  as  the  chikl  begins  to  walk, 
fresh  mechanical  influences  are  brought  to  bear  upon  the  column,  and  the 
abnormal  curvature  may  be  replaced  "by  the  normal  curves  of  the  developed 
spine,  or  by  an  exaggeration  of  those  curves.  If  the  child  has  commenced  to 
walk  at  the  time  that  the  rickety  change  involves  the  spine,  then  the  defor- 
mity produced  will,  as  first  hinted,  consist  in  an  exaggeration  of  the  normal 
curvature  that  should  develop  w^hen  the  child  is  first  able  to  support  the  body 
in  the  erect  position.    Thus  a  lordosis  in  the  lower  segments  of  the  spine 

'  See  Vol.  I.  page  255. 

«  Senator,  Art.  Rickets,  Ziemssen's  Cyclopaedia  of  Medicine,  vol.  xvi.  page  194. 


SPONDYLITIS  DEFORMANS. 


509 


will  appear  in  the  place  of  a  cyphosis  in  the  middle  segment.  Thus  as  Mr. 
Ilaward  expresses  it,  cyphosis  is  the  curvature  of  a  rachitic  infant,  lordosis 
the  curvature  of  the  older  cliild.^  It  must  also  be  borne  m  mmd  that  spinal 
curvatures  may  develop  in  rickets  as  the  consequence  of  a  deformed  tliorax, 
a  deformed  pelvis,  or  deformed  extremities.  ,  ,       .  i 

In  the  matter  of  treatment,  it  is  only  necessary  to  observe  that  the  general 
measures  recommended  in  the  article  on  Rachitis  must  be  carried  out. 
With  reo-ard  to  any  local  treatment,  the  recumbent  position  should  be  ad- 
vised, to%(i  maintained  every  day  for  a  period  that  must  vary  according  to 
the  a^e  of  the  patient,  the  degree  of  the  curvature,  and  the  general  circum- 
stances of  the  case.  As  the  child's  general  health  improves,  the  vertebral 
muscles  must  be  encouraged  in  their  development  by  moderate  and  caretul 
exercise  ;  and  this  end  may  possibly  be  aided  by  friction  of  the  parts,  by 
baths,  and,  in  some  cases,  possibly  by  galvanism.  In  no  instance  should  any 
apparatus  be  applied.  If  the  curve  be  rapidly  on  the  increase,  that  tendency 
must  be  met  by  insisting  on  the  patient  maintaining  as  tar  as  possible  the 
recumbent  posture.  To  encase  the  spine  in  any  rigid  apparatus  would  but- 
foster  still  further  inactivity  in  the  muscles,  and  favor  a  still  further  degree  ot 
feebleness  in  their  action.  If  the  disease  have  ceased  all  active  progress,  and 
the  curvature  alone  remain,  a  return  to  the  normal  condition  of  the  spine  can 
be  more  readily  and  more  surely  brought  about  by  improving  the  muscular 
condition  of  the  back  than  by  applying  an  apparatus.  The  apparatus,  while 
it  mio;ht  remove  the  appearance  of  the  curvature,  would  still  tend  to  per- 
petuate its  potential  existence,  and  possibly  leave  the  column  as  deformed  at 
the  conclusion  of  the  treatment  as  it  was  at  the  commencement. 

The  subject  of  scoliosis,  or  lateral  curvature  of  the  spine,  is  treated  of  in 
the  article  on  Orthopsedic  Surgery. 


Spondylitis  Deformans. 

The  term  "spondylitis,"  from  the  Greek  ortdi^Svxoj,  means  simply  inflam- 
mation of  a  vertebra,  and  is  therefore  equivalent  to  the  term  "  vertebral 
osteitis." 

In  this  sense  the  word  was  first  used,  and  it  is  still  so  employed  by  many, 
although  the  term  has  been  by  no  means  generally  accepted  in  English  surgi- 
cal literature.  The  inflammatory  process,  when  it  involves  the  bones  of  the 
spinal  column,  is  apt  to  assume  many  aspects  and  to  lead  to  several  very  dis- 
tinct clinical  conditions.  Although  it  might  be  well,  from  a  pathological  point 
of  view,  to  consider  all  inflammatory  changes  of  the  vertebral  bones  under 
one  common  heading,  such  a  course  would-be  extremely  inconvenient  when 
the  clinical  aspects  of  the  disease  came  to  be  considered.  It  might  be,  perhaps, 
more  scientific  to  consider  such  conditions  as  Pott's  disease,  osteo-arthritis  of 
the  occipito-atloid  jcnnt,  or  necrosis  of  the  odontoid  process,  under  the  general 
heading,  "  spondylitis,"  but  upon  clinical  and  descriptive  grounds  the  arrange- 
ment would  not  be  advisable.  The  use  of  the  term  therefore— in  at  least  its 
proper  sense— would  appear  to  present  few  and  doubtful  advantages. 

With  regard  to  the  term  "  spondylitis  deformans,"  it  would  be  assumed, 
from  whatlias  just  been  said,  that  it  referred  to  an  inflammation  of  the  ver- 
tebral bones  leading  to  deformity.  It  would  be  a  synonym  therefore  for  such 
an  attection  as  PotX's  disease.  But  by  the  aid  of  that  mysterious  power  that 
appears  to  influence  the  selection  of  scientific  terms,  the  title  spondylitis 
deformans  has  been  applied  to  one  definite  disease,  viz.,  chronic  rheumatic 


1  Treatise  on  Orthopaedic  Surgery,  page  100.    London,  1881. 


510 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


arthritis  of  the  vertebral  articulations.  There  are  not  many  who  would 
allow  this  disease  to  be  ranked  with  simple  inflammations ;  and  even  if  it 
were  an  inflammatory  change,  it  could  hardly  be  said  to  be  essentially  a  change 
involving  the  bones.  Still  the  term  has  been  accepted,  and  very  generally 
accepted,  and,  as  has  occurred  before,  scientific  accuracy  must  give  way  to 
custom. 

Spondylitis  deformans^  then,  is  the  term  used  to  denote  chronic  rheumatic 
arthritis  of  the  vertebral  column.  An  account  of  the  general  pathology  and 
symptoms  of  this  disease  will  be  found  in  the  article  on  Diseases  of  the  Joints.^ 

Etiology. — This  disease  is  met  with  usually  in  later  middle  and  advanced 
life,  and  slight  grades  of  the  disease  are  of  much  more  common  occur- 
rence than  is  generally  supposed.  In  the  subjects,  for  example,  brought 
to  the  dissecting-room  of  the  London  Hospital  Medical  College,  I  have  met 
with  many  examples  of  this  vertebral  aflfection,  and  believe  that  a  slight  de- 
gree of  the  disease  is  one  of  the  commonest  causes  of  the  cyphosis  of  old  age. 
Spondylitis  deformans  is  sometimes  met  with  at  an  earlier  period  of  life.  Dr. 
Allen  Sturge^  records  a  severe  case  in  a  man  aged  26,  and  states  that  Eulen- 
berg  has  met  with  a  typical  instance  of  the  disease  in  a  patient  aged  12 
years.  Dr.  Todd  also  mentions  the  case  of  a  young  girl  who  had  chronic 
rheumatism  of  all  her  joints,  and  anchylosis  of  the  spine.  Many  instances 
have  been  recorded  in  patients  about  thirty. 

With  regard  to  sex,  the  afi^ection  is  much  more  commonly  met  with  among 
males  than  among  females.  Occupation  would  appear  to  have  some  influence 
in  the  etiology  of  the  disease,  spondylitis  deformans  being  more  common  in 
those  whose  employment  involves  frequent  stooping  or  arching  of  the  back. 

As  may  be  supposed,  it  is  of  more  common  occurrence  among  the  poor  than 
among  the  well-to-do,  and  its  appearance  may  in  some  cases  be  very  possibly 
influenced  by  exposure  to  cold  and  damp.  In  at  least  the  severe  cases  of 
spondylitis,  there  is  a  history  of  rheumatic  tendencies  in  the  patient's  family. 

Pathological  Anatomy. — In  this  disease  the  spine  becomes  curved  and 
rigidly  fixed  in  the  abnormal  position.  Any  part  of  the  column  may  be 
involved,  and  in  not  a  few  instances  the  entire  spine  has  shown  evidence  of 
the  disease.  The  lower  dorsal  and  lumbar  regions  are,  however,  the  portions 
most  commonly  alFected,  and  next  in  frequency  comes  the  upper  cervical 
region. 

The  pathological  changes  are  identical  wdth  those  that  indicate  chronic 
rheumatoid  arthritis  in  other  parts,  and  are  marked  in  the  main  by  absorp- 
tion of  the  articular  cartilages,  by  the  outgrowth  of  nodular  masses  of  dense 
bone,  and  by  the  occurrence  of  a  certain  amount  of  true  or  false  bony  anchy- 
losis. 

Among  the  earliest  changes  in  spondylitis,  is  some  absorption  of  the  inter- 
vertebral disks,  and  the  development  of  osteophytes  from  the  bodies  of  the 
vertebrae.  These  osteophytes  are  most  common  at  the  sides  of  the  bodies, 
between  the  edge  of  the  anterior  common  ligament  and  the  transverse  pro- 
cess. They  grow  as  rounded  masses  from  the  contiguous  margins  of  adjacent 
vertebrpe,  and,  meeting  opposite  the  middle  of  the  intervertebral  disk,  become 
locked  together,  and  in  time  may  fuse  in  firm,  bony  anchylosis.  In  the  mean 
while  the  disk  between  the  vertebrae  becomes  shrunken,  friable,  and  of  a  duskier 
color.  In  some  cases  it  may  entirely  disappear,  and  the  vertebrae  it  once 
served  to  separate  may  then  become  firmly  anchylosed  togethei'.^  In  this  way 

»  See  Arthritis  Deformans,  page  369. 

2  Clinical  Society's  Trans.,  vol.  xii.  page  204.    London,  1879. 

8  Bouvier  et  Bouland,  Diet.  Encyclop.  des  Sc.  Med.,  art.  Racliis  (deviations),  Cyphosis. 


SPONDYLITIS  DEFORMANS. 


511 


portions  of  the  column  may  become  converted  into  a  solid,  bony  mass.  The 
lateral  osteophytes  just  alluded  to  may  attain  considerable  size,  and  are  often 
singularly  symmetrical  on  the  two  sides.  In  addition  to  these  outgrowths,  or 
independent  of  them,  irregular,  bony  masses  may  form  in  front  of  the  verte- 
bne,  apparently  in  the  substance  of  the  anterior  common  ligament,  and  may 
also  serve  to  bind  contiguous  bones  together.  Such  a  bond  is  more  often 
effected  by  the  locking  of  the  osteophytic  processes  than  by  their  actual  fusion, 
although  the  latter  condition  is  to  be  met  with. 

With  regard  to  the  articular  processes,  they  become  denuded  of  cartilage ; 
the  bone,  tliereby  exposed,  becomes  more  or  less  ebu mated ;  osseous  masses 
form  about  the  rim  of  the  bone ;  and  the  process  may  end  in  true  bony  anchy- 
losis, or  in  a  tirm  locking  of  the  joint  by  the  development  of  the  osteophytic 
masses.  Dr.  Hilton  Fagge^  records  a  case  of  rigid  cypliosis  in  a  man  aged  34, 
where  there  was  complete  bony  anchylosis  of  the  articular  processes  in  the 
dorsal  region,  together  with  firm  union  of  the  corresponding  laminae  and 
spines  by  means  of  coarse,  new  bone.  The  bodies  in  this  case  were  free  from 
any  osteophytic  growth,  but  were  so  rarefied  and  wasted  that  the  spine  was 
fractured  after  death  by  the  simple  act  of  placing  the  body  in  the  coffin. 
Bouvier  and  Bouland,  speaking  of  anchylosed  cyphosis,  allude  to  the  occur- 
rence of  this  fusion  of  the  laminae  and  spinous  processes,  but  insist,  at  the 
same  time,  upon  its  extreme  rarity In  some  instances  the  costo-vertebral 
joints  are  affected,  and  the  ribs  become  firmly  anchylosed  to  the  spine.  As  a 
result  of  the  above-mentioned  changes,  the  column  becomes  arched  posteriorly, 
and  a  more  or  less  extensive  cyphosis  is  developed.  This  curve  is  generally 
quite  regular,  and  its  extent  will,  of  course,  depend  upon  the  extent  of  the 
disease. 

I  have  met  Avith  two  or  three  instances,  in  specimens  obtained  from  the 
dissecting-room,  where  the  cyphosis  was  associated  with  a  certain  amount  of 
lateral  deviation,  the  lateral  curve  being,  like  that  in  the  antero-posterior 
direction,  quite  rigid.  The  fixity  of  the  column  in  its  false  position  is  a  very 
marked  feature  of  the  disease.  The  changes  observed  in  the  bones  themselves 
are  all  usually  most  marked  about  the  summit  or  greatest  concavity  of  the 
curve. 

As  a  result  of  th-e  curvature,  of  the  bone  changes,  of  the  absorption  of  the 
intervertebral  disks,  etc.,  the  entire  column  becomes  diminished  in  height ;  and, 
as  a  result  of  its  rigid  condition,  the  muscles  about  the  back  atrophy,  and 
often  become  very  shrunken.  The  bony  masses  that  are  developed  about  the 
affected  district  may  press  upon  the  nerves,  as  they  issue  from  the  interverte- 
bral foramina,  and  lead  to  a  limited  paralysis ;  and,  according  to  Senator,' 
the  spinal  deformity  may  be  of  such  a  character  as  to  cause  compression  or 
irritation  of  the  cord  with  its  attendant  consequences. 

Spondylitis  deformans  in  the  upper  cervical  region  is  attended  with  like 
changes  in  the  atlo-occipital  and  atlo-axoid  joints.  The  articular  cartilages 
and  the  intervertebral  disks  may  become  absorbed,  osteophytic  deposits  form 
about  the  rim  of  the  affected  joint-cavities,  and  a  rigid  anchylosis,  that  may 
depend  upon  fusion  of  the  bones  involved,  is  the  common  and  the  final 
result.  In  some  cases,  where  the  axis  is  conspicuously  affected,  the  odontoid 
process  may  be  found  irregular  in  outline  and  greatly'enlarged.  iS"o  curve  is 
formed  when  the  disease  attacks  this  region,  but  the'^joints  become  fixed,  and 
the^  movements  of  the  head  being  thus  "more  or  less  restricted,  a  constrained 
positioii  is  assumed.  Lastly,  at  least  one  case  has  been  put  on  record  of  de- 
generation of  the  cord  following  disease  in  this  portion  of  the  spine.* 

*  Trans.  Path.  Society,  vol.  xxviii.  p.  201.    London,  1877.  2  Lqc.  cit. 

3  Ziemssen's  Cyclopaedia  of  Medicine,  vol.  xvi.  1877. 

4  E.  Rotter.    Deutsches  Archiv  f.  klin.  Med.,  Bd.  xiii.  S.  403.  1874. 


512 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


Symptoms. — The  disease  usually  commences  with  pain  in  the  back.  This 
pain  may  be  severe  and  radiating,  and  of  the  character  of  rheumatic  pains. 
In  Dr.  Sturge's  case  the  onset  of  the  pain  was  so  sudden  and  severe  as  "  to 
take  away  the  patient's  breath."  It  will  soon  be  noticed  that  the  back  is 
becoming  stiff,  and  that  the  patient  has  some  little  difficulty  in  stooping,  or 
in  moving  the  head.  There  is  no  tenderness  of  the  parts,  nor  is  there  of 
necessity  any  actual  pain  when  movements  of  the  spine  are  attempted ;  but 
the  stiffness  is  very  conspicuous  and  irksome,  and  some  "  rheumatic  pains  " 
about  the  back  may  be  more  or  less  constant.  After  a  prolonged  rest  the 
column  will  usually  appear  unduly  stiff*;  and  on  the  other  hand,  after  exten- 
sive movements,  the  back  may,  in  the  earlier  stages  of  the  disease,  appear 
more  lissome,  and  be  moved  with  less  discomfort.  As  time  goes  on,  the 
patient  begins  to  lose  his  upright  carriage  ;  he  appears  diminished  in  height, 
acquires  a  constant  stoop,  and  develops  an  antero-posterior  curvature  of  the 
spine,  with  the  convexity  backwards.  The  cyphosis  that  results  from  this 
disease  is  generally  well  marked,  of  regular  outline,  and  often  of  considerable 
extent.  Its  conspicuousness,  moreover,  is  accentuated  by  that  wasting  of  the 
sacro- vertebral  muscles  that  in  time  ensues.  The  curve  may  be  of  such  a 
character  that  the  patient  prefers  to  support  himself  with  a  stick  when 
walking ;  the  abdomen  projects,  and  the  shoulders  appear  often  unduly  pro- 
minent, owing  to  the  scapulae  being  more  or  less  separated  from  the  chest- 
wall  in  consequence  of  alterations  in  the  thorax.  If  the  upper  cervical  ver- 
tebrae are  involved,  the  movements  of  the  head  become  limited  to  a  variable 
extent,  the  chin  is  poked  forwards,  and  that  constrained  position  is  assumed 
which  is  familiar  in  cases  of  disease  about  the  summit  of  the  column.  The 
rigidity  of  the  spine,  when  the  malady  is  well  developed,  is  usually  very 
marked,  and  may  be  absolute. 

The  thorax  becomes  more  or  less  rigid,  and  may  assume  the  deformity 
detailed  in  the  paragraphs  on  "  cyphosis."  The  fixity  of  the  ribs  may  depend 
not  only  upon  the  alteration  in  the  dorsal  spine,  or  the  formation  of  osteo- 
phytes about  the  costo-vertebral  joints,  but  upon  actual  anchylosis  of ^  those 
joints.  In  the  latter  instance  the  breathing  is  entirely  abdominal,  as  it  was 
in  the  case  recorded  by  Dr.  Hilton  Fagge,  and  alluded  to  above. 

In  spondylitis  deformans  there  are  usually  evidences  of  chronic  rheumatoid 
arthritis  in  some  other  part  or  parts  of  the  body. 

The  duration  of  the  disease  varies.  Its  course  is  always  chronic,  and  is 
to  be  estimated  by  years.  The  lighter  grades  of  the  disease  have  probably 
little  effect  in  shortening  the  patient's  life,  and,  as  is  well  know^n,  a  good 
old  age  may  be  attained  by  those  whose  backs  have  been  stiff  and  painful, 
and  bent,  for  a  good  number  of  years.  When  the  disease  occurs  in  early  or 
in  middle  life,  the  prognosis  is  by  no  means  as  favorable.  Life  may  be  con- 
siderably curtailed  by  the  malady,  and  indeed,  if  it  assume  by  any  means  a 
severe  form,  death  usually  results  in  a  comparatively  few  years. 

As  regards  treatment,  it  can  only  be  asserted  that  the  condition  is  incurable, 
and  that  neither  local  nor  general  measures  are  of  any  permanent  or  substan- 
tial value.  Some  relief  may  be  given  by  the  treatment,  such  as  it  is,  that  is 
usually  advised  in  chronic  rheumatic  arthritis,  and  an  account  of  which  will 
be  found  elsewhere.^ 

Caries  and  Necrosis. 

Caries  and  necrosis  are  both  of  common  occurrence  in  the  spinal  column  : 
but  the  former  is,  of  the  two,  infinitely  the  more  frequent.  The  large  amount 


'  h5(Mi  Vol.  III.,  pa-e  4H9,  supra. 


INTERVERTEBRAL  ARTHRITIS. 


513 


of  cancellous  tissue  that  enters  into  the  composition  of  the  vertebr?e,  will 
explain  the  greater  tendency  of  the  column  to  caries,  and  for  the  same  rea- 
son it  follows  that  the  bodies  are  the  usual  parts  attacked  by  the  malady. 
Necrosis,  on  the  other  hand,  is  chiefly  met  with  in  the  posterior  segments  of 
the  spine,  and  when  occurring  in  the  anterior  portions  of  the  column  usually 
implicates  such  parts  as  contain  much  compact  tissue,  and  therefore  princi- 
pally involves  the  first  and  second  cervical  vortebrjie. 

The  matter  of  caries  is  fully  discussed  in  the  sections  on  Pott's  disease  and 
Disease  of  the  Atlo-axoid  region. 

The  principal  and  most  frequent  examples  of  necrosis  of  the  spine  are  also 
detailed  in  those  sections  ;  and  it  only  remains  here  to  allude  to  such  cases  of 
necrosis  of  the  column  as  cannot  be  well  referred  to  either  of  these  clinical 
divisions.  These  cases  are  but  few  in  number,  and  are  due  probably  in  all 
instances  to  injury.  Thus  I  have  seen  necrosis  of  several  of  the  dorsal  spines 
follow  upon  a  severe  laceration  of  the  back,  that  had  exposed  and  injured 
those  processes. 

A  like  necrosis  has  followed  upon  certain  fractures  and  dislocations  of  the 
spine  attended  with  crashing  and  comminution  of  the  bones. 

Mr.  Bickerstetli  records  a  remarkable  ( ase  of  a  man,  aged  twenty -two,  who 
was  shot  in  the  neck.  The  lesion  involved  the  fifth  and  sixth  cervical  verte- 
brse.  After  an  interval  of  some  months  he  became  the  subject  of  dysphagia 
and  paralysis  of  both  arms.  The  wound  was  open,  and  there  was  intense 
inflammation  of  the  pharynx.  He  ultimately  expectorated  two  small  pieces 
of  bone,  and  a  dense  mass  of  tissue  that  was  discovered  to  be  an  interver- 
tebral fibro-cartilage.  A  perfect  recovery  followed,  although  some  stifl:ness 
of  the  neck  persisted.^ 


Intervertebral  Arthritis. 

This  term  obviously  implies  inflammation  of  the  joints  between  the  ver- 
tebrae, and  includes  not  only  arthritis  of  the  true  joints  between  the  articular 
processes,  but  also  inflammatory  affections  of  the  intervertebral  disks.  The 
term  is  too  general,  and  too  wide  in  its  application  to  be  of  use  in  any  trea- 
tise that  is  founded  upon  a  clinical  rather  than  a  pathological  basis.  It  might 
be  of  great  advantage  in  the  light  of  pure  pathology— to  consider  all  forms 
of  vertebral  arthritis  under  one  common  heading — -but  such  an  arrangement 
would  tend  to  confuse  well-marked  and  familiar  clinical  outlines,  and  would 
be  in  direct  opposition  to  commonly  accepted  notions  of  the  varieties  of  ver- 
tebral disease. 

The  intervertebral  joints  that  are  the  most  commonly  involved  are  those 
between  the  axis  and  between  the  latter  bone  and  the  occiput.  These  afl:ec- 
tions  are  fully  discussed  in  the  chapter  on  Diseases  of  the  Alto-axoid  Region. 
A  special  form  of  intervertebral  arthritis  is  considered  under  the  heading 
Spondylitis  Deformans. 

The  principal  and  most  common,  inflammatory^,  or  destructive  processes  in 
the  intervertebral  disks,  are  considered  in  the  section  on  Pott's  Disease,  and 
it  is  necessary,  therefore,  in  this  place  to  do  no  more  than  call  attention  to 
some  rare  aspects  of  intervertebral  arthritis  that  cannot  be  included  under 
any  of  the  above-mentioned  headings.  These  examples  of  the  disease  are 
twofold:  (1)  Arthritis  of  the  true  joints  of  tbe  spinal  column  following  upon 
injury,  and  (2)  certain  peculiar  cases  of  perforation  of  an  intervertebral  disk. 

(1)  The  vertebral  column  is  frequently  the  seat  of  concussions  and  sprains. 

^  Medical  Times  and  Gazette,  vol.  i.  1862,  page  614. 

VOL.  IV. — 33 


514 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


These  Injuries  must  involve  to  some  extent  at  least  the  joints  that  connect 
the  various  vertehrjfi  together.  If  the  more  superficial  joints  of  the  body  are 
exposed  to  sprain  or  contusion,  they  commonly  enough  become  the  seat  of 
synovitis,  and  there  is  nothing  in  the  structure  of  the  joints  between  the 
articular  processes  of  two  vertebrse  that  exempts  them  from  a  like  conse- 
quence. I  believe,  indeed,  that  simple  synovitis  of  certain  of  the  synovial 
joints  of  the  spine,  is  common  after  sprains  and  contusions  of  the  back,  and 
that  such  a  condition  can  probably  explain  the  long-contiimed  pain  and  stitJ- 
ness  that  often  persist  after  such  injuries,  and  that  are  usually  so  very  well 
localized.  There  is  no  reason  to  suppose  that  this  synovitis  is  different  from 
other  forms  of  synovitis.  It  may  be  acute  or  chronic;  and  it  may  end  in  reso- 
lution or  pass  to  suppuration.  "  I  am  aware  of  no  actual  demonstration  of 
simple  synovitis  of  the  vertebral  joints ;  but  many  cases  have  been  recorded 
of  suppurative  synovitis  of  these  joints  that  has  followed  upon  sprains  and 
like  lesions.  The  main  symptoms  are  long-continued,  local  pain,  and  rigidity 
from  the  painfulness  of  movement  and  some  amount  of  muscular  contraction. 
I  am  well  aware  that  these  symptoms  may  occur  in  cases  where  the  muscles 
only  are  lacerated  or  contused,  and  perhaps  the  ligamentous  structures  torn, 
but  there  is  nothing  to  disprove  the  suggestion  that  in  some  instances  these 
symptoms  may  be  due  to  intervertebral  synovitis.  Shaw  states  that  not  only 
may  this  synovitis  of  the  joints  between  the  articular  processes  go  on  to  sup- 
puration, but  the  purulent  collection  thus  formed  may  cause  limited  j)aralysis 
by  pressure  upon  the  nerves  as  they  issue  from  their  respective  foramina. 
Moreover,  the  joint-abscess  may  burst  into  the  spinal  canal  and  lead  to  para- 
plegia and  death.  1 

(2)  Dr.  John  Ogle  has  placed  on  record  two  remarkable  cases  of  peculiar 
perforation  of  an  intervertebral  fibro-cartilage  that  in  each  instance  led  to 
death  from  implication  of  the  medulla  spinalis. 

The  first  case  occurred  in  a  man  aged  50,  who  had  presented  no  distinct 
evidence  of  spinal  mischief  until  one  day,  while  at  his  meals,  a  piece  of  a 
mutton  bone  became  impacted  in  his  gullet.  This  was  easily  disgorged,  but 
the  act  was  immediately  followed  by  a  paroxysm  of  coughing,  during  which 
much  pus  was  brought  up.  He  experienced  also  much  pain  in  the  neck.  In 
process  of  time  he  'became  paralyzed— first  in  the  upper  and  then  in  the 
lower  extremities— and  gradually  sank,  sensation  having  become  impaired 
some  few  dfiys  before  death.  At  the  autopsy,  a  hole  was  found  in  the  pos- 
terior wall  of  the  gullet,  that  led  directly  to  a  perforation  in  the  fibro-car- 
tilage between  the  fourth  and  fifth  cervical  vertebrae.  The  perforation  pre- 
sented an  ulcerated  appearance,  and  had  gone  right  through  the  disk,  and  so 
opened  into  the  spinal  canal.    The  cord  and  its  meninges  were  inflamed.^ 

The  second  case  was  that  of  a  woman,  aged  fifty-two,  who  suffered  from 
post-pharyngeal  inflammation  connected  with  some  slight  erosion  of  the  surr 
face  of  the  bodies  of  certain  cervical  vertebrse.  She  died  from  spinal  arach- 
nitis, and  the  post-mortem  examination  revealed  a  perforation  in  one  of  the 
cervical  fibro-cartilages,  that  had  extended  back  and  opened  into  the  spinal 
canal.^ 


Pott's  Disease  of  the  Spine. 

^Nomenclature.- There  is  a  well-known  aftection  of  the  vertebral  column 
that  is  most  common  in  the  young,  and  that  is  marked  by  certain  very  defi- 

>  Holmes's  System  of  Surgery,  2d  ed„,  vol.  ii.  page  367. 

«  Path.  Soc.  Trans.,  vol.  iv.  1853,  page  27.  *  Ibid.,  voL  xv.  1863,  page  1. 


pott's  disease  of  the  SPlxNE. 


515 


nite,  general  features.  The  spine  becomes  rigid  and  tends  to  develop  an  angular 
deformity,  an  abscess  with  some  peculiarities  may  form,  paraplegia  may 
ensue,  and,  after  death,  the  anterior  segments  of  the  column  will  be  found 
more  or  less  extensively  damaged  by  a  destructive  process.  Various  names 
have  been  given  to  this  disease,  and  some  explanation  may  be  offered  as  to 
why  the  particular  name  that  is  adopted  here  has  been  selected.  Among  the 
terms  applied  to,  or  associated  with,  this  malady,  may  be  mentioned  caries 
of  the  spine,  vertebral  tuberculosis  (Xelaton),  vertebral  arthritis  (Ripoll), 
osteitis  of  the  spine,  angular  curvature  of  the  spine,  and  Pott's  disease. 

The  term  "  Caries  of  the  spine"  is  very  definite,  but  its  very  preciseness  is 
an  objection  to  its  use  in  the  present  instance.  The  morbid  process  in  this 
malacly  is  indeed,  in  the  vast  majority  of  all  cases,  a  caries  of  the  bone,  but 
at  the  same  time  cases  are  recorded  where  the  bone  has  been  exempt  and  the 
disease  has  been  limited  to  the  intervertebral  fibro-cartilages.  On  the  other 
hand,  it  can  by  no  means  be  said  that  all  cases  of  vertebral  caries  are  asso- 
ciated with  the  general  symptoms  above  mentioned,  so  that,  if  the  clinical 
-entity  of  the  "Pott's  disease"  is  to  be  maintained,  the  term  now  criticized  is 
both  too  narrow  and  too  wide.  The  terms  "  vertebral  tuberculosis"  and 
"vertebral  arthritis"  are  to  be  discarded,  inasmuch  as  they  commit  the  user 
to  certain  very  definite  and  limited  views,  in  the  one  case  as  to  the  nature  of 
the  morbid  process,  and  in  the  other  as  to  its  primary  seat.  The  term 
^'osteitis  of  the  spine,"  on  the  other  hand,  is  too  indefinite  to  express  the 
peculiar  clinical  attributes  of  the  present  aftection.  Inflammation  is  common 
enough  in  the  bones  of  the  column,  but  it  is  only  in  a  comparatively  small 
number  of  instances  that  that  process  leads  to  the  definite  disease  known  by 
many  as  Pott's  disease.  It  would  certainly  be  no  gain  to  clinical  surgery 
to  forcibly  associate  this  disease  with  such  other  forms  of  osteitis  of  the 
spine  as  necrosis  of  the  spinous  processes  after  injury,  or  inflammation  of  the 
odontoid  body.  The  common  and  much  used  term  "angular  curvature"  is 
open  to  the  gravest  objections.  In  the  first  place,  the  term  is  in  itself  ridicu- 
lous, involving,  as  it  does,  an  obvious  contradiction.  An  angular  curve  must, 
from  a  geometrical  point  of  view,  be  classed  with  a  square  circle,  or  a  round 
triangle.  Then,  again,  the  angular  deformity  is  but  one  symptom  of  the 
disease,  and  that  symptom,  be  it  noted,  not  of  necessity  a  constant  one. 
^[oreover,  unwholesome  ideas  as  to  the  treatment  of  the  disease  may  be  per- 
petuated by  the  prominence  thus  given  to  an  important  but  isolated  symp- 
tom. Finally,  I  would  urge  the  use  of  the  term  "  Pott's  disease"  upon  these 
grounds.  The  meaning  of  the  expression  is  well  known,  and  its  clinical 
associations  are  familiar.  The  term  is  extensively  employed,  not  only  in 
England  and  America,  but  especially  on  the  Continent.  In  France,  indeed, 
the  title  "  mal  de  Pott"  is  the  generally  accepted  name  for  this  malady. 
Then,  again,  the  term  commits  the  user  to  no  particular  pathological  opinion, 
and  may  be  used  by  men  holdino-  the  most  opposed  views  in  pathology,  to 
express  the  same  association  of  clinical  features.  Lastly,  the  term  serves  to 
l)erpetuate  the  nanie  of  a  man  who  well  deserves  the  honor,  and  who  was  the 
first  to  remove  this  disorder  of  the  spine  from  the  region  of  a  confused  igno- 
rance, and  from  the  especial  province  of  the  quacks. 

Etiology. — Age. — Pott's  disease  may  occur  at  almost  any  period  of  life. 
It  has  been  met  with  in  infants  in  arms,  and  in  patients  far  advanced  in  years. 
l>ryant,i  indeed,  details  an  instance  where  the  disease  attacked  a  foetus  in 
utero.  The  specimen  is  preserved  in  Guy's  Hospital  Museum,  and  shows 
'"the  bodies  of  three  or  four  of  the  dorsal  vertebrae    ....    clearly  fused 


I  Manual  for  the  Practice  of  Surgery,  vol.  i.,  2d  ed.,  p.  278. 


516 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


together  from  disease,  giving  rise  to  angular  curvature."  Cases,  however,  of 
Pott's  disease  at  these  extreme  periods  of  life  are  exceedingly  rare.  The 
malady  is  usually  met  v^dth  between  early  childhood  and  adolescence,  and  in 
the  great  majority  of  all  cases  the  disease  commences  between  the  ages  of  two 
and  ten  years.  Instances  are  met  with  of  the  disease  commencing  in  adults, 
but  such  instances  are  comparatively  few,  and  the  onset  of  Pott's  disease  in 
patients  past  middle  life  is  very  rare.  This  affection  is  indeed  essentially  a 
disease  of  childhood. 

Sex. — Sex  appears  to  have  little  or  no  influence  in  the  etiology  of  the  dis- 
ease. It  has  been  asserted  by  many — and  especially  by  those  who  urge  a 
traumatic  origin  for  Pott's  disease — that  it  is  more  common  in  male  than  in 
female  children.  My  own  observation  would  lead  me  to  believe  that  it  is 
equally  common  in  the  two  sexes,  but  Mr.  Fisher's^  statistics  show  a  greater 
number  of  cases  among  females.  These  statistics  are  probably  the  most  valu- 
able that  have  been  published.  Of  500  cases  of  angular  deformity  treated  at 
the  ^sTational  Orthopsedic  Hospital,  261  were  in  females  and  239  in  males. 
Allowing  for  the  preponderance  of  females  over  males  in  the  general  popula- 
tion, these  figures  would  make  it  appear  that  the  disease  is,  perhaps,  equally 
common  in  the  two  sexes,  and  would  at  least  correct  the  assertion  that  the 
malady  particularly  affects  boys. 

Constitutional  Condition. — Pott's  disease  is  usually  met  with  in  unhealthy 
children,  and  especially  in  those  who  present  that  phase  of  ill  health  known 
as  scrofula.    It  must  be  confessed  that  on  this  point  there  has  been  no  small 
amount  of  dispute,  and  while  some  have  urged  that  every  case  is  directly  due 
to  scrofula,  others  have  maintained  that  that  diathesis  has  nothing  to  do  with 
the  production  of  the  disease.    Many  of  these  discrepancies  are  to  be  ex- 
plained by  the  various  conceptions  that  are  held  as  to  the  nature  of  struma. 
Those  who  expect  every  patient  with  Pott's  disease  to  present  a  certain  phy- 
siognomy, will  certainly  be  disappointed,  as  will  also  those  who  may  expect 
every  such  patient  to  present  glandular  disease,  or  to  come  of  a  decidedly 
"  tubercular"  stock,  or  to  finally  die  of  some  tubercular  malady.    Scrofula,  as 
I  have  tried  to  demonstrate  in  a  recent  work  on  the  subject,^  is  rather  a  ten- 
dency to  a  peculiar  form  of  chronic  inflammation.    Of  the  character  of  this 
inflammation  I  will  speak  subsequently.    The  diathesis  is  rather  to  be  esti- 
mated by  certain  morbid  tendencies  in  the  tissues,  than  by  any  peculiarity  of 
feature  or  descent.    In  support  of  the  assertion  that  angular  deformity  is  most 
usually  met  with  in  the  strumous,  I  would  draw  attention  to  these  facts.  ^  In 
a  great  number  of  instances,  the  patient's  immediate  relations  are  the  subjects 
of^acknowledged  scrofulous  disease.  •  In  many  instances  there  is  a  history  of 
phthisis  or  of  tuberculosis  in  the  family.    The  patient  often  exhibits  some 
other  evidence  of  a  strumous  habit.    This  may  be  seen  by  a  tendency  to 
chronic  catarrhs,  by  the  occurrence  possibly  of  certain  skin  affections,  or  by  a 
disposition,  it  may  be,  to  certain  glandular  enlargements.    In  not  a  few  in- 
stances I  have  notes  of  cases  where  the  spinal  disease  was  cotemporary  with, 
or  preceded  or  followed  by,  some  such  gross,  strumous  ailment  as  "  white  swell- 
ings" of  , a  joint,  or  caries,  or  necrosis  of  some  bone.    Lastly,  as  I  shall  point 
out  when  dealing  with  the  pathology  of  this  disease,  the  morbid  changes 
that  take  place  in  the  vertebrse  are  very  often  identical  with  changes  occurring 
in  acknowledged  scrofulous  disorders.    Some  authors  have  objected  to  Pott's 
disease  being  classed  among  strumous  affections,  because  many  of  those  who 
suft'er  from  the  disease  do  not  present  at  the  same  time  great  glandular  swell- 

'  Essays  on  the  Treatment  of  Deformities  of  the  Body,  p.  11.    London,  1879. 
^  Scrofula  and  its  Gland  Diseases.    London,  1882.    See  also  my  article  on  *'  Scrofula,"  in 
Holmes's  System  of  Surgery,  3d  ed.    London,  1882. 


pott's  disease  of  the  spine. 


517 


ings,  or  other  strumous  malady.  A  few  do  show  these  eomplications,  while 
the  majority  do  not ;  and  the  condition  of  these  latter  is,  I  think,  to  be  ex- 
plained by  that  antagonism  that  appears  to,  exist  between  the  various  stru- 
mous disorders,  and  that  does  not  favor  the  appearance  upon  tlie  same 
patient,  and  at  the  same  time,  of  more  than  one  gross  manifestation  of  the 
disease.  In  the  book  just  ahuded  t(^,  I  have  endeavored  to  fully  demonstrate 
this  antagonism.  While  then,  I  would  not  for  one  moment  insist  that  all  the 
victims  of  Pott's  disease  are  of  necessity  scrofulous,  I  would  urge  that  the 
majority  of  such  patients  present  reasonable  evidences  of  this  diathesis.  I 
have,  for  exam[»le,  met  with  several  instances  of  this  spine-affection  in  (diil- 
dren  who  have  appeared  in  perfect  health  as  regards  their  general  condition, 
and  who  have  moreover  presented  no  suspicion  of  struma  in  their  families ; 
but  such  instances  are  exceptional.  Lastly,  I  believe  it  will  be  very  gene- 
rally allowed  that  Pott's  disease  is  more  common  among  the  poor  than  among 
the  rich,  or  well  to  do,  and  that  it  is  most  common  in  association  with  those 
i>:eneral  conditions  which  are  the  most  favorable  to  the  production  of  struma. 
Some  few  writers  have  maintained  that  angular  deformity  may  be  due  to 
rheumatism  or  gout,  but  there  would  appear  to  be  little  or  no  foundation  for 
this  statement.  On  still  scantier  grounds  has  masturbation  being  assigned  as 
a  cause  of  this  disease.^ 

Lijtiry. — There  can  be  no  doubt  that  injury  bears  an  important  part  in  the 
etiology  of  Pott's  malady.  In  those  cases  in  wdiich  the  disease  attacks  children 
who  are  apparently  in  robust  health,  and  who  present  no  constitutional  taint 
of  any  kind,  I  believe  that  an  injury  is  to  be  assigned  as  the  actual  cause  of 
the  mischief  in  the  spine.  In  those  cases,  moreover,  in  adults  who  appear  to 
be  in  all  other  respects  in  perfect  health,  a  history  of  injury,  distinct  and 
grave,  is  seldom,  if  ever,  absent.  The  frequency  with  which  the  disease  would 
appear  to  commence  about  the  junction  of  a  vertebra  with  its  interarticular 
tibro-cartilage,  supports  the  theory  of  an  injury  as  an  essential  cause.  For  it 
is  well  known  that  the  point  of  junction  of  a  rigid  with  an  elastic  segment  of 
a  column  is  a  point  of  weakness.  Allowing,  then,  that  an  injury  is,  in  certain 
cases,  an  essential  cause  of  angular  deformity,  I  doubt  if  the  majority  of  sur- 
geons would  go  further,  and  assert  with  Dr.  Sayre  that  this  disease  "is  almost 
always,  if  not  alwa3^s,  produced  through  some  injury  to  the  bone  or  car- 
tilage."^ There  must  be  very  few  children  who  reach  the  age  of  ten  years 
without  having  met  with  some  accident,  trifling  although  it  may  be,  in 
which  the  back  has  been,  directly  or  indirectly,  involved.  Any  inquirer  who 
starts  with  a  bias  in  favor  of  injury  as  an  essential  cause  of  Pott's  disease, 
will  not  lack  material  to  support  his  opinion.  The  only  question  is  as  to  the 
value  of  that  material.  Of  how  many  children  at  the  age  of  ten,  could  it  not 
be  probably  said  that  "so  many  months  ago  it  fell  and  hurt  its  back,"  or 

had  a  bad  tumble,"  or  "  had  something  strike  it  in  the  back?"  Those  who 
maintain  the  importance  of  injury  in  this  disease,  must  also  accept  the  onus 
of  explaining  why  Pott's  disease  is  not  more  common  than  it  is,  and  why  a 
given  injury  will  produce  the  malady  in  one  child,  while  it  has  no  permanent 
effect  upon  another.  In  scrofulous  children,  in  children  already  predisposed 
by  heredity  or  acquired  defects  to  certain  phases  ot  chronic  inflammation,  it 
is  easy  to  understand  that  a  very  slight  lesion  may  excite  a  carious  action  in 
the  vertebrae.  Whether  such  a  lesion  is  essential,  or  not,  it  is  difficult  to  say, 
and  still  niore  difficult  to  prove.  There  is  the  further  question  as  to  wdiether 
this  lesion  must  of  necessity  be  "  an  injury"  in  the  usual  meaning  of  that 
word,  or  whether  it  may  not  be  caused  by  undue  use  of  the  part,  by  dispro- 

'  See,  for  example,  South's  edition  of  Chelius's  Surgerv,  vol.  1.  page  280. 
*  Spinal  Disease  and  Spinal  Curvature,  p.  2.    London,  1S77. 


518 


MALrORMATIONS  AND  DISEASES  OF  THE  SPINE. 


portion  between  the  strength  of  the  column  and  the  weight  it  maintains,  or  hy 
undue  pressure  exercised  upon  some  especial  part  of  the  vertebral  segments. 
Lastly,  if  traumatism  were  so  essential  a  feature  in  Pott's  disease,  it  would  not 
be  unreasonable  to  expect  that  some  definite  relation  should  exist,  other  things 
being  equal,  between  the  injury  and  the  consequent  disease.  But  no  such 
relation  exists.  A  severe,  extensive,  and  acute  form  of  spinal  caries  may 
occur  with  the  absence  of  a  history  of  any  definite  lesion,  while,  on  the  other 
hand,  a  severe  injury  to  the  back  may  be  attended  with  no  ill  results  other 
than  those  immediately  connected  with  the  accident. 

Considered  generally,  the  etiology  of  Pott's  malady  bears  a  very  striking 
resemblance  to  the  etiology  of  "  white  swelling,"  or  strumous  joint  disease, 
and  there  is  an  almost  complete  identity  between  the  various  opinions  that 
have  been  advanced  as  to  the  causes  of  the  two  complaints. 

Pathological  Anatomy. — The  morbid  change  that  constitutes  the  essential 
feature  of  Pott's  disease  is,  with  some  slight  reservation,  a  caries  or  molecular 
disintegration  of  the  vertebral  bodies.  This  change  may  attack  any  part  of 
the  column,  but  is  more  commonly  met  with  in  the  lower  dorsal  region  than 
elsewhere.  In  some  rare  cases,  two  distant  parts  of  the  spine  may  be  involved 
at  the  same  time,  or  may  be  attacked  independently  at  difi:erent  periods.  An 
example  of  this  latter  circumstance  is  recorded  by  Shaw.^  Although  the 
disease  may  be  limited  to  a  single  vertebra,  such  an  occurrence  is  rare,  and  in 
most  instances  many  of  these  bones  are  involved,  and  often  in  very  varying 
degrees.  Bryant^  reports  a  case  where  no  less  than  twelve  vertebrae  w^ere  in- 
volved. The  morbid  process  nearly  always  commences  in  the  bone ;  it  may, 
however,  commence  in  an  intervertebral  fibro-cartilage,  and  there  are  some 
who  assert  that  the  earliest  change  may  take  place  in  the  periosteum,  or  in 
the  spinal  ligaments.  There  does  not  appear  to  be  any  positive  evidence  to 
support  the  theory  of  the  origin  of  this  disease  from  the  tw^o  last-named 
structures. 

The  whole  pathological  process  in  Pott's  disease  may  be  divided  into  two 
distinct  periods  or  phases  :  first,  the  period  of  destruction  or  softening  ;  and, 
secondly,  the  period  of  repair.  The  changes  themselves  can  be  best  con- 
sidered (1)  as  they  affect  the  bone,  and  (2)^as  they  affect  the  intervertebral 
cartilage. 

1.  Period  of  Destruction  or  Softening.^ — (1)  Changes  in  the  Bones. — These 
changes  consist  in  a  caries  that  has  some  few  peculiarities.  The  morbid 
action  is  sin2:ularly  limited  to  the  anterior  segments  or  bodies  of  the  vertebrae. 
The  body  may  be  extensively  and  even  entirely  destroyed,  yet  will  the  morbid, 
action  have  little  or  no  tendency  to  extend  to  the  posterior  segment  of  the 
bone,  to  the  laminae,  the  pedicles,  and  the  various  processes ;  seldom,  indeed, 
does  it  extend  as  far  posteriorly  as  the  articular  processes  and  intervertebral 
joints,  although,  as  a  somewhat  rare  occurrence,  these  parts  of  the  bone  may 
be  involved.  The  disease  may  commence  in  any  part  of  the  body  of  the 
vertebra,  or  at  several  parts  at  one  and  the  same  time.  Most  usually  the 
earliest  changes  would  appear  to  be  in  the  anterior  part  of  the  bone,  not 
far  from  the  anterior  surface.  Another  common  spot  for  the  commence- 
ment of  the  disease  is  that  part  of  the  body  of  a  vertebra  nearest  to  the  inter- 
vertebral disk.  It  must  be  remembered  that  this  part  of  the  centrum  is  an 
epiphysis,  and  the  disease  would  appear  in  many  cases  to  begin  as  an  epiphy- 

1  Holmes's  System  of  Surgery,  2d  ed.,  vol.  iv.  p.  112.    London,  1870. 

2  Manual  for  the  Practice  of  Surgery,vol.  i.  p.  277. 

3  After  d(iscribirig  the  process  as  it  affects  the  bones  and  cartilages  it  will  be  well  to  include 
under  this  heading  an  account  of  the  "  deformity  "  and  the  "  abscess." 


pott's  disease  of  the  spine. 


519 


sitis,  as  it  is  called.  Certain  it  is,  that  for  some  time  the  miscliief  may  remain 
limited  to  that  portion  of  the  bone  which  corresponds  to  the  epiphysis.  Folliu 
and  Duplay  state  that  the  earliest  change  in  Pott's  disease  is  often  to  be  noticed 
about  the  posterior  part  of  the  body,  near  its  junction  with  the  pedicles;  and 
other  observers  have  cited  the  centre  of  the  bone  as  a  frequent  spot  for  the 
conmiencement  of  the  disease. 

The  change  itself  would  be  described,  in  the  language  of  the  text-books,  as 
an  osteitis  interna^  or  as  a  caries  fangosa,  and,  very  briefly,  the  following  are  the 
alterations  that  are  to  be  noted  in  the  part:  A  certain  area  in  the  cancellous 
substance  of  a  vertebral  body  becomes  congested,  and  all  the  spaces  in  the 
bone  become  engorged  with  blood.  Into  the  immediate  cause  of  this  limited 
congestion  we  cannot  now  enter.  This  vascular  disturbance  is  soon  followed 
by  grosser  changes,  which  consist,  in  the  main,  of  two  distinct  processes — a 
softening  and-  breaking  down  of  the  bone  structure,  and  a  development  of 
certain  fungous  granulations.  To  properly  appreciate  these  changes,  it  is 
needful  to  recall  to  mind  the  fact  that  two  elements  enter  into  the  formation 
of  bone,  viz.,  inorganic  matter  and  an  organic  matrix.  The  relation  which  these 
two  elements  bear  to  one  another  may  be  compared  to  the  relation  that  exists 
between  the  plaster  and  the  laths  in  a  lath-and-plaster  wall.  Just  as  the 
laths  support  or  hold  together  the  plaster,  so  does  the  organic  matrix  of  bone 
serve  to  support  the  inorganic  elements  or  lime-salts.  Kow,  it  is  obvious 
that  the  morbid  process  in  inflammation  of  bone  must  be  limited  to  the 
organic  matter  of  the  afi:ected  tissue,  and  that  the  inorganic  material  can  take 
none  but  a  purely  passive  part  in  any  pathological  change.  Inflammation, 
to  speak  roughly  and  generally,  has  a  tendency,  in  the  flrst  place,  to  soften 
the  tissue  that  it  invades.  When  inflammation  attacks  bone — or,  rather,  when 
it  attacks  the  organic  matter  of  a  bone — it  softens  that  material,  and  one  might 
almost  say  that  it  dissolves  it.  The  result  of  such  a  change  is,  that  the  matrix 
is  no  longer  able  to  support  the  inorganic  elements,  and  the  structure  crumbles 
down,  just  as  would  a  lath-and-plaster  wall  if  it  were  possible  by  some  pro- 
cess to  dissolve  out  the  laths  without  seriously  disturbing  the  plaster.  It  is 
needless  to  say  that  this  softening  and  disintegrating  change  is  no  mere 
chemical  process,  but  is  brought  about  by  active  changes  in  the  part  itself, 
and  in  the  bloodvessels  that  are  concerned  in  its  nutrition. 

Into  the  minute  features  of  the  process,  it  is  unnecessary  here  to  enter. 
Suffice  it  to  say  that  the  partition  walls  between  neighboring  cancellous 
spaces  are  broken  down,  and  that  one  large  and  irregular  space  results  from  the 
fusion  of  several  small  ones.  Thus,  the  bone  becomes  lighter  and  more  spongy, 
more  cancellous  apparently  in  its  structure,  and  more^ friable  undoubtedly  to 
the  touch.  These  bony  spaces  are  by  no  means  empty,  nor  have  they  for  con- 
tents but  the  debris  that  has  resulted  from  neighboring  disintegration.  On 
the  contrary,  they  are  occupied  by  a  "  fungous"  granulation-tissue  that  has 
been  derived  partly  from  the  altered  cell-elemenT:s  of  the  bone,  and  partly 
from  an  exudation  provided  by  the  bloodvessels  in  the  area  of  disease.  The 
fungous"  character  of  these  granulations  can  hardly  be  said  to  be  apparent 
until  there  is  such  a  loss  of  parts  that  they  find  themselves  projecting  from  a 
free  surface.  These  granulations  are  very  intimately  connected  with  the  dis- 
integration of  the  bone.  Indeed,  they  appear  to  penetrate  the  parts  and 
carry  destruction  in  their  wake.  It  is  by  them  that  the  process  spreads,  and 
it  is  to  them  that  the  pathologist  has  turned  for  a  clue  to  the  nature  of  the 
entire  process.  When  the  disease  reaches  the  periosteum,  the  granulations  are 
described  by  Lannelongue-as  perforating  that  membrane,  and  as  piercing  it,  as 
it  were,  often  at  many  points.  The  periosteum,  readily  altered,  Avould  become 
a  part  of  this  granulation-material,  and  would  in  time  be  destroyed,  as  the 
bone  had  been  destroyed.    Thus  would  the  bone  be  bared  and  an  erosion  in 


520 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


its  substance  be  exposed,  or  a  deeper  cavity  in  its  interior  be  made  manifest. 
Such  are  the  main  features  of  this  caries  fungosa.  The  mischief  most  usually 
would  appear  to  commence  at  some  little  distance  below  the  surface  of  the  bone, 
but  hi  certain  instances  the  layer  of  compact  bone  next  to  the  periosteum 
has  been  credited  with  exhibiting  the  earliest  evidences  of  disease.  Pos- 
sibly— as  above  remarked — the  mischief  may  sometimes  commence  in  the 
periosteum. 

!  The  gross  and  visible  result  of  the  carious  change,  however,  is  this :  Irregu- 
lar cavities  are  formed  in  the  diseased  vertebral  bodies.  There  may  be  several 
cavities  in  the  same  centrum,  or  one  only,  and  the  situation  of, the  loss  of  sub- 
stance may  vary  considerably.  If  the  cavity  forms  deep  down  in  the  bony 
substance,  it  may  continue  to  increase  until  nearly  all  the  cancellous  portions 
of  the  body  are  destroyed,  and  nothing  is  left  but  the  outer  shell  of  compact 
bone.  This  probably  soon  gives  way,  and  the  cavity  opens  upon  the  surface. 
In  other  cases  the  destructive  action  may  early  make  its  way  towards  the 
surface  of  the  bone,  and  lead  to  an  excavation  in  the  bone  that,  while  com- 
paratively small,  is  yet  deep.  It  is  remarkable  that  the  carious  process  tends, 
with  the  very  rarest  possible  exceptions,  to  progress  towards  the  anterior  sur- 
face of  the  bone,  and  not  towards  that  surface  that  bounds  the  spinal  canal. 

It  will  be  seen  that  these  cavities  and  excavations  will  var};-  greatly  in 
appearance.  There  may  be  a  cavity  deeply  hidden  in  the  bone.  There  may 
be  a  cavity  near  the  surface,  whose  walls  are  formed  partly  by  bone,  partly 
by  thickened  periosteum  and  ligament.  In  other  cases  the  anterior  surface 
of  the  bone  is  laid  bare,  and  thus  are  exposed  erosions  varying  in  extent  and 
depth,  or  deeper  and  more  cavernous  losses  of  substance.  As  long  as  the 
destructive  process  is  in  any  way  active  or  progressive,  so  long  will  the  walls 
of  these  cavities  be  lined  by  the  granulation-tissue  just  alluded  to.  The  con- 
tents of  the  cavities  vary  greatly  according  to  the  duration,  and  perhaps 
according  also  to  the  nature  of  the  morbid  process.  In  recent  cases  the  con- 
tents may  be  laudable  pus,  or  more  usually  curdy  pus,  made  up  of  a  thinnish 
opaque  fluid,  with  flakes  of  a  denser  matter.  Seldom,  indeed,  is  the  con- 
tained matter  quite  homogeneous.  In  less  recent  cases  the  contents  may  be 
thick  or  creamy,  or  still  further  inspissated  so  as  to  be  caseous  and  firm.  In 
any  case  there  is  usually  mixed  with  the  matter  some  bony  debris  that  can 
be  felt  like  grit  when  the  contents  of  these  cavities  is  passed  between  the 
finger  and  the  thumb ;  and  in  certain  instances  this  debi^is  may  appear  as 
actual  and  visible  sequestra. 

Lastly,  with  regard  to  the  extent  of  the  disease  in  the  vertebral  column, 
regarded  as  a  whole,  the  utmost  diversity  exists.  As  already  remarked,  only 
one  body  may  be  diseased,  although,  as  a  rule,  many  are  attacked.  The 
extent  to  which  the  individual  centra  are  involved  varies  greatly.  There 
may  be  merely  a  small  cavity  or  excavation  in  each  of  the  diseased  vertebrae, 
or  several  of  these  bodies  may  be  entirely  destroyed,  and  no  trace  be  left  of 
them  other  than  is  provided  by  the  undestroyed  posterior  segments.  As 
a  rule,  the  intervertebral  cartilages  are  more  or  less  extensively  diseased, 
but  cases  are  occasionally  met  with  where  extensive  loss,  of  several  contiguous 
vertebral  bodies  is  associated  with  little  or  no  appreciable  destruction  of  the 
intervening  disks.  In  the  place  of  deep  excavations  in  certain  of  the  bones, 
there  may  be  found  a  superficial  erosion  involving  the  anterior  and  lateral 
surfaces  of  a  number  of  the  bodies,  and  it  is  remarkable  that  when  such 
erosions  exist  they  are  seldom  limited  to  a  small  portion  of  the  column.  Some 
further  observations  will  be  made  upon  this  subject  in  dealing  with  the 
deformity  that  forms  so  important  a  feature  in  the  disease. 

Before  leaving  the  matter  of  the  osseous  changes,  it  may  be  well  to  briefly 
discuss  the  nature  of  the  process  that  leads  to  these  changes.    It  is  very  gene- 


pott's  disease  of  the  spine. 


521 


rally  allowed  that  the  process  is  to  be  classed  as  a  caries,  but  the  great  matter 
in  dispute  is,  whether  that  caries  is  simple  or  tubercular.  A  vast  amount 
has  been  written  upon  this  subject,  and  a  good  deal  of  it  to  very  little  pur- 
pose. Many  pathologists  have  insisted  that  there  is  a  distinct  tuberculosis 
of  the  spinal  column,  wdiile  they  have  at  the  same  time  allowed  that  in 
many  instances  the  process  is  non-tubcrcnlar.  Most  elaborate  distinctions 
have  been  pointed  out  as  serving  to  distinguish  the  simple  from  the  tuber- 
cular caries :  but  these  distinctions,  falling  short  (as  they  have  until  quite 
recent  time)  of  microscopic  demonstration,  are  for  the  most  part  useless  and 
delusive.  It  has  been  urged  that  in  the  tubercular  process  the  cavities  formed 
are  peculiar  in  their  de[>th,  in  their  walls,  and  in  their  contents.  The  pres- 
ence of  caseous  collections  has  been  considered  absolute  demonstration  of 
tuberculosis,  and  little  opaque  specks  have  been  pointed  out  in  the  inflamed 
bone  as  veritable  tubercles.  It  is  now  known  that  tubercles  in  inflamed  bone 
are  bodies  not  to  be  criticized  by  the  unaided  eye,  that  the  minute  opaque 
specks  are  but  altered  inflammatory  products,  and  that  caseous  matter  by  no 
means  of  necessity  indicates  a  tubercular  change.  It  is  well  known  that 
tubercular  action  cannot  be  judged  of  merely  by  the  destruction  it  effects, 
nor  by  the  outline  assumed  by  the  excavations  that  it  leaves.  It  is  also  well 
known  that  the  simple  factor  of  chronicity  can  so  modify  the  inflammatory 
process  as. to  lead  to  a  great  diversity  of  appearances. 

The  question  then  still  remains,  Is  the  pathological  process  in  Pott's  disease 
tubercular  or  not?  If  by  "tubercle"  be  meant  the  "primitive  or  elementary 
tubercle"  of  Koster,  the  "tubercular  follicle"  of  Charcot,  or  the  "submiliary 
tubercle"  of  other  authors,  and  if  the  presence  of  this  body  constitutes  a 
tuberculosis,  then  is  the  caries  in  Pott's  disease  very  often  tubercular.  In 
the  fleshy  granulations  of  the  diseased  bone,  and  in  the  altered  soft  parts 
that  lie  about  it,  genuine  tubercles  have  been  detected,  and  Lannelongue  has 
quite  recently  demonstrated  the  manner  in  wdiich  the  carious  action  spreads 
by  the  development  of  tubercular  tissue. 

It  may,  I  think,  be  considered  as  distinctly  proved  that  a  local  tuberculosis 
takes  a  part  in  at  least  some  of  the  cases  of  Pott's  disease,  and,  as  far  as  I 
have  been  able  to  see,  it  probably  takes  a  part  in  quite  the  majority  of  all 
cases.  Unfortunately,  a  very  grave  and  often  most  inappropriate  clinical 
meaning  has  been  attributed  to  local  manifestations  associated  with  tuber- 
cle. Any  individual  who  presents  tubercle  in  his  body,  is  considered  to  be 
possessed  with  a  very  fatal  ailment,  and  to  be  liable  to  death  from  the  devel- 
opment of  some  more  general  and  widespread  form  of  tuberculosis.  Into 
the  nature  of  tubercle-producing  processes  I  cannot  now  enter,  but  I  have 
endeavored  in  the  book  already  alluded  to,  to  assign  to  them  a  somewhat  more 
simple  significance  than  they  are  usually  credited  with.  As  a  matter  of  fact, 
the  bulk  of  patients  with  Pott's  disease,  even  if  they  do  present  tubercle  in  the 
spinal  bones,  do  not  die  of  general  tuberculosis.  Indeed,  as  far  as  my  own 
experience  goes,  that  form  of  death  is  tolerably  unusual.  Then  again  the 
fact  must  be  recognized,  that  tubercle-producing  processes  may  undergo 
spontaneous  cure,  and  are,  when  quite  local,  susceptible  to  treatment.  This 
has  been  fully  demonstrated  in  the  matter  of  scrofulous  glands,  which  often 
present  the  most  perfect  forms  of  tubercle.  I  have  endeavored  elsewhere  to 
show  that  tubercle  is  no  neoplasm  in  any  other  sense  than  that  it  is  an  in- 
flammatory neoplasm,  and  that  it  is  the  outcome  of  a  peculiar  and  distinctive 
inflanunator}'  process. 

The  main  features  of  this  inflammatory  process  are  these :  it  is  usually 
chronic,  and  is  apt  to  be  induced  by  very  slight  irritation,  and  to  persist  after 
the  irritation  that  induced  it  has  disappeared.  The  exudations  in  such  a 
process  are  remarkable  for  their  cellular  character,  and  for  the  large  size  of 


522 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


some  of  their  elements.    Such  exudations  show  also  a  remarkable  tendency 
to  resist  absorption,  and  to  linger  in  the  tissues,  the  affected  area  becoming 
rapidly  non-vascular.    Among  the  common  products  of  these  inflammations 
are  o'iant-cells,  and,  if  a  certain  stage  of  the  process  be  reached,  tubercles. 
The  tendency  of  the  process  is  to  degenerate,  not  to  organize,  and  the  degene- 
ration usually  takes  the  form  of.  caseation.   At  the  same  time,  these  inflamma- 
tions have  a  tendency  to  extend  locally  and  to  infect  adjacent  parts,  and  their 
products  present  certain  peculiar  properties  when  inoculated  upon  animals. 
Lastly,  the  great  feature  of  the  process  is  this:  it  tends  to  commence  in  and 
to  most  persistently  involve  l^^mphatic  tissue,  and  so  actively  is  the  marrow 
or  lymph  tissue  of  bone  involved  in  the  condition  now  under  notice,  that  this 
at  first  consists  essentially  in  an  inflammation  of  marrow.   This  account  will, 
I  think,  very  fairly  represent  the  nature  of  the  process  in  many  cases  of  Pott's 
malady  of  the  spine.    It  must,  however,  be  confessed  that  this  condition  is 
not  met  wdth  in  all  instances.    It  is  not  to  be  expected  in  the  caries  that 
may  follow  after  injury  in  a  robust  person  free  from  any  disposition  to 
tubercle-producing  inflammations.     Such  caries  will  usually  be  more  active 
in  its  progress,  will  show  less  disposition  to  indiscriminate  spreading,  will 
be  surrounded  by  a  barrier  of  healthier  action,  and  Avill  show  a  less  degene- 
rate condition  of  its  products.   On  the  whole,  it  will  present  a  more  favorable 
aspect  of  the  disease,  but,  apart  from  such  marked  cases  as  these,  it  would 
be  scarcely  possible  to  diagnose  the  presence  of  tubercle  with  any  certainty 
from  naked  eye  appearances  only. 

(2)  The  Changes  in  the  Intervertebral  Fihro-cartilages. — In  most  cases  of  Pott's 
disease,  the  intervertebral  disks  share  in  the  destructive  change.  These  bodies 
become  softened  and  friable,  show  more  or  less  extensive  and  often  irregular 
losses  of  substance,  and  may  be  so  entirely  destroyed  as  to  leave  no  trace.  In 
cases  where  many  vertebrse  are  attacked  by  a  superficial  erosion,  a  like  ero- 
sion is  generally  to  be  seen  on  the  front  or  sides  of  the  corresponding  disks, 
or  in  the  centre  of  the  disk  a  large  cavity  filled  with  more  or  less  fluid  matter 
may  be  discovered,  that  may  be  fairly  compared  to  the  cavities  formed  in  the 
bone.  There  is  generally  a  disproportion  between  the  amount  of  destruction 
in  the  bones  and  that  in  the  intervening  cartilages.  As  a  rule,  the  destruc- 
tion is  most  marked  in  the  vertebral  body,  a  condition  to  be  explained  pos- 
sibly by  the  fact  that  the  mischief  usually  commences  in  the  bone  and  then 
spreads  to  the  articular  disk.  In  this  way  the  bone  may  be  found  extensively 
destroyed,  and  the  cartilage  thereby  laid  bare,  and  marked  by  a  certain  amount 
of  softening  of  its  parts,  and  by  some  irregular  losses  of  substance.  If  the 
bodies  of  two  or  three  adjacent  vertebrae  are  entirely  destroyed,  there  will  be 
probably  no  trace  of  the  disks  that  once  intervened  between  them,  although, 
in  some  cases,  fragments  may  still  be  detected  among  the  debris^  of  such  an 
outline  as  to  faintly  mark  out  the  position  of  the  lost  centra.  In  exceptional 
cases  the  disease  would  appear  to  commence  in  the  intervertebral  fibro-car- 
tilages,  and  those  bodies  may  not  only  present  the  greater  amount  of  destruc- 
tion, but  may  exhibit  the  sole  changes  observed  in  the  column.  Broca^  gives 
the  case  of  a  young  man,  whose  spine,  after  death,  showed  superficial  erosion 
of  all  the  dorsal  vertebrae,  with  destruction,  however,  of  no  less  than  nine  of 
the  intervertebral  articulations.  In  the  place  of  the  fibro-cartilages  was  a 
whitish,  pap-like  matter,  and  some  bony  debris^  derived  probably  from  the 
rubbing  together  of  the  bared  surfaces  of  bone.  Chassaignac^  reported  a  case, 
also  in  an  adult,  where  there  was  no  trace  of  any  intervertebral  disks  between 
the  second,  third,  and  fourth  lumbar  vertebrae.    The  bones  appeared  sound. 


1  Gaz.  Hebdom.,  p.  298.  1864. 


2  Gaz.  des  Hopitaux,  p.  156.  1858. 


POTT  S  DISEASE  OF  THE  SPINE. 


523 


and  were  anchylosed  together.  An  abscess  had  formed,  but  it  was  in  procesa 
of  cure. 

In  an  early  volume  of  the  Pathological  Society's  Transactions  is  an  account 
of  a  case  where  the  bodies  of  the  six  lower  dorsal  vertebne  were  carious  on 
the  surface,  but  where  little  or  no  trace  of  the  corresponding  disks  was  to  be 
found. ^  Mr.  Adams  gives  the  case  of  a  man,  aged  43,  who  died  of  lumbar 
abscess.  There  was  no  deformity  of  the  spine.  The  only  lesion  found  in  the 
column  was  due  to  the  entire  disappearance  of  the  disk  between  the  fourth 
and  fifth  lumbar  vertebne.  Between  these  bodies  (which  are  described  as  a 
trifle  "  indurated")  a  gap  existed  that  was  exactly  of  the  size  and  shape  of 
the  lost  fibro-cartilage.  The  same  observer  records  also  a  like  case  where  the 
intervertebral  cartilages  between  the  tenth  and  eleventh  dorsal  and  the  third 
and  fourth  lumbar  vertebne  had  been  entirely  destroyed,  without  any  corre- 
sponding loss  of  substance  in  the  adjacent  bones.  In  this  instance  there  was 
a  psoas  abscess,  but  no  deformity  of  the  back.  Mr.  Adams  believes  that  the 
disease  may,  from  first  to  last,  be  limited  to  the  cartilages  between  the  verte- 
bral bodies.^ 

Before  dealing  with  the  process  of  repair  in  Pott's  disease,  it  will  be  neces- 
sary to  give  some  account  of  two  very  conspicuous  results  of  the  process  of 
destruction,  viz.,  the  deformity  and  the  abscess. 

The  Deformity. — When  the  destructive  process  has  attained  a  certain  magni- 
tude in  the  anterior  segments  of  the  vertebrae,  a  gap  is  produced  that  destroys 
the  continuity  of  the  column,  as  far,  at  least,  as  the  part  of  it  in  front  of  the 
vertebral  canal  is  concerned.  It  is  obvious  that  the  existence  of  such  a  gap 
would  be  incompatible  with  any  great  pressure  upon  the  column,  and,  if  the 
loss  of  substance  were  considerable,  it  would  be  scarcely  compatible  with  the 
erect  posture.  What  usually  takes  place  in  Pott's  disease,  therefore,  is  this : 
The  column  yields  at  the  diseased  point,  it  bends  backward,  the  gap  is  elimi- 
nated by  the  approximation  of  the  vertebra  above  the  gap  with  the  vertebra 
below,  and  in  this  way  an  angular  projection  of  the  posterior  segments  of  the 
column  is  produced.  It  is  needless  to  say  that  the  development  of  this  defor- 
mity is  the  most  conspicuous  feature  in  the  disease. 

While  this  falling  together  of  the  vertebrae  about  the  seat  of  the  disease  is 
essential  to  maintain  any  degree  of  stability  in  the  column,  it  at  the  same 
tirne  serves  probably  to  keep  up  and  to  aggravate  the  carious  action.  By 
this  alteration  in  the  configuration  of  the  column,  two  diseased  surfaces  are 
brought  in  contact,  and,  more  than  that,  are  pressed  together,  and  probably 
rubbed  together.  However  injurious  such  approximation  of  parts  may  be, 
it  is  still  very  essential  for  the  purpose  of  repair,  and  for  the  subsequent  con- 
solidation of  the  weakened  spine.  The  projection — as  above  observed — is 
angidar,  and  the  apex  of  the  angle  usually  corresponds  to  the  posterior  seg- 
ment of  that  vertebra  in  whose  body  the  destruction  has  been  the  most  exten- 
sive. There  is  some  relation  between  the  extent  of  the  deformity  and  the 
amount  of  disease,  although  that  relation  is  by  no  means  a  constant  one.  If 
only  one  or  two  vertebral  bodies  are  lost,  but  are  entirely  lost,  a  sharp  angle 
is  produced;  but,  on  the  other  hand,  if  many  bones  are  involved,  and  none" of 
them  to  any  great  extent,  a  more  rounded  projection  results,  and  a  deformity 
more  approaching  a  curve  is  produced.  If  the  anterior  segments  of  the 
column  be  examined  at  the  seat  of  the  deformity,  very  various  conditions 
niay  be  met  with,  depending  upon  the  nature  and  extent  of  the  destruction. 
Stiveral  vertebrae  may  be  blended  together  in  a  confused  mass,  or  tw^o  ver- 


*  Trans.  Path.  Soc,  vol.  iv.  p.  7.  London,  1853. 
«  Ibid.,  vol.  V.  p.  241.    London,  1854. 


524  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

tebr^fi  partly  destroyed,  may  be  found  so  pressed  together  as  to  have  dis- 
placed backwards  some  fragment  of  a  third  and  intermediate  body  more 
extensively  destroyed  than  themselves.  Or  the  vertebrse,  m  fallmg  m  together 
to  close  up  the  gap,  may  have  included  a  sequestrum  of  varymg  dimensions 
that  lies  buried  deeply  in  the  angle  of  the  deformity.  Or,  if  the  gap  involve 
only  the  anterior  half  of  the  body  of  a  vertebra,  the  posterior  half  may  be 
found  to  have  yielded  to  the  superincumbent  weight  and  to  the  inflammatory 
softenlno;  that  invades  it,  and  to  have  brought  about  the  typical  disfigure- 
ment by^a  bendino;  or  yielding  of  its  parts. 

Further  details  as  to  the  deformity  in  this  disease  will  be  reserved  until 
the  symptoms  of  the  malady  come  to  be  considered. 

Abscess  (Psoas  Abscess  ;  Lumbar  Abscess  ;  Iliac  Abscess,  etc.)— An  abscess 
usuallv  presents  itself  externally  at  some  time  in  the  course  of  Pott's  disease 
of  the"^  spine.  There  are  cases,  however,  where  the  malady  runs  its  entire 
course  and  ends  in  anchylosis  and  cure,  and  yet  no  abscess  makes  its  appear- 
ance. Such  cases  are  not  infrequent,  but  they  cannot  be  regarded  as  any  evi- 
dence of  the  existence  of  angular  deformity  without  abscess.  Probably  m  all 
these  cases  an  abscess  has  existed  at  some  stage  of  the  disease.  This  abscess, 
as  the  cure  has  advanced,  has  itself  undergone  cure;  its  contents  have  become 
inspissated  and  caseous,  or  even  calcareous;  its  walls  have  become  shrunken 
and  inert ;  and  but  meagre  traces  of  a  once  large  collection  of  matter  have 
persisted.  I  am  not  aware  of  any  specimen  that  can  of  itself  oflter  an  un- 
doubted example  of  spinal  caries  without  abscess,  and  although  the  matter 
may  still  be  regarded  as  unproven,  it  is  probable  that  m  all  instances  some 
suppurative  collection  is  formed.  The  importance  of  the  abscess  m  Pott  s 
malady  cannot  be  exaggerated.  It  usually  forms  the  most  troublesome  feature 
in  the  history  of  the  case,  and,  more  than  that,  it  is  directly  or  indirectly  the 
most  common  cause  of  death  in  those  who  are  afflicted  with  the  disease,  i 
propose  to  deal  first  with  the  mode  of  formation  of  the  abscess,  and  secondly 
with  the  various  forms  of  the  abscess  as  determined  by  position,  etc.  ^ 

Formation  of  the  Abscess.— Lsinne]onQ^ue^  has  described  this  process  m  con- 
siderable detail,  and  his  account  agrees  in  its  general  points  with  that  most 
usually  ffiven  by  pathologists.  He  speaks  of  the  granulations  m  the  bone  as 
penetrating  the  periosteum,  and  as  spreading  the  disease  m  the  parts  outside 
that  membrane.  He  speaks  of  the  soft  parts  around  as  becoming  inflamed 
and  involved  in  the  process,  and  as  presenting  granulation-tissue  akm  to  that 
which  has  been  developed  in  the  bone.  Indeed,  he  urges  that  the  morbid  pro- 
cess in  the  bone  and  in  the  soft  parts  outside  it  are  identical,  and  are  modited 
only  by  diversity  of  structure  and  opportunities  for  extension  and  develop- 

^  The  debris  and  suppurative  matters  that  result  from  the  caries  in  the  bone  are 
first  included,  perhaps,  within  bony  walls,  and  then  within  walls  formed  partly 
by  the  diseased  bone  and  partly  by  the  inflamed  sott  parts  about  it.  l^astly, 
if  the  purulent  collection  acquires  any  magnitude,  the  wall  that  bounds  it  is 
derived  practically  from  the  soft  parts  alone,  and  the  share  taken  by  the  bone 
in  its  limits  becomes  very  insignificant.  As  the  disease  is  m  the  anterior 
seo-raents  of  the  column,  the  abscess  appears  upon  the  front  surtace  ot  tne 
spme,  not  usually  immediately  in  front-on  account  of  the  resistance  ottered 
by  the  anterior  common  ligament— but  a  little  to  one  side  of  the  body  ot  the 
diseased  vertebra.  The  collection  will  at  first  be  small  and  sessile.  As  it 
increases,  it  tends  to  gravitate,  and  so  move  downwards  on  the  spine.   In  this 


I  Abces  froids  et  tuberculose  osseuse.    Paris,  1881. 


pott's  disease  of  the  spine. 


525 


way  it  becomes  pedunculated,  and  its  fundus,  or  most  dependent  part,  acquires 
dimensions  quite  out  of  proportion,  often,  to  the  size  of  its  attachment.  The 
abscess  when  in  this  condition  has  been  aptly  compared  by  Follin  and 
Duplay  to  a  leech,  gorged  with  blood,  hanging  on  to  the  column.  The  direc- 
tion the  purulent  collection  tends  to  take — viz.,  a  direction  downwards  along 
the  front  of  the  column — is  to  .be  explained  by  gravity,  by  the  less  resistance 
oiFered  in  this  position,  and  by  the  decided  resistance  offered  to  the  progress 
of  the  abscess  by  the  structures  at  the  posterior  part  of  the  spine.  The  path- 
ology of  such  an  abscess  is  identical  with  the  pathology  of  like  abscesses  else- 
where. It  will  be  obvious  that  the  abscess  will  at  first  occupy  the  hollow  or 
angle  produced  by  the  deformity,  and  this  circumstance  will  explain  the  fact 
that  large  collections  of  pus  may  form  in  front  of  the  dorsal  spine,  in  this 
disease.  Without  any  injurious  pressure  been  exercised  upon  the  lungs.  The 
contents  of  the  cyst  vary.  When  small,  the  pus  is  usually  curdy,  and  con- 
tains flaky  matters  with,  possibly,  some  bony  debris.  When  of  large  size,  the 
matter  may  still  present  a  curd-like  appearance,  although  more  usually  it  is 
tolerably  thick  and  homogeneous. 

Varieties  of  the  Abscess. — There  are  cases  where  the  abscess  may  remain 
closely  adherent  to  the  seat  of  disease  at  the  spine,  and  after  attaining  a  cer- 
tain size  may  cease  to  grow.  To  such  collections  the  name  of  vertebral  abscess 
may  be  given.  It  is  obvious  that  they  could  not  be  detected  during  life;  that 
they  would  indicate  but  a  comparatively  slight  or  non-progressive  form  of  the 
disease,  and  that  they  might  afford  examples  of  resolution  or  spontaneous  cure. 
More  usually,  however,  the  abscess  increases,  and  advancing  towards  the  sur- 
face ultimately  discharges  itself  from  some  part  of  the  exterior  of  the  body. 
Considerable  variety  is  shown  in  the  direction  or  route  whereby  these  sup- 
purative collections  reach  the  surface,  and  this  variety  in  routes  has  led  to 
some  variety  in  names.  The  situation  of  the  bone-disease  will  obviously 
m.odify  to  some  considerable  extent  the  point  at  which  the  abscess  will  ulti- 
mately present  itself. 

If  the  disease  be  in  the  cervical  spine,  the  abscess  usually  discharges  itself 
at  some  point  about  the  sides  or  back  of  the  neck,  although  it  may  in  rare 
cases  present  itself  behind  the  pharynx  (post-pharyngeal  abscess),  or  open 
into  the  gullet  or  trachea,  or  pass  down  into  the  thorax,  or  wander  to  the 
anterior  part  of  the  neck.  If  the  disease  be  in  the  dorsal  region,  the  suppu- 
ration will  usually  follow  the  course  of  the  psoas  muscle,  and  thus  reach  the 
groin  (psoas  abscess).  Or  it  may  incline  back^vards  and  discharge  itself  in 
the  loin  (lumbar  abscess);  or  it  may  extend  no  lower  down  than  the  iliac  fossa 
(iliac  abscess) ;  or  it  may  pass  that  district  and  reach  the  gluteal  region,  or 
the  perineum  (gluteal  abscess,  etc.).  Even  w^hen  all  these  routes  are  exhausted, 
the  abscess  may  still  present  itself  in  other  and  more  unusual  situations.  When 
the  mischief  is  in  the  lumbar  spine,  the  abscess  most  commonly  points  in  the 
lumbar  or  iliac  regions,  or  may  follow  the  course  of  the  psoas  muscle,  or 
present  itself  in  one  of  the  less  usual  situations  to  be  hereafter  described. 

It  will  be  most  convenient  to  give  a  very  brief  description  of  each  of  these 
varieties  of  abscess  depending  upon  Pott's  disease. 

Psoas  Abscess. — This  form  of  abscess  is  most  usually  met  with  in  disease  of 
the  lower  dorsal  or  upper  lumbar  region  ;  but  it  may  occur  with  spinal  caries 
in  any  part  of  the  dorso-lumbar  portion  of  the  column. 

If  the  abscess  commences  in  the  dorsal  region,  the  collection  is  placed 
()ehind  the  pleura,  and  gravitates  along  the  front  of  the  vertebrae  until  it 
reaches  the  diaphragm.  It  may  pass  through  the  diaphragm,  either  by  creep- 
ing along  by  the  side  of  the  aorta,  or  by  making  for  itself  a  passage  through 
that  partition  by  inflammatory  absorption.    Its  subsequent  course  has  been 


526  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

very  ably  described  by  Mr.  Shaw.^    "When  the  abscess,"  he  writes,  "has 
perforated  the  diaphragm  and  gained  its  abdominal  side,  it  comes  into  relation 
with  the  heads  of  the  psoas  muscle.    That  muscle  arises  by  one  set  of  fibres 
from  the  sides  of  the  bodies  of  the  vertebrae,  by  another  from  the  roots  of  the 
transverse  processes ;  and  stretched  across  both  orifices  in  front  are  the  liga- 
menta  arcuata.    As  the  abscess,  therefore,  travels  downwards,  it  has  to  pass 
throuo-h  a  narrow  strait ;  it  is  prevented  from  enlarging  on  the  forepart  by  the 
resistance  of  the  ligatnenta  arcuata,  and  at  the  back  by  that  of  the  spine  and 
lowest  rib  ;  hence,  in  order  to  proceed,  it  has  to  force  its  way  in  the  line  of  the 
psoas  muscle.  That,  however,  can  only  be  done  by  penetrating  into  its  interior. 
It  accomplishes  this,  in  the  first  place,  by  inserting  its  most  advanced  part, 
like  a  wedo-e,  between  the  two  orifices  ;  it  then  splits  and  distends  the  fibres, 
so  as  to  form  a  cavity  for  the  reception  of  the  pus ;  the  muscular  fibres  become 
incorporated  with  the  walls  of  the  abscess,  and  the  psoas  at  length  is  con- 
verted, more  or  less  thoroughly,  into  an  abscess.    But  the  muscle,  charged 
wdth  pus,  does  not  expand  equally  in  every  direction.   The  fascia  iliaca  forms 
a  kind  of  sheath  for  it ;  and  this  being  particularly  strong  on  the  inner  side, 
and  united  firmly  to  the  brim  of  the  true  pelvis,  prevents  the  growth  of  the 
abscess  invv  ardly.    On  the  outer  side,  however,  the  connections  are  loose ; 
and  there  enlargement  takes  place  freely.    The  abscess  now  chiefiy  occu- 
pies the  hollow  between  the  united  fibres  of  the  iliacus  mternus  and  psoas 
muscles  on  the  inside,  and  the  crest  of  the  ilium  on  the  outside.    When  the 
advanced  part  reaches  the  level  of  Poupart's  ligament,  a  certain  retardation 
occurs ;  and  then  a  bulging  will  be  observed  along  the  line  of  the  flexure  of 
the  groin.    The  abscess  now  perforates  the  abdominal  walls.  ......  and 

the  opening  is  invariably  at  one  place,  namely,  behind  Poupart's  ligament, 
between  the  united  tendons  of  the  iliacus  and  psoas  muscles  and  the  anterior 
inferior  spinous  process  of  the  ilium.  The  situation  corresponds  to-  the  point 
of  iunction  of  the  outer  with  the  middle  third  of  Poupart's  ligament  '  i  he 
abscess  then  descends  a  certain  way  down  the  thigh,  and  opens  usually  about 
the  insertion  of  the  psoas.  n      -,  .  j 

By  this  process,  the  entire  psoas  muscle  may  be  destroyed  and  converted 
into  a  mere  bag  of  pus,  but,  no  matter  how  complete  the  destruction,  the 
branches  of  the  lumbar  plexus  that  traverse  the  muscle  remain  intact,  and 
lie,  dissected  out,  across  the  purulent  cavity.  This  cavity  is  generally  very 
irreo-ular  in  its  dimensions.  Where  it  passes  the  diaphragm  and  the  abdo- 
minal walls,  it  is  usually  narrowed  into  a  small  "  neck,"  and  there  are  many 
cases  where  the  continuity  between  parts  of  the  abscess-cavity  has  been 
destroyed  by  a  temporary  or  permanent  closure  of  the  "  neck"  situate  at  the 

abdominal  parietes.  ^      •      •    xi         •  • 

The  part  of  the  abscess-cyst  just  above  the  perforation  m  the  parietes  is 
usually  of  considerable  dimensions,  and  like  dimensions  may  also  be  attained 
by  the  abscess  in  the  thigh.  On  reaching  the  limb,  the  pus  may  leave  the  psoas, 
and  extend  iiidefinitely  about  the  front  of  the  thigh,  forming  a  large  collection 
of  matter,  or  it  may  proceed  down  the  limb  and  point  at  almost  any  part  ot  the 
extremity.  Erichsen,  indeed,  cites  a  case  where  an  abscess,  which  took  origin 
in  disease  of  the  dorsal  vertebrse,  opened  by  the  side  of  the  tendo  Achillis. 

Sometimes  the  abscess  cavity  bifurcates  high  up,  and  the  pus  descends  m 
both  psoas  muscles,  forming  a  double  psoas  abscess ;  and  the  same  condition 
may 'be  met  with  where  two  abscesses  form,  one  on  either  side,  and  descend 
independently  towards  the  pelvis.  Pus  from  disease  of  the  lumbar  vertebrae 
may  enter  the  psoas  muscle  at  any  part  of  its  length,  and  lead  to  the  forma- 
tion of  a  definite  psoas  abscess. 

1  Holmes's  System  of  Surgery,  2d  ed.,  vol.  iv.  page  119. 

2  Science  and  Art  of  Surgery,  6th  ed.,  vol.  ii.  242. 


pott's  disease  of  the  spine. 


527 


Pus  may  leave  the  psoas  muscle  at  almost  any  point,  and  lead  to  abscess 
in  some  other  situation. 

Lumbar  Abscess, — This  abscess  usually  has  its  origin  from  some  disease  of 
the  lumbar  spine.  The  pus,  guided  by  the  fasciae  of  the  part,  passes  along  the 
posterior  abdominal  wall,  in  front  of  the  quadratus  lumborum  muscle,  and 
having  reached  the  edge  of  that  muscle,  becomes  superficial  in  the  space 
bounded  by  the  external  oblique  and  latissimus  dorsi  muscles,  the  iliac  crest, 
and  the  last  rib ;  or  the  pus  may  pierce  the  quadratus,  or  proceed  along  its 
inner  parts,  and  ultimately  point  behind,  at  the  outer  edge  of  the  sacro-lum- 
balis  muscle.  A  lumbar  abscess  may,  however,  be  but  an  offshoot  from  a 
psoas  abscess,  or  it  may  proceed  from  disease  in  the  dorsal  spine  where  the 
purulent  collection  has  avoided  the  psoas  entirely,  and  has  proceeded  direct 
to  the  lumbar  region.  Pus  in  this  region  also  may  avoid  the  fasciae,  and, 
escaping  into  the  loose  subperitoneal  connective  tissue,  may  set  up  a  peri- 
nephritic  or  a  pericsecal  abscess. 

The  term  iliac  abscess  is  applied  to  a  purulent  collection  in  the  iliac  fossa, 
and  such  an  abscess  may  be  due  to  disease  in  either  the  lumbar  or  the  dorsal 
spine.  It  may  be  merely  an  offshoot  from  a  psoas  abscess,  or  a  psoas  abscess 
may  leave  the  muscle  at  the  pelvic  brim,  and,  entering  the  iliac  fossa,  con- 
tinue to  develop  there.  In  other  cases  the  pus  may  be  directed  to  the  iliac 
region  by  the  aorta  and  common  and  external  iliac  arteries,  or,  in  the  case  of 
lumbar  disease,  the  matter  may  gravitate  directly  to  this  region. 

Gluteal  abscess  is  not  common,  and  pus  may  reach  this  region  in  many 
ways.  An  iliac  abscess  may  increase  considerably,  and  in  time  mount  up 
over  the  crest  of  the  ilium,  and  so  reach  the  gluteal  region.  Or  pus  may  be 
conducted  to  the  great  sacro-sciatic  notch  by  the  common  and  internal  iliac 
arteries,  and  may  escape  from  that  notch,  either  above  or  below  the  pyriformis 
muscle.  In  other  cases,  the  matter  may  appear  to  simply  gravitate  to  the 
floor  of  the  pelvis  and  escape  at  any  convenient  spot.  It  may  especially  follow 
the  great  sciatic  nerve,  and,  pursuing  the  course  of  that  nerve,  the  abscess 
may  reach  as  far  even  as  the  ham.^  Lastly,  the  matter  may  pass  towards  the 
middle  line,  and  may  point  in  the  perineum  or  ischio-rectal  fossa. 

Some  idea  of  the  relative  frequency  of  these  abscesses  in  spinal  disease,  may 
be  gained  from  the  folio w^ing  table  by  M.  Michel : — ^ 

He  gives  the  following  as  the  result  of  an  examination  of  48  cases  of  Pott's  disease 
iiccompanied  by  abscess  : — 

In  39  of  the  cases  the  abscess  was  about  the  pelvis.  In  6  it  was  in  the  neck,  and  in 
3  it  was  found  in  the  dorsal  region. 

Of  the  39  abscesses  about  the  pelvis — 

13  were  about  the  groin, 

14  occupied  the  iliac  fossae  and  the  upper  and  inner,  or  outer,  part  of  the 

corresponding  thigh, 
1  appeared  by  the  anterior  superior  spine  of  the  ilium, 
7  were  in  the  lumbar  region,  , 
3  in  the  gluteal  region,  and 
1  in  the  perineum. 
Of  the  6  about  the  neck — 

1  was  in  the  supra-clavicular  fossa. 

3  presented  at  the  sides  of  the  neck,  and 

2  were  post-pharyngeal.  , 
The  3  abscesses  in  the  dorsal  region  appeared  near  the  middle  line,  and  by  the  sides 

of  the  diseased  vertebrj3e. 

>  FoUin  and  Duplay,  op.  cit.,  tome  Hi.  p.  666.  1868-9. 
2  Diet.  Eucyclop.  des  Sc.  Med.,  Art.  Rachis.    Paris,  1874. 


528 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


Rare  Forms  of  Spinal  Abscess.— {1)  In  disease  of  the  dorsal  spine  the  pus  inay 
proceed  more  or  less  directly  backwards,  and  present  itself  by  the  sides  of  the 
corresponding  spinous  processes.   (2)  In  disease  of  the  same  region  the  matter 
may  pass  forwards  beneath  the  pleura  and  along  the  intercostal  spaces,  and 
thus  reach  the  anterior  mediastinum.    Here  it  may  be  discharged  by  the  side 
of  the  sternum.   If  the  collection  occupy  the  precordial  region  it  may  receive 
pulsations  from  the  heart.    (3)  Mr.  W.  Adams  has  recorded  a  case  that  I 
believe  to  be  unique,  where  the  pus  pursued  an  upward  direction.    The  case 
was  that  of  a  lad,  aged  12,  with  disease  of  the  last  two  dorsal  and  upper  two 
lumbar  vertebrae.    There  was  angnlar  deformity.    The  abscess  took  at  once 
an  upward  course,'  and  opened  opposite  the  spine  of  the  seventh  cervical  ver- 
tebra.   (4)  Mr.  Shaw^  has  recorded  a  case  where  the  abscess  follow^ed  the 
course  of  the  inguinal  canal,  and,  presenting  at  the  external^  ring,  closely 
resembled  a  hernia.    He  cites,  also,  a  like  case  recorded  by  Sir  B.  Brodie.^ 
(5)  Broca^  has  recorded  a  case  where  a  psoas  abscess  opened  into  the  hip- 
joint,  having  effected  an  entry  through  the  anterior  part  of  the  capsule.  (6) 
Leudet*  notes  an  instance  of  the  abscess  opening  into  the  spinal  canal.  (7) 
Several  cases  have  been  put  on  record  where  the  abscess  opened  into  the  lung, 
and,  in  some  of  these  instances,  fragments  of  carious  bone  were  expectorated.* 
In  M.  Michel's  monoo;raph,  above  alluded  to,  a  case  is  quoted  where  the 
abscess  opened  both  into  the  lungs  and  also  into  the  oesophagus.    (8)  In  many 
instances  a  collection  of  pus  derived  from  some  spinal  mischief  may  open  nito 
the  intestinal  canal ;  and  usually,  if  not  always,  into  the  colon.-  There  may  be 
an  opening  into  the  gut  and  one  also  through  the  skin,  so  that  Avhile  pus 
passes  from  the  rectum,  some  fecal  matter  may  also  escape  through  the  cuta- 
neous aperture.    I  have  seen  an  example  of  this  condition,  and  several  cases 
have  been  recorded.    Lallemand^  has  given  the  account  of  a  man,  aged  19, 
who  developed  an  abscess  in  the  ischio-rectal  fossa.    This  ultimately  became 
a  fistula  in  ano.   When  subjected  to  operation,  a  number  of  pieces  of  necrosed 
bone  were  encountered.    It  was  then  discovered  that  the  man  had  "  a  delor- 
mity"  of  the  lumbar  spine.   It  was  supposed  that  in  this  case  the  abscess  was 
spinal,  and  the  pieces  of  bone  derived'from  the  vertebrae,  but  the  evidence  as 
to  vertebral  caries  was  very  scanty,  and  the  body  was  not  exammed  after 
death.    (9)  A  spinal  abscess  may  discharge  its  contents  by  the  urmary 
bladder ;  an  account  of  a  case  presenting  this  complication  is  recorded  by 

^^The  matter  of  implication  of  the  spinal  cord  in  Pott's  disease  will  be  con- 
sidered with  the  "  symptoms  of  the  malady." 

II.  The  Period  of  Eepair.— While  destructive  changes  are  going  on  in 
the  anterior  segments  of  the  column,  a  process  of  repair  is  to  be  observed 
about  the  posterior  segments.  An  adhesive  form  of  inflammation  appears  to 
be  excited  about  these  parts.  The  periosteum  covering  the  spinous  and  other 
processes  becomes  inflamed,  a  like  change  takes  place  m  the  ligaments  that 
pass  between  the  various  portions  of  the  posterior  vertebral  segments,  and  m 
this  change  the  adjacent  connective  tissue  has  also  a  share.  In  this  way  the 
laminae,  and  the  transverse  and  spinous  processes  that  correspond  to  the  dis- 
eased portion  of  the  spine,  become  matted  together  by  inflammatory  material. 
As  the  change  advances,  the  products  of  the  inflammation  organize,  and  the 
adhesion  between  the  various  parts  concerned  becomes  much  more  intimate  and 

1         jjj^    p  ]^23  ^  C)n  Diseases  of  the  Joints,  p.  267. 

8  Bull,  de  laSoc'.  Anat.,  tome  xxvi.  p.  406.  *  Ibid,  tome  xxviii.  p.  253. 

5  See  cases  by  Triquet  (ibid.,  tome  xxii.  p.  450)  and  DeviUe  (ibid.,  tome  xxvni.  p.  139),  also 
case  by  Shaw  (loc.  cit.,  p.  125).  _ 
•    «  Arch.  Gen.  de  Med.,  tome  vii.  p.  474.  Ifc35.       '  Loc.  cit.,  p.  1^5. 


pott's  disease  of  the  spine. 


529 


strong.  If  at  this  stage  the  specimen  be  macerated,  the  bones  in  the  posterior 
segment  will  be  found  to  present  here  and  there  irregular  bony  outgrowths, 
the  result  of  periostitis,  but  there  will  be  no  direct  or  indirect  bony  union' 
between  any  two  adjacent  vertebrae.  As  the  process  of  repair  advances,  ossi- 
fication occurs  in  the  fibrous  material  that  has  been  formed,  the  periosteal 
new  growths  assume  a  greater  magnitude,  adjacent  vertebrae  become  locked 
together  by  the  contact  of  stalactitic  processes,  and  in  certain  cases  the  posterior 
segments  of  several  of  the  vertebrae  about  the  seat  of  disease  may  be  firmly 
blended  by  a  true  anchylosis. 

This  process  of  repair  in  the  posterior  segments  of  the  column  appears  early 
in  the  course  of  the  malady,  and  is  seldom  absent  in  any  but  the  most  severe 
cases.    Evidences  of  it  may  be  trifling,  but  they  are  usually  to  be  noted. 

The  importance  of  this  process  cannot  be  exaggerated.  By  the  time  that 
the  disease  has  so  far  advanced  in  the  anterior  part  of  the  spine  as  to  destroy, 
perhaps,  several  successive  bodies,  the  process  in  the  posterior  segments  will 
probably  have  brought  about  such  consolidation  of  the  column  as  to  prevent 
that  gross  bending  or  breaking  of  the  weakened  spine  that,  without  such  con- 
solidation, would  be  almost  inevitable. 

With  regard  to  the  reparative  processes  in  the  anterior  portions  of  the 
column,  it  must  be  remembered  that  the  parts  lost  in  Pott's  disease  are  never 
replaced,  and  that  in  no  case — after  either  slight  or  severe  destruction— can  the 
spine  ever  quite  return  to  its  normal  condition.    If  the  gap  formed  by  the  loss 
of  tissue  be  considerable,  the  vertebrse,  in  falling  together  to  produce  the  defor- 
mity, lessen  the  dimensions  of  the  cavity  and  help  to  expel  its  contents. 
Bony  surfaces  above  and  below  the  seat  of  disease  are  thus  brought  too;ether.* 
If  the  process  of  cure  at  once  advances,  the  granulations  that  cover  the  exposed 
bone  develop  into  fibrous  tissue,  and  with  this  material  the  cavity  in  time 
becomes  more  or  less  entirely  filled.    In  certain  instances,  some  portion  of  the 
fibrous  tissue  may  ossify,  and  a  more  or  less  complete  union  of  true  bone 
ensue.  ^  This  true  anchylosis,  however,  is  of  rare  occurrence.    If  an  abscess 
exists,  Its  contents  become  more  or  less  absorbed,  what  was  once  pus  becomes 
putty-like  or  caseous  matter,  the  cyst  shrinks,  its  walls  become  greatly  thick- 
ened and  more  fibrous,  and  by  clinging  close  about  the  seat  of  the  disease 
serve  to  bridge  over  any  gap  that  may  have  formed,  and  to  still  further 
strengthen  the  weakened  part.    In  some  cases  the  absorption  of  the  abscess- 
contents  would  appear  to  be  very  complete ;  and  in  other  instances  the  puru- 
lent matter,  alter  becoming  caseous,  may  finally  undergo  a  calcareous  meta- 
morphosis.  The  portion  of  the  column  that  has  experienced  loss  of  substance 
IS  strengthened  also  by  a  thickening  of  the  periosteum,  and  by  a  develop- 
ment ot  much  fibrous  tissue  in  such  soft  parts  as  are  in  the  immediate 
vicinity.    By  the  blending  of  these  altered  parts  with  the  remnants  of  the 
abscess-wall,  a  very  substantial  support  may  be  afiPorded. 

In  addition  to  these  means  of  immobilizing  the  spine,  the  ^ap  may  be 
bridged  over  by  stalactitic  processes  of  bone  formed  by  the  vertebra  that  im- 
mediately encroach  upon  the  gap.  Sometimes  these  bridges  of  bone  may 
serve  t^  fuse  the  vertebrae  together  by  a  true  osseous  anchylosis,  while  in  other 
cases  they  may  give  support  to  the  part  by  merely  becoming  locked  together. 
Ihese  masses  of  new  bone  are  seen  most  often  about  the  sides  of  the  ver- 
tebral bodies,  and  appear  sometimes  as  if  derived  from  the  anterior  common 
ligament. 

When  the  loss  of  substance  is  limited  to  a  mere  surface-erosion  on  the  bone 
the  deficiency  is  supplied  by  a  fibrous  formation,  although  in  some  very 
rare  cases,  Follin  and  Duplay  assert  that  the  excavation  may  be  covered  in  by 
a  plate  ot  new  bone  formed  from  the  adjacent  sound  bone  and  periosteum.* 

VOL.  IV. — 34  *  Op.  cit.,  tome  iii.  p.  666. 


530  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

Where  the  intervertebral  disks  are  alone  destroyed,^  and  in  some  cases 
where  the  loss  of  bone  is  very  limited,  the  vertebrfB  on  either  side  ot  the  gap 
may  become  fused  together  by  a  true,  central,  bony  anchylosis^^  in  addition, 
posiibly,  to  union  by%ony  processes  at  their  j^nphery.  M.  MicheP  alludes 
[o  a  case  where  the  •fibro-cartilages  between  all  the  lower  cervical  vertebree 
had  been  lost,  and  where  the  bodies  concerned  had  become  welded  together 
bv  firm,  but  irregular,  new  bone.  .... 

If  sequestra  have  formed  they  may  be  ehmmated,  or  if  they  remain  in  situ 
they  will  be  usually  encysted  and  hidden  from  view.  The  tissue  that  incloses 
them  may  be  either  fibrous  or  bony,  although  it  more  usual  y  belongs  to  the 
softer  structure.  Cloquet^  records  a  case  m  which  the  last  two  dorsal  and 
two  upper  lumbar  vertebra  were  necrosed,  apparently  en  masse  but  in  which 
the  entire  sequestra  were  firmly  inclosed  in  a  solid,  fusiform  cyst  of  bone.  By 
this  means  the  solidity  of  the  spine  had  been  mamtained. 

Lastly,  it  must  be  remembered  that  the  longer  the  disease  has  lasted,  the 
less  can  the  vertebral  column  look  to  the  spinal  muscles  for  support.  From 
long  continued  disuse  these  muscles  waste,  and  become  degenerate,  and  by 
their  feebleness  add  an  additional  source  of  weakness  to  the  already  debili- 
tated column. 

Symptoms  of  Pott's  Disease.— The  symptoms  of  Pott's  disease  of  the  spine 
vary  considerably,  both  in  their  comparative  frequency  and  in  their  intense- 
ness  They  vary  also  in  the  order  and  time  of  their  appeara,nce,  and  will 
obviously  be  influenced  by  the  locality  of  the  mischief  m  the  column.  They 
can  be  most  conveniently  considered  under  the  following  distmct  heads  :  (1), 
Rigidity  of  the  spine.  (2)  Local  pain.  (3)  The  spmal  deformity.  (4)  The 
abscess.  (6)  The  cord  and  nerve  symptoms.  (6)  The  gait  and  general  aspect. 
(7)  Some  general  symptoms. 

(1)  RiqidUy  of  the  Spme.-A  rigidity  of  that  part  of  the  vertebral  column 
which  is  the  seat  of  the  disease  is  usually  the  earliest  sign  of  Pott  s  malady,  and 
Ts,  apart  from  this  fact,  a  feature  of  great  importance.    This  rigidity  is,  when 
of  early  occurrence,  due  to  contraction  of  the  muscles  of  the  back,  and  is 
nature's  mode  of  endeavoring  to  keep  the  inflamed  parts  at  rest.  It  is  exact  y 
to  be  compared  to  that  rigidity  of  inflamed  joints  that  is  to  be  especially 
observed  when  disease  commences  in  the  articular  ends  of  the  bones.    At  a 
later  period  of  the  vertebral  disease,  this  symptom  is  also  due  to  the  permanent 
rigidity  of  the  posterior  segments  of  the  spine,  and  to  those  v-anous  conditions 
that  lead  to  a  false  or  true  anchylosis  of  the  diseased  portion  of  the  co  "mn.  In 
advanced  cases,  where  the  muscles  have  become  flaccid  and  atrophied,  this 
latter  condition  is  probably  the  sole  cause  of  the  symptom.    To  fully  appre- 
ciate this  early  evidence  of  spinal  caries,  it  is  well  to  make  one's  self  familiar 
with  the  degree  of  mobility  permitted  in  the  norma  column  m  children  and 
Tdults  of  various  ages.    In  examining  a  young  child,  it  is  most  convenient  to 
have  t  placed  flat  upon  its  face,  and  then,  on  lifting  up  the  lower  limbs  and 
moving  them  (together  with  the  pelvis)  in  various  directions,  with  the  unoc- 
cupied^  and  plated  upon  the  back,  any  rigidity  of  the  column  can  be  soon 
estLated.    In  Pott's  malady,  the  portion  of  the  «P"^e  which  is  the  seat  of 
the  disease,  appears  to  move  in  a  piece,  and  will  permit  of  little  oi  no  bend- 
nj  o  ro  a  ion'^in  any  direction.    In  adults  this  feature  can  be  investigated 
n^the  same  manner,  if  an  assistant  moves  the  lower  lin>bs  and  pelvis,  and 
also  by  making  the  patient  stoop  and  lean  first  to  the  one  side  and  then  to 
the  other!  or  attempt  any  series  of  movements  that  will  test  the  mobility  of 
the  spinal  column. 

.  Loc.  cit.,  p.  478.  '  Ga^-  des  Hop.,  1858,  p.  108. 


pott's  disease  of  the  spine. 


531 


(2)  Local  Pam.— The  symptom  of  pain,  localized  at  the  seat  of  disease,  is  of 
very  uncertain  occurrence,  and  is,  perhaps,  more  often  absent  than  present.  For 
diagnostic  purposes  it  is  of  no  value.  On  this  point,  Mr.  Fisher  well  observes 
that  "  local  pain  in  the  back  is  much  more  frequently  met  v^ith  when  no 
disease  of  the  spine  exists  than  when  the  vertebrae  are  affected. In  many 
cases  no  pain  is  complained  of  in  the  back,  at  the  seat  of  disease,  throughout 
the  whole  course  of  the  ailment,  and  in  other  instances  it  is  scarcely  severe 
enough  to  draw  comment  from  the  patient.  This  local  pain,  when  present,  is 
usually  deep  seated,  dull,  uncertain  in  its  duration,  and  worse  at  nio-ht  and 
on  vigorous  movement.  It  is  often  much  aggravated  by  any  motion  that 
Jars  the  spine,  and  may  be  found  to  be  made  worse  when  the  spine  is  per- 
cussed. Mr.  Howard  Marsh,  speaking  of  this  symptom,  says  that  the  pai n  may 
be  felt  either  at  the  affected  spot  or  below  it,  but  very  rarely  above  it.^  The 
pain,  when  present,  is  usually  most  obvious  at  the  earlier  stages  of  the  disease, 
iuid  ceases  to  be  noticed  when  the  spinal  column  has  become  more  consoli- 
dated. It  was  the  custom  in  less  recent  times  to  attach  much  importance  to 
this  local  pain,  and  its  recognition  was  accomplished  in  doubtful  cases  by 
pressing  a  hot  sponge  along  the  spine.  This  method  of  investigation  has, 
however,  been  long  proved  to  be  useless.  The  pain  to  which  reference  is  now 
made  is  due  to  inflammation  of  the  bones,  and  proceeds,  probably,  directly 
from  those  tissues.  It  must  be  clearly  distinguished  from  the  severe,  parox- 
ysmal, and  often  agonizing  pain  that  sometimes  radiates  from  the  back,  and 
is  due  to  some  nerve-irritation. 

In  some  cases,  where  the  mischief  is  acute,  there  may  be  swelling  and  heat 
about  the  affected  part  of  the  spine.  Such  symptoms,  however,  are  extremely 
uncommon. 

(3)^  The  Spinal  Defonnity.— This  deformity,  the  so-called  "angular  curva- 
ture," is  the  most  conspicuous  symptom  in  Pott's  disease.  The  method  by 
which  it  is  produced  has  been  already  detailed  in  the  paragraph  on  the  path- 
ology of  the  disease.  In  many  cases  it  is  the  first  symptom  noticed ;  and, 
indeed,  in  hospital  practice  it  is  unusual  for  a  patient  to  be  brought  for  treat- 
ment at  a  stage  of  the  disease  antecedent  to  the  occurrence  of  the  deformity. 
The  deformity  makes  itself  evident  at  an  earlier  period  in  some  parts  of  the 
«pine  than  it  does  in  others,  and  the  conspicuousness  of  the  "curvature"  is 
greatly  influenced  by  its  site. 

The  deviation  of  the  column  is  seen  earliest  when  the  dorsal  region  is 
attacked,  the  explanation  being  that  the  dorsal  spine  has  already  a  normal 
curvature  backwards.  The  spinous  processes  also,  in  this  region,  are  of  great 
length,  and  are  soon  rendered'  prominent  by  being  separated"  somewhat  from 
one  another.  In  the  lumbar  region  the  deformity  is  very  slow  to  appear, 
owing  to  the  fact  that  the  normal  curve  in  this  part  of  the  column  is  directly 
forwards;  and,  moreover,  there  must  be  considerable  destruction  of  the 
vertebral  bodies  before  it  can  make  itself  evident.  In  the  cervical  reo-ion  no 
regular  deformity  is  produced.  In  this  region  the  muscles  are  better  able 
to  support  and  balance  the  diseased  segments,  with  the  result  that,  as  the 
destructive  process  advances,  the  head  simply  subsides  vertically  towards  the 
trunk,  and  the  column  becomes  shortened.  In  some  cases— either  from  un- 
equal destruction  of  the  bones,  or  from  unusual  muscular  action— the  cervical 
spine  acquires  a  slight  lateral  deviation  to  one  or  other  side.  In  any  case, 
the  marked  rigidity  of  the  column  is  very  conspicuous.  ' 

It  will  thus  be  seen  that  the  deformity  in  Pott's  disease  will  be  most  con- 
spicuous, and  will  reach  its  greatest  degree  of  development,  when  situate  in 


»  Op.  cit.,  p,  12. 


2  British  Medical  Journal,  vol.  i.  p.  913.  1881. 


532  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

the  dorsal  re^^ion.  It  must  not  be  supposed,  however,  that  an  "  angular 
curvature"  of  necessity  appears  in  all  cases  of  Pott's  disease  below  the  cervi- 
cal reo-ion.  In  some  cases— especially  in  lumbar  disease— no  delormity  ap- 
nears  throughout  the  whole  progress  of  the  malady  ;  but  at  the  same  time 
it  must  be  confessed,  that  the  absence  of  distort  on  m  dorsal  disease  is  very 
unusual.  Bouvier  endeavored  to  construct  a  table  to  show  the  relative  fre- 
quency of  deformity  in  the  various  segments  of  the  spine,  with  the  following 
results : — ' 

Out  of  101  instances  of  Pott's  disease  there  were  _ 

10  cases  of  lower  cervical  disease,    3  with  deformity,  7  with  none. 
55       "  dorsal       "       45  "  10  " 

36       "  lumbar      "       20  "  16  " 

These  statistics  are,  however,  of  but  slight  val^ie,  inasmuch  as  the  duration 
of  the  disease  is  not  given  in  the  various  cases.  And  it  may  not  be  unrea- 
sonable to  suggest  tlmt  in  some  of  the  cases  credited  with  no  deformity,  an 
"  ano-ular  curvature"  may  have  in  time  developed.      ,     ^         ,        .    , , 

The  deformity  itself  consists  in  a  bending  backwards  of  the  column  m  the 
antero-posterior  plane  of  the  body,  and  its  great  feature  is  this:  it  is  angular 
Ind  median.    The  extent  and  prominence  of  the  "  curvature'' will  depend 
not  only  upmi  the  seat  of  the  mischief,  but  upon  the  amount  of  bone  lost  m 
the  anterior  segments.    A  sharp  and  abrupt  angle  will  usually  indicate  a 
severe  but  limfted  loss  of  bony  tissue,  while  a  more  extensive  and  more 
rounded  deformity  will  probably  indicate  a  slight  degree  of  destruction  of 
mai^  vertebra..    In  some  cases  the  bending  of  the  column  may  be  so  severe 
that  the  two  parts  of  the  spine  form  a  right  angle  with  one  another,  oi  the 
anterioi  surface  of  the  vertebra  above  the  excavation  may  rest  on  the  upper 
s  rface  of  the  vertebra  below  it.    When  the  disease  is  of  long  standing,  the 
Zminence  of  the  deformity  may  be  increased  by  the  wasting  that  occurs  in 
?he  muscles  of  the  back.    In  certain  cases  there  may  be  some  slight  latera 
deviation  of  the  spine  in  addition  to  the  antero-posterior  displacement  This 
S  on  would  Appear  to  be  met  with  only  in  the  lumbar  and  dorso-lumbar 
?eS  s!  a°d  is  due  either  to  unequal  destruction  ot  the  vertebm,  or  to  un- 
3  muscular  action.    In  all  cases  compensatory  curves  are  formed  both 
above  a"d  below  the  seat  of  the  deformity.  It  is  only  by  means  of  such  coni- 
Ttensation  that  the  patient  can  retain  the  erect  posture.    These  curves  aie 
E  St  s  en  when  the'disease  is  situate  in  the  dorsal . spine  -dj;!!  obviously 
vary  in  degree  according  to  the  extent  of  the  original  detormity.  Income 
cases  of  Pott's  malady  involving  the  lumbar  region,  where  the  destruction  oi 
?he  bodies  has  been  sudden  and  severe,  no  compensation  is  possible :  the  erect 
Sturf  cannot  be  maintained,  the  column  falls  forwards,  and  the  patient  can 
onlv  nroa-ress  when  upon  his  hands  and  feet,  or  knees.  ,  „„ 

?n   eS  all  instances  the  deformity  develops  slowly,  but  cases  have  been 
recorded  in  which  the  "angular  curvature"  appeared  with  comparative  sud- 
denness   In  such  cases-of  Which  Michel  gives  examples-the  deformitj^ha. 
nsuallv  aBpeared  during  some  unwonted  or  forced  movement,  a,nd  has  been 
Te  o  a  gFvTng  wav  oflome  of  the  supports  furnished  to  the  diseased  parts 
Jr  to  frXre  ff  the  posterior  segments  of  the  column  at  ^^e  seat^ 
I)elr,ech  Nekton,  and  Louis  all  record  instances  where  this  sudden  toimation 
o^^^tC "curve''  has  been  associated  with  sudden  paraplegia.    The  rapidity 
itl  whieh  the  deformity  develops  depends  to  some  extent  ,"Pon  the  pat-^^^^^ 
movements  and  upon  the  non-observance  of  rest.    Shaw,^  howevei,  lecoios 
a  else  Xre  no  increase  of  the  spinal  deviation  occurred  during  a  period  of 
fourteen  yeai",  ahhough  the  patiLit  was  engaged  all  the  while  in  the  work 

■  Quoted  by  Michel,  loc.  cit.  '  Loc.  cit.,  page  114. 


pott's  disease  of  the  spine. 


533 


of  a  blacksmith.  At  the  end  of  the  period  mentioned,  an  abscess  appeared. 
Like  examples  have  been  put  on  record  by  others.  It  is  important  also  to 
note  that  the  deformity  may  commence  and  may  increase  while  the  hori- 
zontal position  is  being  observed.  Such  cases  show  that  the  weight  of  the 
column  above  the  seat  of  disease  is  by  no  means  the  only  factor  in  producing 
the  angular  deviation,  but  that  the  abdominal  muscles  may  also  be  active 
agents. in  that  direction. 

(4)  The  Abscess. — The  chief  points  in  connection  with  this  symptom  have 
already  been  dealt  with  in  considering  the  pathology  of  the  disease  ;  and  some 
further  tacts  will  be  noted  in  dealing  with  the  matter  of  diagnosis.  So 
variable  is  the  evolution  of  the  symptoms  of  Pott's  disease,  that  the  spinal  ab- 
scess may  be  the  very  first  evidence  of  the  malady,  and,  on  the  other  hand, 
this  affection  may  run  its  entire  course,  and  end  in  anchylosis  and  cure,  with- 
out any  trace  of  abscess  having  been  observed. 

The  absence  of  abscess  is,  however,  quite  the  exception.  As  to  the  period 
of  the  disease  at  which  this  symptom  should  become  evident,  nothing  posi- 
tive can  be  said.  It  may  appear  before  any  deformity  is  obvious  ;  it  may  be 
the  very  earliest  symptom ;  it  may  not  appear  until  the  disease  has  existed 
for  many  years.  Many  cases  are  recorded  where  the  abscess  did  not  appear 
for  ten,  fifteen,  twenty,  or  more  years  after  the  commencement  of  the  disease, 
the  patient  having  in  the  mean  time  apparently  made  a  perfect  recovery. 
It  is  probable  that  all  such  cases  are  examples  of  what  Sir  James  Paget^  has 
called  "residual  abscess,"  that  is* to  say,  an  abscess  taking  its  origin  from  the 
residues  or  relicts  of  past  suppuration.  The  patient  has  caries  of  certain 
vertebrae,  and  an  abscess  is  formed  at  the  seat  of  disease,  but  does  not  tend 
to  reach  the  surface  of  the  body.  In  time  a  process  of  cure  takes  place,  the 
wall  of  the  abscess  shrinks,  its  contents  become  more  or  less  absorbed,  and 
.  perhaps  no  trace  is  left  but  some  small  collection  of  caseous  matter.  As  long 
as  the  patient's  health  remains  good,  and  as  long  as  no  injury  or  unusual 
circumstance  tends  to  irritate  the  part,  so  long  does  this  residuum  of  a  past 
inflammation  remain  inert.  But  when  these  untoward  conditions  are  pro- 
vided, the  ill-disposed  material  acts  as  an  injurious  foreign  body,  and  an  ab- 
scess that  perhaps  reaches  the  surface  is  the  result. 

As  to  the  influence  of  local  and  general  conditions  upon  the  formation  of 
the  abscess,  something  a  little  more  definite  can  be  said.  As  may  be  surmised, 
the  more  acute  and  rapid  is  the  spinal  mischief,  the  more  certain  and  the  earlier 
IS  an  abscess  likely  to  appear.  Moreover,  a  general  condition  of  ill-health  is 
apt  to  affect  the  formation  of  the  abscess  in  a  like  injurious  manner.  The 
same  may  be  said  of  neglect  of  treatment,  of  persistence  in  movement  and 
exercise,  and  of  direct  injury  to  the  diseased  parts.  In  opposition  to  these 
general  statements,  however,  numerous  exceptions  have  been  recorded.  Mr. 
Fisher  mentions  the  case  of  a  gentleman  who  had  presented  a  projection  of 
the  spine  for  more  than  two  years,  no  abscess  appearing  until  the  end  of 
that  period,  although  the  patient  had  during  the  whole  time  indulged  in  the 
usual  athletic  pursuits  of  young  men.  Then  again,  an  abscess  may  be  asso- 
ciated with  a  form  of  Pott's  disease  that  has  assumed  a  very  chronic  course, 
has  given  little  or  no  trouble,  and  has  led  to  but  trifling  deformity.  On  the 
other  hand,  instances  are  recorded  of  an  absence  of  external  abscess,  though 
the^disease  is  accompanied  with  severe  deformity  and  paraplegia. 

The  general  features  of  the  abscesses  that  accompany  Pott's  maladv  are 
identical  with  those  of  cold  abscess  in  general,  and  require  no  especial  descrip- 
tion.   Lannelongue^  has  shown  that  the  surface-temperature  over  these  col- 


^  Clinical  Lectures  and  Essays.    London,  1877. 


Loo.  cit.,  page  171. 


534  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

lections  is  hmhev  than  that  of  the  corresponding  surface  on  the  other  side  of 
the  body.  He  quotes  the  case  of  a  child,  aged  7i  years  with  a  lumbar  de- 
formity and  a  large  psoas  abscess  at  the  upper  part  of  the  lelt  thigh.  This 
abscess  showed  an  absolute  absence  of  any  of  the  common  signs  ot  inflamma. 
tion  and  was  indeed  a  typical  cold  abscess,  yet  the  temperature  noted  was  as 


On  one  occasion.  On  another  occasion, 

o  r,  /  OQO 


follows :  

„  •       -11  H7°  G  (9d°.7  F.)       37°. 5  (99°. 3  F.) 

Temperature  in  axilla,  .  .  •  ;  iiol)llo  A\  <ifi°5)97°7F) 
Surface  temperature  of  thigh  on  healthy  side,  37°.0  98  .6  F.  36  .5  J7  ./  t.) 
Surface  temperature  of  thigh  over  abscess,       37°.2  (99°.0  J .)       37  .1  (98  .8  1- .) 

Lannelongue  has  also  shown  that  this  feature  in  the  temperature  applies  to 
all  cold  abscesses. 

(5^  The  St/mptoms  depending  upon  Implication  of  the  Spinal  Cord  and  Spinal 
jV«-m.-Considering,  on  the  one  hand,  the  position  of  the  spina  C'ord  and 
nerves,  and,  on  the  other,  the  great  deformity  in  the  column  and  the  great 
destruction  of  parts  often  produced  by  Pott's  disease,  it  is  no  matter  of  wonder 
that  these  delicate  nerve-structures  sometimes  sufter  injury.    They  aw,  how- 
ever, by  no  means  constantly  involved     The  frequent  imm™ity  of  the  cord 
in  Pott's  malady  is,  to  some  extent,  to  be  explained  by  the  fact  that  the  coid 
occupies  the  posterior  portion  of  the  vertebral  column,  a  part  not  only  as  a 
rule  exempt  from  destructive  disease,  but  the  seat  actually  of  extensive  repa- 
rative chano'es.   It  also  must  be  borne  in  mind  that  the  changes  in  the  column 
are  of  such  a  nature  as  to  cause  the  inflammatory  products  to  take  a  lorward 
direction,  while  the  development  of  the  deformity  is  usually  so  slow  that  the 
cord  has  time,  as  it  were,  to  accommodate  itself  to  the  change.    And  it  is 
marvellous  to  what  changes  the  cord  will  accommodate  itself,  if  only  the 
morbid  influences  around  it  are  slow  in  their  action.    In  any  case  ot  Pott  s 
disease  with  severe  deformity,  the  cord  must  not  only  be  abruptly  bent,  and 
compelled,  possibly,  to  occupy  a  much  more  limited  space  than  in  the  normal 
condition,  but  it  would  appear  that  m  some  mstances  it  must  be  actually 
shortened.    Still,  it  is  common  to  have  examples  of  severe  spinal  deformity 
without  nervous  symptoms  of  any  kind.  \    i.    a  ^  n  a 

Roudily  speaking,  the  symptoms  that  are  now  to  be  detailed  may  be 
ascribe!  either  to  irritation  of  the  spinal  cord  and  nerves,  or  to  such  an  injury 
to  those  parts  as  may  cause  temporary  or  permanent  interruption  of  their 
functions  Thus,  there  may  be,  on  the  one  hand,  severe  pain  or  hyperBesthesia^ 
and  on  the  other  loss  of  sensation.  And  as  regards  the  motor_  tracts,  there 
may  be  muscular  spasms  and  increased  I'eflex  action  in  one  mstance,  and 
absolute  paralysis  of  certain  parts  in  another.     .  ,  ^  , 

The  post-mortem  examination  of  patients  with  Pott's  disease,  who  have 
exhibited  nerve-symptoms  during  life,  will  give  very  various  results,  in 
some  eases,  the  meninges  of  the  cord  will  be  found  much  thickened  at  the  seat 
of^isease  or,  in  other  instances,  a  considerable  inflammatory  exudation  will 
exist  between  those  membranes  and  the  spinal  wall  and  intimate  adhesions 
may  be  found  between  those  parts.    As  regards  the  cord  itself,  it  may  be 
congested,  or  inflamed,  or  the  seat  of  a  definite  sclerosis.  _  In  many  c.ises^it 
wilf  show  some  limited  softening,  that,  while  of  very  varying  extent,  will  be 
found  most  usually  to  involve  the  motor  regions  of  the  cord.  Injurious 
pressure  will  be  found  in  most  instances  to  be  the  cause  of  these  conditions 
ind  especially  of  the  condition  of  softening  m  the  medulla  spinalis.  Ihe 
pressure  ma/be  effected  by  the  abrupt  bonding  ot  the  spme,     be  caused  by 
detached  vertebrse,  or  displaced  fragments  ot  bone;  or  it  may  be  due  to  the 
bulffing  of  inflammatory  products  toward  the  spinal  canal,  or  to  the  undue 
prominence  in  the  same  direction  of  new  bone  formations.    As  regards  the 


pott's  disease  of  the  spine. 


535 


spinal  nerves,  they  are  liable  to  become  inflamed  on  account  of  their  proximity 
to  the  seat  of  disease.  They  are  liable  to  irritation  from  the  near  presence  of 
fragments  of  bone,  or  displaced  portions  of  the  column.  They  are  susceptible, 
also,  to  varying  degrees  of  injury  from  pressure.  When  many  vertebrie  are 
lost,  the  corresponding  intervertebral  foramina  are  usually  more  or  less  in- 
volved, and  in  such  instances  Michel  observes  that  it  is  common  for. many 
successive  spinal  nerves  to  issue  from  one  huge  and  irregular  intervertebral 
foramen  produced  by  the  disease. 

It  is  extremely  difficult  to  say  in  vs^hat  cases  cord  and  nerve  symptoms  are 
to  be  expected,  and  in  what  cases  they  are  not  apt  to  occur.  They  may 
appear  early  in  quite  slight  cases,  or  they  may  be  entirely  absent  in  the  most 
severe  examples  of  the  disease. 

As  to  the  relation  between  .the  cord-symptoms  and  the  local  condition  in  the 
vertebral  column,  these  few  points  can  alone  be  mentioned :  Cord-symptoms  are 
more  apt  to  occur  in  cases  where  the  disease  progresses  rapidly,  and  the  de- 
formity is  sooner  produced  than  in  cases  where  the  opposite  conditions  obtain. 
Cord-symptoms  are  more  apt  to  occur  in  cases  associated  with  deformity  than 
in  those  unattended  with  deviation  of  the  column.  According  to  Bouvier's 
statistics  on  this  point,  out  of  64  cases  of  Pott's  disease  with  deformity,  par- 
alysis occurred  in  33  instances ;  whereas  only  8  examples  of  paralysis  were 
met  with  in  32  cases  of  the  disease  unassociated  with  deformity.  Allowing 
for  many  exceptions,  cord-symptoms  are  more  apt  to  occur  in  severe  forms  of 
the  disease,  in  cases  associated  with  much  muscular  weakness,  in  cases  where 
undue  movement  has  been  allowed  or  no  treatment  adopted,  and  in  cases 
where  accident  has  suddenly  added  to  the  extent  of  the  deformity. 

The  various  symptoms  may  most  conveniently  be  considered  under  two 
heads — first,  disturbances  of  sensation,  and  secondly,  disturbances  of  the 
motor  system. 

Disturbances  of  Sensation. — Pain  transmitted  along  a  certain  nerve  or  nerves 
is  very  often  the  first  symptom  of  disturbance  of  the  great  nerve-structures. 
This  pain  is  probably  due  to  irritation  of  some  of  the  spinal  nerves  as  they 
issue  from  the  intervertebral  foramina,  although  it  may  in  some  cases  be  due 
to  a  disturbance  in  the  medulla  spinalis  itself.  The  seat  of  the  pain  varies — • 
as  Mr.  Howard  Marsh  has  well  pointed  out — with  the  locality  of  the  bone- 
mischief.  In  caries  of  the  lower  cervical  region,  the  pain  is  apt  to  radiate 
over  the  shoulders  and  down  the  arms,  or  over  the  upper  part  of  the  front  of 
the  chest.  In  dorsal  disease,  the  pain  follows  the  intercostal  nerves,  and  may 
be  felt  at  the  sides,  or  in  front  of  the  trunk,  about  the  middle  line.  When  the 
malady  attacks  the  lumbar  spine,  the  pain  tends  to  radiate  about  the  loins 
and  pelvis,  or  to  run  down  the  limbs  and  to  extend  even  to  the  feet.^  The 
characters  of  this  pain  are  tolerably  distinctive.  It  is  sometimes  severe,  usu- 
ally sharp  and  paroxysmal,  rather  than  continuous.  It  is  indeed  a  neuralgic 
pain. 

It  is  often  limited  to  one  side  of  the  body,  or  even  to  one  nerve.  For  ex- 
ample, in  cases  of  dorsal  disease,  intercostal  neuralgia  of  a  single  space  is  by 
no  means  uncommon.  The  pain  may  be  associated  with  hyperaesthesia  of  the 
part  supplied  by  the  afi:ected  nerve,  or  of  a  part  supplied  by  some  adjacent  trunk. 
But  such  a  complication  is  not  common.  The  pain  is  very  usually  made 
worse  by  exercise  and  violent  movement,  and  a  sudden  jarring  of  the  column 
niay  render  it,  for  the  moment,  almost  agonizing ;  on  the  other  hand,  the  pa- 
tient is  easier  when  in  the  recumbent  posture,  and  often  the  painful  sensation 
will  entirely  disappear  when  a  little  extension  is  applied  to  the  column. 

1  The  Diagnosis  of  Caries  of  the  Spine  in  the  Stage  preceding  Angular  Curvature.  British 
Medical  Journal,  vol.  i.  page  913.  1881. 


5»36  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

This  "  nerve-pain"  is  very  different  from  the  dull,  deep-seated,  and  well- 
localized  pain  already  spoken  of  in  a  previous  paragraph.  The  latter  is  a 
"bone-pain,"  is  worse  at  night,  is  perhaps  modified  by  the  weather,  and,  if 
increased  on  movement,  is  increased  to  no  severe  extent.  The  one  depends 
upon  the  irritation  of  a  nerve-trunk,  the  other  upon  actual  disease  in  the  bone, 
aua-mented  by  the  mutual  pressure  of  the  parts.  ^ 

In  some  instances,  the  patient  may  complain  of  a  painful  sensation  about 
the  bodv,  as  of  a  cord  tied  around  it,  about  the  level  of  the  epigastrium  or 
umbilicus.  This  sensation  may  be  an  extremely  painful  one,  and  may, 
according  to  some  French  authors,  be  very  like  the  pam  of  a  linear  burn. 
The  symptom,  although  common  in  many  affections  of  the  cord,  is  certainly 
extremelv  rare  in  Pott's  disease,  as  Mr.  Marsh  has  recently  pointed  out.  The 
same  writer  has  also  drawn  attention  to  the  fact  that  the  pain  when  located 
about  the  abdomen,  may  be  readily  the  cause  of  a  faulty  diagnosis.  He 
records  the  case  of  a  child,  a2:ed  five,  who  suffered  from  a  pam  m  the  stomach 
supposed  to  be  due  to  indige^stion,  for  which,  indeed,  she  was  treated  for  some 
weeks.  The  pain  was  in  reality  due  to  disease  in  the  mid-dorsal  vertebrae, 
and  could  have  been  distinguished  from  the  pain  of  indigestion  by  the  fact 
that  it  was  not  worse  after  meals,  that  it  was  increased  by  vigorous  move- 
ment,  and  relieved  by  recumbency.  The  ''lightning"  pains  that  are  so  coni- 
mon  in  certain  diseases  of  the  cord  are  not  met  with  m  Pott  s  malady,  although 
tingling  sensations  may  be  felt  in  parts,  or  a  discomfort  described  as  "  prick- 

Lasth^^^  there  may  be  a  loss  of  sensation  in  parts  below  the  seat  of  the  ver- 
tebral disease.  This  anaesthesia  is  quite  uncommon,  and  never  occurs  alone, 
but  when  present  is  always  associated  with  loss  of  motion,  which,  in  nearly 
every  instance,  will  be  found  to  have  preceded  it,  and  to  be  of  a  more  exten- 
sive character.  It  is  rare  for  the  loss  of  sensation  to  be  absolute.  L  sually 
there  is  only  a  sense  of  numbness,  or  an  anaesthesia  of  a  comparatively  limited 
district.  The  instances  of  complete  loss  of  all  sensation  below  the  seat  of 
disease  are  very  few,  and  have  in  all  examples  been  associated  with  absolute 

^^^^Iturbances  of  the  Motor  Nervous  Sijstem.— These  disturbances  may  be 
classed  under  two  heads :  (a)  Those  marked  by  nerve-irritation,  convulsions, 
spasms,  etc. ;  (b)  those  marked  by  loss  of  nerve-function,  or  palsies. 

(a)  These  disturbances  may  assume  a  variety  of  aspects.  In  the  least 
marked  instances,  there  may  be  simply  undue  reflex  irritability.  In  such 
cases  on  touching  or  gently  tickling  the  sole  of  the  foot,  the  limb  is  violently 
drawn  up,  or  movements  may  be  induced  in  it  by  equally  trifling  irritation. 
In  other  cases  this  morbid  condition  of  the  nerve-centre  may  express  itself  in 
an  involuntary  jactitation  of  the  limbs,  that  may  be  brought  about  by  very 
slight  peripheral  disturbances. 

In  severe  grades  of  this  condition,  the  limbs  below  the  seat  of  the  vertebral 
disease  may  exhibit  spasmodic  or  convulsive  movements.  These  spasms  may 
sometimes  be  very  violent,  and  associated  with  considerable  pam.  They  may 
occur  spontaneously,  but  can  be  induced  or  rendered  more  vigorous  by  imtat- 
ino-  the  periphery,  as  by  tickling  the  feet  or  pinching  the  skm,  etc.  J.hese 
symptoms  are  practically  limited  to  the  muscles  of  the  lower  limbs,  and  to 
the  abdominal  and  sacro-lumbar  muscles.  Only  one  limb  may  be  affected,  or 
only  one  muscle  or  set  of  muscles  in  that  limb,  and  when  both  sides  of  the 
body  exhibit  these  spasmodic  attacks,  the  symptoms  are  usually  more  marked 
on  one  side  than  on  the  other. 

In  other  instances  the  spasm  may  be  continuous,  and  the  legs  may  remain 
rigidly  drawn  up.  This  form  of  contraction  may  be  associated  with  much 
pain  may  be  of  limited  or  unequal  extent,  and  may  alternate  or  be  associated 


pott's  disease  of  the  spine. 


537 


with  the  intermittent  or  clonic  spasm  just  referred  to.  The  condition  is 
generally  known  as  "  spastic  contraction,"  and  is  perhaps  somewhat  more  fre- 
quent than  is  the  condition  marked  by  interrupted  spasm.  So  rigid  may  the 
patient's  body  become  in  some  cases  where  the  muscles  of  the  lower  limb  and 
back  are  the  seat  of  continuous  muscular  contraction,  that,  according  to  Shaw, 
he  may  be  turned  over  in  bed  like  a  log. 

Among  the  peculiar  phases  of  motor-nerve  disturbance  in  Pott's  disease 
ma}^  be  mentioned  torticollis,  observed  in  some  cases  of  caries  of  the  cervical 
spine,  and  also  a  severe  and  intermittent  form  of  dyspnoea,  occasionally  met 
with  in  caries  of  the  same  situation,  and  due,  according  to  Michel,  to  irrita- 
tion, or  perhaps  paralysis,  of  the  phrenic  nerve. 

(b)  Palsies. — The  usual  form  of  motor  paralysis  observed  in  angular  de- 
formity is  paraplegia.  This  may  be  complete,  and  equally  marked  in  the  two 
lower  limbs.  It  usually  develops  slowly,  although  cases  are  recorded  of  sudden 
paraplegia  in  connection  with  the  sudden  appearance  of  the  spinal  deformity. 
The  loss  of  motor  power  may  be  more  marked  in  one  extremity  than  in 
another,  or  may  be  limited,  more  or  less,  to  one  particular  set  of  muscles.  In 
other  instances  there  may  be  mere  feebleness  in  the  part,  which  feebleness 
may,  like  the  more  complete  losses  of  power,  be  of  limited  or  unequal  extent. 
It  is  probable  that  many  of  the  cases  of  marked  paralysis  of  a  limited  set  of 
muscles  are  due  to  pressure  upon  the  spinal  nerves  rather  than  to  an  injury 
to  the  cord  itself.  With  reference  to  the  previous  symptoms,  the  order  adopted 
in  their  development  is  usually  as  follows :  First,  involuntary  jactitation  of 
the  limbs,  then  constant  muscular  spasm,  and,  lastly,  paralysis.  Often,  how- 
ever, the  loss  of  power  is  preceded  by  no  evidences  of  spasm.  The  paraplegia 
in  Pott's  malady  has  certain  peculiarities.  It  is  very  usually  unassociated  with 
any  loss  of  sensation,  or  allied  with  but  trifling  disturbances  of  that  function. 
It  is,  moreover,  very  seldom  accompanied  by  loss  of  control  over  the  bladder 
or  rectum,  and  w^hen  such  a  complication  is  present,  it  is  usually  but  slightly 
marked,  and  often  preceded  by  a  painful  tenesmus.  In  incomplete  palsies 
the  muscular  sense  remains  unimpaired.  On  account  of  the  comparative 
rarity  of  defects  in  sensation,  bed-sores  are  as  unusual  in  Pott's  disease  as 
they  are  common  in  other  forms  of  paraplegia.  Lastly,  this  form  of  loss  of 
power  may  be  entirely  recovered  from,  as  will  be  mentioned  when  the  matter 
of  prognosis  is  discussed.  The  reaction  of  the  paralyzed  muscles  to  electricity 
remains  normal,  unless  the  condition  is  of  such  long  standing  that  the  muscular 
tissue  has  become  disorganized. 

The  convulsive  movements  already  referred  to  may  sometimes  be  observed 
in  the  paralyzed  limbs,  and  when  present  constitute  a  very  distinctive  feature. 
They  can  only  occur  in  cases  that  are  comparatively  recent,  and  will  obviously 
not  be  possible  when  the  muscular  structure  has  become  much  changed  from 
prolonged  disease. 

(6)  Tlie  Gait  and  General  Aspect. — In  marked  cases  of  the  disease,  the 
patient  in  walking  keeps  the  spine  peculiarly  rigid.  He  walks  with  his  legs 
only,  often  shuffling  the  feet  along,  and  swaying  the  body  to  and  fro.  His 
movements,  therefore,  are  stiff  and  ungraceful.  When  asked  to  pick  up  an 
object  from  the  ground,  instead  of  bending  the  back,  he  bends  the  lower 
limbs,  and  approaches  the  object  sideways,  as  it  were.  This  attitude  is  well 
shown  in  drawings  in  Prof.  Agnew's  article  on  Surgical  Diagnosis.^ 

In  cases  where  the  deformity  is  marked,  the  patient  stands  with  the  head 
thrown  back,  and  often  supports  himself  by  resting  his  hands  upon  the 
thighs.    If  one  side  of  the  column  be  more  afl:ected  than  the  other,  the 


»  See  Vol.  I.,  page  348,  Figs.  21  and  22. 


538 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


patient  is  disposed  to  lean  the  body  towards  the  less  affected  side.  When  in 
the  recumbent  posture,  the  patient  prefers  to  lie  upon  his  side,  and  when 
movino;  from  that  position  to  the  sitting  posture,  he  effects  the  movement  by 
turning  over  on  to  his  belly,  and  then  raises  himself  by  his  hands  and  knees. 
As  a  consequence  of  the  angular  deviation  of  the  column,  the  whole  trunk 
appears  shortened  and  out  of  proportion  to  the  extremities.  The  antero- 
posterior diameter  is  increased,  and  the  sternum  protrudes.  In  severe  disease 
of  the  dorsal  spine  this  protrusion  of  the  sternum  may  be  considerable.  The 
ribs  are  often  rendered  more  or  less  rigid,  not  only  by  the  constrained  posi- 
tion induced  by  the  spinal  and  thoracic  deformity,  but  often  also  by  destruction 
or  anchylosis  of  the  costo-vertebral  joints.  Lastly,  the  shoulders  appear  to 
be  raised,  and  the  head  and  neck  to  be  more  or  less  sunken  towards  the 
thorax.  One  feature  that  has  been  particularly  alluded  to  by  Sayre,  is  the 
short,  "  grunting"  respiration  often  observed  in  cases  of  dorsal  disease  with 
much  deformity  both  of  chest  and  spine.  Dr.  Sayre  asserts  that  this  symp- 
tom is  often  immediately  relieved  when  the  patient  is  suspended. 

(7)  General  Symptoms.— Oi  the  general  symptoms  that  may  accompany 
Pott's  disease,  little  need  be  said.  The  patient  may  or  may  not  present  evi- 
dence of  struma,  or  be  afflicted  with  any  concomitant  scrofulous  disease. 
Seldom  will  the  subject  of  the  malady  present  the  appearance  of  actual  good 
health.  When  external  discharge  of  matter  is  accomplished,  there  will  pro- 
bably be  a  rise  of  temperature,  some  wasting,  and  increasing  debility,  with 
all  the  familiar  symptoms  of  hectic  fever.  If  the  suppuration  be  of  long 
standing,  svmptoms  may  arise  that  point  to  amyloid  or  fatty  degeneration  of 
the  visceral!  At  any  time  there  may  be  certain  visceral  complications  of  a 
less  chronic  character,  more  or  less  directly  connected  with  the  seat  of  the 
disease.  With  regard,  indeed,  to  any  general  symptoms  that  have  not  been 
mentioned,  they  may  be  said  to  be  such  only  as  are  incidental  to  all  condi- 
tions of  feeble  health,  and  to  all  states  of  extensive  and  continued  suppuration. 

Diagnosis  of  Pott's  Disease. — The  main  points  upon  which  the  diagnosis 
of  Pott's  disease  is  to  be  based,  have  been  exposed  in  the  preceding  pages. 
It  remains,  however,  to  discuss  the  differential  diagnosis,  and  to  set  forth  the 
means  whereby  this  malady  may  be  distinguished  from  such  diseases  as,  in 
certain  features,  may  have  resemblance  to  it.  The  matter  can  be  best  con- 
sidered under  the  three  heads:  The  spinal  deformity;  the  cord  and  nerve 
symptoms ;  the  abscess.  .  . 

(1)  The  Spinal  Deformity.— The  great  features  of  the  spinal  deviation  m 
Pott's  disease  are  its  angularity,  its  median  position,  and  its  general  rigidity. 

In  cyphosis  there  is  a  bending  backwards  of  the  spine,  but  in  this  condition 
the  deformity  assumes  the  outline  of  a  curve  that  usually  involves  in  an 
equal  degree  a  large  portion  of  the  column.  There  is  in  the  first  instance 
no  rigidity,  and,  except  in  cases  of  spondylitis  deformans,  at  no  time  abso- 
lute or  complete  rigidity. 

Cases  of  Pott's  disease,  where  a  deformity  exists  associated  with  some 
lateral  deviation  of  the  column,  but,  at  the  same  time,  with  an^  absence  of 
any  more  familiar  evidences  of  the  malady,  may  possibly  be  mistaken  for 
lateral  curvature.  Shaw  gives  an  instance  in  illustration  of  this.  He  says 
that  he  "was  consulted  about  a  girl,  aged  fifteen,  who  had  a  projection  at  the 
dorso-lumbar  region,  with  a  distinctly  marked  deviation  of  the  spme  to  one 
side,  simulating  closely  lateral  curvature.  The  medical  attendant  had  consid- 
ered the  case  to  be  of  that  kind,  and  had  put  the  patient  on  a  course  of  calis- 
thenic  exercises.  It  was  distinctly  ascertained,  however,  that  the  prominence 
was  the  eftect  of  caries ;  and  the  principal  diagnostic  sign  was  the  directness 


pott's  disease  of  the  spine. 


539 


with  which  the  spinous  processes  stood  out  backwardly  against  the  skin ;  for 
it  is  a  never-failing  observation  in  regard  to  lateral  distortion,  that,  owing  to 
the  rotation  of  the  column  on  its  long  axis,  which  always  accompanies  incur- 
vation, the  spinous  processes  are  pointed  laterally,  towards  the  concavity  ; 
and  that  to  such  a  degree  that  they  are  nearly  hidden  from  view  by  the  over- 
lapping of  the  edge  of  the  longissimus  dorsi."^ 

Aneurisms  of  the  abdominal  and  thoracic  aorta  may  cause  such  an  erosion  of 
the  spine  as  to  lead  to  the  angular  deformity  of  Pott's  disease.  If  the  de- 
struction of  bone  be  still  more  extensive,  nerve-symptoms  are  produced  from 
pressure,  that  may  have  the  characters  of  those  met  with  in  caries,  and  that 
may  go  on  even  to  paraplegia.^  In  such  cases  the  distinctive  symptoms  of 
aneurism  would  be  present,  and  the  diagnosis  patent.  At  the  same  time,  it 
must  be  noted  that  these  aneurisms  occur  usually  at  a  time  of  life  when 
spinal  caries  is  very  rarely  met  with. 

Michel  refers  to  a  case  recorded  by  Mazet,  where  during  life  there  was  an 
"  angular  curvature"  of  the  column,  and  near  it  a  large  fluctuating  tumor 
like  a  chronic  abscess.  It,  however,  proved  to  be  a  hydatid  cyst  growing  from 
the  vertebral  canal. 

(2)  The  Cord  and  Nerve  Symptoms. — In  cases  where  the  characteristic  de- 
formity exists,  there  can  be  no  difiiculty  in  diagnosing  these  symptoms ;  or 
in  any  case  at  least  where  such  symptoms  coexisted  with  "  angular  curve," 
it  would  be  safe  to  ascribe  the  former  to  the  same  disease  that  had  caused 
the  latter. 

The  most  difficult  cases  of  Pott's  malady  to  recognize  are  those  associated 
with  no  deformity.  In  some  such  cases,  a  psoas  or  lumbar  abscess  may 
exist  and  assist  the  diagnosis,  but  when  that  symptom  is  absent,  an  opinion 
has  to  be  based  to  a  great  extent  upon  such  nervous  disturbances  as  may  be 
present.  In  these  cases,  without  deformity,  the  spine  will  be  found  to  be  more 
or  less  rigid  in  one  part;  there  may  be  local  pain,  increased  on  exercise  and 
relieved  by  extension;  and  there  may  be  some  peculiarity  in  the  patient's  gait 
and  movements.  If  any  symptoms  of  nerve  or  cord  disturbance  exist,  they 
may  be  of  great  value,  and  it  is  now  necessary  to  point  out  with  what  other 
conditions  those  symptoms  may  be  confused.  In  "  hysteria  of  the  spine^''  the 
patient  may  complain  of  severe  pain  about  some  part  of  the  column,  of  inability 
to  move  the  back  or  to  maintain  the  erect  posture  without  great  suftering, 
and  possibly  of  radiating  pains  along  certain  nerves,  such  as  the  intercostal. 
The  pain  may  be  localized  about  the  vertebra  prominens,  and  the  normal 
projection  of  this  vertebra  may  lay  the  foundation  for  the  assertion  that  the 
spine  is  growing  out."  If  the  patient  has  taken  to  her  bed — as  is  not  in- 
frequently the  case — under  the  impression  that  she  has  severe  spinal  mischief, 
the  spinous  processes  of  many  vertebrae  may  in  time  appear  unduly  promi- 
nent, from  atrophy  of  the  muscles  from  disuse.  If  the  case  be  associated 
with  "  hysterical  paraplegia,"  a  fresh  complication  is  introduced.  In  these 
examples  of  simulated  disease,  however,  there  will  generally  be  distinct  evi- 
dences of  hysteria,  an  absence  of  any  real  angular  deformity,  and  no  rigidity 
of  the  affected  part.  The  pain,  moreover,  will  be  of  that  limited  and  ago- 
nizing character  common  in  hysterical  neuralgia.  Lastly,  when  the  spine  is 
being  examined,  the  patient  will  probably  wince  and  jerk  the  back  away  every 
time  that  the  column  is  touched,  a  manoeuvre  that  would  certainly  not  be 
executed  if  the  tenderness  depended  upon  caries. 

In  cases  of  muscular  rheumatism  of  the  back,  there  may  be  much  local  pain 
and  a  good  deal  of  rigidity  of  the  part.    Such  cases,  however,  may  be  distin- 

1  Loc.  cit.,  page  111. 

2  Quincke,  Diseases  of  Arteries  ;  Ziemssen's  Cyclopaedia  of  Medicine,  vol.  vi.  p.  434. 


540 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


guished  from  those  of  Pott's  disease  by  the  following  features.  The  rheumatic 
pain  is  diffused,  and  follows  no  particular  nerve  ;  the  pain  is  increased  rather 
than  relieved  by  extension;  the  parts  are  tender  often  over  a  wide  area;  and 
the  disease  is  more  common  at  an  age  when  Pott's  disease  is  rare.  There 
will,  probably,  be  in  addition  a  history  of  rheumatic  affections. 

Cases  of  commencing  hip-disease  in  children  have  been  mistaken  for  an 
early  stage  of  Pott's  malady.  Children  so  afflicted  often  cry  if  moved  much  ; 
keep  the  spine,  pelvis,  and  hip-joints  as  rigid  as  possible ;  are  disinclined  for 
any  exercise ;  and  often  complain  of  vague  pains  that  may  not  be  very  accu- 
rately localized.  A  little  care  in  the  examination  of  doubtful  cases,  however, 
will  soon  eliminate  the  instances  of  hip-mischief.  Infantile  paralysis  may 
in  some  way  imitate  the  paraplegia  of  Pott's  disease,  from  which  it  can, 
however,  be  distinguished  by  the  history  of  the  case,  the  atrophy  of  the 
affected  muscles,  and  the  absence  of  any  rigidity  or  any  pain  about  the  spine. 
FoUin  and  Duplay  assert  that  muscular  weakness  associated  with  rickets  may 
resemble  the  loss  of  power  sometimes  met  with  in  Pott's  malady,  but  it  is 
difficult  to  appreciate  the  grounds  of  such  resemblance,  or  to  imagine  that  it 
could  be  so  close  as  to  cause  confusion  in  diagnosis.  One  author  reaches  the 
extreme  limit  of  doubtful  refinement  in  diagnosis,  when  he  points  out  how 
Pott's  malady  without  deformit}^  is  to  be  distinguished  from  chronic  ne- 
phritis. 

(3)  The  Abscess. — The  differential  diagnosis  of  abscess  from  spinal  disease 
appearing  in  various  regions,  can  only  be  given  in  the  merest  outlhie. 

Abscesses  in  the  lumbar  or  iliac  regions  must  be  distinguished  from  simple 
chronic  abscesses,  from  perinephritic  and  pericsecal  abscesses,  from  abscesses 
due  to  disease  of  the  ilium,  and  from  certain  fluctuating  renal  tumors.  In  the 
simple  chronic  abscess,  the  symptoms  will  be  purely  negative.  In  the  peri- 
nephritic and  pericmcal  abscesses,  there  will  probably  be  evidence  of  some 
disturbance  of  the  viscera  about  which  the  pus  has  formed,  and  an  absence  of 
all  the  local  signs  of  Pott's  disease.  The  latter  abscess  is  met  with  only  on 
the  right  side  of  the  body,  and  the  pus  it  discharges  is  usually  of  feculent 
odor.  It  must  also  be  remembered  that  pus  from  spinal  caries  may  occupy 
the  connective  tissue  about  the  kidney  or  csecum.  Caries  or  necrosis  of  the 
ilium  can  in  the  early  stages  be  little  more  than  suspected,  and  the  symptoms 
of  abscess  will  advance  vfithout  any  evidence  of  Pott's  malady  appearing. 
The  fluctuating  renal  tumor  may  be  hydatid,  cystic,  or  cancerous,  or  due  to 
distension  of  the  kidney  with  urine  or  pus. 

With  regard  to  the  inguinal  region,  it  is  here  that  the  typical  psoas  abscess 
is  met  with.  In  this  abscess  there  will  be  a  smooth,  round,  fluctuating  swell- 
ing below  the  groin,  and  about  the  site  of  the  ilio-psoas  insertion.  There 
will  probably  be  a  second  collection  to  be  felt  in  the  iliac  region  above  the 
groin.  The  collection  in  the  thigh  can  be  more  or  less  reduced  on  pressure, 
and  will  present  a  distinct  impulse  on  coughing  or  on  tapping  the  iliac  tumor. 
In  some  instances  the  communication  between  the  iliac  and  inguinal  collec- 
tions may  be  for  a  time  cut  off,  when  the  lower  tumor  will  present  simply  the 
features  of  a  chronic  abscess.  Psoas  abscess  in  the  groin  may  be  mistaken  for 
abscess  from  hip-disease,  but  in  the  latter  instance  there  will  be  more  or  less 
rigidity  of  the  joint  in  a  flexed  and  adducted  posture,  with  tilting  up  of  the 
pelvis  on  the  diseased  side.  The  spine  will  be  in  a  condition  of  lordosis,  and 
often  unduly  mobile.  There  will  be  no  impulse  at  the  collection  on  coughing, 
and  the  other  evidences  of  hip-mischief  will  probably  be  present.  Cases  are 
recorded  where  the  spinal  abscess  has  been  mistaken  for  a  femoral  hernia. 
Shaw  gives  an  excellent  example  of  such  a  case  where  a  truss  was  actually 
ordered.  The  psoas  abscess  is,  however,  nearly  always  to  the  outer  side  of 
the  femoral  vessels,  and,  on  examination,  the  femoral  canal  will  be  found  to 


pott's  disease  of  the  spine. 


541 


be  clear.  The  hernia,  if  reducible,  is  returned  with  a  peculiar  gurgle,  and  is 
of  slow  formation.  If  of  any  size,  it  will  also  be,  as  a  rule,  tympanitic  on 
percussion.  The  following  case— recorded  by  Shaw^— will  show  how  closely 
a  cancerous  tumor  about  the  groin  may  imitate  a  spinal  abscess.  He  had 
under  his  care  "a  female,  of  middle  age,  who  had  lateral  curvature  of  the 
spine  from  girlhood ;  and  in  whom  the  hump  was  so  prominent  and  abrupt, 
that  it  mio:ht  be  mistaken  for  angular  deformity  from  caries  of  the  vertebrae. 
She  was  acimitted  for  a  tumor  that  occupied  the  inner  side  of  the  left  wing 
of  the  pelvis,  and  was  on  a  level,  at  its  anterior  part,  with  the  crest  of  the 
ilium.  An  oval-shaped,  projecting  lobe,  in  course  of  time  formed  on  its  most 
dependent  face,  near  Poupart's  ligament ;  and  the  feeling  communicated  to 
the  finger,  when  examining  that  part,  bore  the  greatest  resemblance  to  what 
is  conveyed  by  pus,  when  near  the  surface  of  an  abscess.  The  subsequent 
progress  and  termination  of  the  case  showed  that  the  tumor  was  one  of  me- 
dullary cancer."  Among  other  tumors  in  the  inguinal  region  that  may 
possibly  be  confused  with  spinal  abscess,  are  bubo ;  varix  of  the  saphenous 
vein;  fatty,  cystic,  and  other  soft  or  fluctuating  tumors;  and  possibly  some 
cases  of  aneurism. 

Before  concluding  the  matter  of  diagnosis,  it  is  to  be  observed  that  it  is 
scarcely  possible  to  diagnose  with  any  certainty  the  nature  of  the  bone-mis- 
chief during  life.  In  less  recent  times,  much  was  written  on  the  distinctions 
between  simple  and  tubercular  caries,  and  on  this  point  the  arrangement  of 
Broca  was  perhaps  the  most  popular.  He  asserted  that  tubercular  osteitis 
occurred  in  children,  and,  as  a  rule,  in  the  cervical  and  dorsal  regions,  and  that 
it  soon  led  to  deformity,  and  to  paraplegia.  Whereas  simple  caries  appeared 
usually  in  adults,  and  in  the  lumbar  spine,  and  was  marked  by  a  very  tardy 
deformity  and  no  paralytic  symptoms.  This  arrangement  is  very  fascinating, 
but  must,  in  the  present  state  of  our  knowledge,  be,  I  think,  discarded  as 
useless 

Progress,  Prognosis,  etc. — The  progress  of  the  disease  is,  as  a  rule,  slow. 
In  some  cases  it  may  be  so  slow,  and  produce  so  few  symptoms,  that  the  malady 
is  hardly  noticed  by  the  patient.  Thus  cases  are  recorded  where  the  patient 
followed  a  laborious  employment  during  the  development  of  the  disease, 
and  where  years  elapsed  before  any  troublesome  symptoms — such  as  abscess 
or  cord- troubles — appeared.  There  are  cases,  on  the  contrary,  where  the 
malady  has  been  acute,  and  has  pursued  a  rapid  course.  But,  as  a  rule, 
even  these  acute  cases  are  not  acute  from  the  first.  They  begin  as  chronic 
maladies,  and  then,  for  some  particular  reason,  take  on  an  acute  action.  The 
great  feature,  however,  in  the  progress  of  Pott's  disease  is  its  uncertainty. 
Seldom  is  its  progress  uniform,  but  marked  rather  by  the  utmost  variety, 
not  only  in  the  rate  at  which  it  advances,  but  also  in  the  period  at  which 
certain  symptoms  appear,  and  in  the  general  features  of  those  symptoms 
themselves.  The  actual  time,  therefore,  occupied  by  the  disease  must  vary 
considerably.  Except  in  very  few  instances,  it  can  hardly  run  its  course  in 
less  than  six  or  nine  months,  although  Michel  asserts  that  the  period  of  time 
from  the  commencement  to  the  termination  of  the  malady  may  be  as  little  as 
three  months.  In  the  majority  of  cases,  the  duration  of  the  active  disease  is 
to  be  estimated  by  years,  and  not  by  months,  and  perhaps  one  or  two  years 
would  be  an  average  time  for  the  period  occupied  by  the  course  of  the  dis- 
ease. It  would  be  difficult,  perhaps  impossible,  to  detail  the  circumstances 
that  influence  the  rate  of  progress  of  spinal  caries.  It  may  be,  here,  only 
necessary  to  observe  that  the  malady,  as  a  rule,  advances  more  rapidly  in 


*  Loc.  cit.,  page  126. 


542 


MALFORMAa^IONS  AND  DISEASES  OF  THE  SPINE. 


adults  than  it  does  in  children,  and  in  the  cachectic  and  ill-nourished  than  in 
those  orio-inallj  robust.  It  must  be  understood  that  the  disease  is  considered 
to  end  when  anchylosis  has  ensued,  and  at  any  time,  of  course,  the  period  of 
the  disease  may  be  terminated  by  death.  In  cases  of  cure,  the  deformity  still 
persists,  and  patients  may  live  a  lifetime  with  all  the  outward  signs  of 
Pott's  malady,  and  yet  enjoy  good,  or  at  least  fair,  health. 

The  prognosis  with  regard  to  the  deformity  is  therefore  very  distinct.  The 
lost  parts  of  the  vertebral  column  are  never  restored,  and  the  deformity  never 
disappears.  With  regard  to  the  abscess,  perfect  cure  may  be  brought  about 
without  the  appearance  of  any  purulent  collection ;  or  the  pus  may  remain 
stationary  for  an  indefinite  time,  and  then  either  entirely  disappear  or  dis- 
charge itself  from  the  surface.  The  usual  course,  however,  is  for  an  abscess 
to  form  that  comes  in  time  to  the  surface,  and  then  discharges  itself,  and  this 
particularly  applies  to  cases  of  Pott's  disease  in  adults.  When  the  abscess 
has  opened,  and  has  discharged  for  a  considerable  period,  cure  may  still  fol- 
low ;  the  sinuses  may  close,  the  discharge  cease,  and  the  spine  consolidate. 
This  fortunate  result  would  appear  to  be  most  usual  when  the  abscess  opens 
close  to  the  seat  of  the  disease.  Michel^  has  collected  22  examples  of  cure 
following  upon  the  natural  or  artificial  evacuation  of  the  abscess.^  Of  these 
abscesses  8  were  psoas,  1  appeared  at  the  sciatic  notch,  1  in  the  perineum,  and 
12  in  the  dorso-lambar  region.  As  already  observed,  a  residual  abscess  may 
appear  at  almost  any  time,  and  in  any  case  of  Pott's  malady  that  has  under- 
gone cure,  or  what  is  practically  a  cure. 

The  paraplegia  in  Pott's  malady  may  persist,  but  at  the  same  time  it  is  not 
infrequently  recovered  from.  The  recovery  may  be  complete  and  permanent, 
or  it  may  be  only  partial,  and  a  certain  set  or  sets  of  muscles  may  remain 
absolutely  paralvzed,  or  the  patient  may  always  present  some  feebleness  in  the 
whole  series  of  muscles  that  have  been  aflfected.  Cases  of  recovery  are  recorded 
in  quite  severe  examples  of  paraplegia.  Thus  Dr.  Sowers  reports  an  instance 
in  a  little  2;irl  aged  SJ  years,  whose  lower  limbs  were  entirely  paralyzed,  and 
w^ho  in  ad^dition  had  some  loss  of  power  in  both  upper  extremities,  and  also 
in  the  bladder.  She  made  a  complete  recovery.  As  may  be  supposed,  the 
prognosis  is  much  more  favorable  in  children  than  in  adults.  More  than  one 
attack  of  paralysis  may  be  recovered  from.  Thus  Shaw  quotes  the  case  of  a 
boy,  aged  six,  who  had  two  attacks  of  paraplegia  in  two  years.  He  recovered 
perfectly  from  both  attacks.  I^ichels  gives  an  account  of  a  man,  aged  24, 
who  had  three  attacks  of  paraplegia  in  eight  years. 

It  remains  now  to  consider  the  prospects  of  cure  in  any  case,  and  the  causes 
of  death.  A  cure  is  much  more  common  in  children  than  in  adults,  and  in 
those  cases  associated  with  deformity  than  in  those  without.  The  following 
statistics  given  by  Michel  bear  upon  this  point.  In  33  fatal  cases  without  de- 
formity, 24  died  of  the  disease  itself,  and  9  of  some  other  disorder.  In  68 
fatal  cases  with  deformity,  35  died  of  the  disease  itself,  and  33  from  some 

other  cause.  -,      i  i  i  ^  4.  r 

The  extent  of  the  disease  has  also  to  be  considered,  and  the  general  state  ot 
the  patient's  health.  The  presence  of  abscess  or  of  paraplegia  will  very  mate- 
rially lessen  the  prospects  of  cure ;  and  paralysis  in  connection  with  cervi- 
cal disease  is  peculiarly  apt  to  end  in  death.  mi  + 
When  death  ensues,  it  is  most  commonly  from  the  abscess.  Ihe  patient 
dies  of  hectic,  or  of  amyloid  degeneration  of  the  viscera,  or  of  pyaemia,  or  of 
simple  asthenia— worn  out  by  excessive  discharge— or  indeed  by  any  of 
those  modes  of  death  that  result  from  long-continued  suppuration.  Very 
often  a  sudden  change  for  the  worse  occurs  in  the  patient's  condition  when 

I  Log.  cit.,  p.  493. 


pott's  disease  of  the  spine. 


543 


the  abscess  is  opened,  and  out  of  28  cases  reported  by  Michel,  where  the  time 
of  the  evacuation  of  the  abscess  was  known,  death  followed  in  20  days  in  10 
instances.  The  same  author  also  gives  the  following  as  the  causes  of  death 
in  44  cases  of  spinal  abscess. 

In  14  cases  death  resulted  from  tuberculosis  of  the  lungs. 

In  16  "  "  "  marasmus. 

In   5  "  "  "  "  sloughing  of  the  limbs  from  oedema. 

In    4  "  "  "  "  pysemia. 

In    2  "  "  "  "  arachnitis. 

In    2  "  "  "  "  pus  in  the  medullary  canal. 

In    1  "  "  "  "  pneumonia. 

In  some  cases  the  patient  dies  from  extension  of  the  mischief  in  the  cord, 
or  from  actual  inflammation  of  the  cord  or  its  membranes. 

Any  thoracic  complication  is  apt  to  be  dangerous  in  those  cases  of  Pott's 
disease  which  are  associated  with  deformed  chest. 

Among  the  less  usual  causes  of  death,  may  be  mentioned  hemorrhage,  as 
in  a  case  observed  by  Legouest,*  where  fatal  bleeding  occurred  from  the 
vertebral  artery  in  an  instance  of  cervical  caries,  and  as  in  another  case  re- 
corded by  Fuller,^  where  the  abdominal  aorta  was  perforated.  [The  editor^ 
has  recorded  a  case  of  psoas  abscess  Avhich  ended  fatally  through  hemorrhage 
from  a  branch  of  the  internal  iliac  artery.]  Death  has  also  occurred  from 
suffocation  due  to  the  sudden  discharge  of  a  spinal  abscess  into  the  bronchi, 
and  from  like  unusual  causes. 

Treatment  of  Pott's  Disease. — This  may  be  considered  under  the  heads 
of  local  and  general  treatment. 

Local  Treatment. — The  treatment  of  the  spine  in  Pott's  disease  has  been  for 
a  considerable  period  a  subject  of  dispute,  and  is  still  a  matter  upon  which 
much  difference  of  opinion  exists.  These  differences  involve,  however,  rather 
matters  of  detail  than  general  principles,  and  it  is  more  than  probable  that  they 
will  become  still  less  conspicuous  when  our  knowledge  of  the  pathology  of  the 
disease  is  more  distinct.  The  indications  for  local  treatment  are  well  expressed 
by  Mr.  Fisher,  in  his  essay  on  this  deformity.  They  are :  "  First,  the  obtain- 
ing a  condition  of  immobility  for  the  diseased  bones ;  secondly,  the  relieving 
them  from  the  pressure  caused  by  the  weight  of  the  body  above  ;  thirdly,  the 
relaxation  of  local  muscular  contraction ;  and,  lastly,  the  restoring  of  the 
spine,  as  far  as  possible,  to  its  normal  condition."*  With  regard  to  this  last 
indication,  the  term  "  normal"  must  be  used  in  a  very  modified  sense.  A 
consolidation  of  the  diseased  part  is  the  issue  hoped  for,  and  a  rigidity  of  the 
region  is  desired,  that  obtains  in  no  normal  spine.  Moreover,  the  removal  of 
the  deformity  must  always  be  a  secondary  consideration  in  treatment.  De- 
formity of  some  amount  is  necessary  for  substantial  cure,  and  no  method  of 
treatment  can  be  more  injurious  than  that  proposed  for  the  sole  purpose  of 
removing  the  disfigurement.  Local  treatment  wdth  this  object  is  the  usual 
expedient  of  the  "  bone-setter"  who  treats  Pott's  disease.  He  professes  to  recog- 
nize in  the  deformity  a -dislocation  of  the  spine,  and  proceeds  to  restore  the 
parts  by  violent  extension,  and  by  manipulation  of  a  no  more  gentle  character. 
Under  such  measures  the  posterior  segments  of  the  column,  upon  which  the 
main  hope  of  cure  depends,  have  been  broken  across,  and  sudden  paraplegia, 
or  even  death,  has  been  the  result.    The  indications  just  mentioned  may  be 

1  Gazette  Hebdom.,  p.  76.    1861.  2  Ibid.,  p.  524.  1859. 

3  Principles  and  Practice  of  Surgery,  3d  ed.,  p.  662,  Philadelphia,  1882. 

4  Op.  cit..  p.  18. 


544  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

carried  out  by  (1)  the  recumbent  posture ;  (2)  certain  mechanical  appliances ; 
(3)  a  rigid  jacket  applied  during  extension  of  the  column.  ^ 

(1)  Treatment  by  prolonged  recumbency  is  of  extreme  value  in  Pott  s  dis- 
ease   Indeed,  considered  in  the  abstract,  or  apart  from  certain  difficulties 
and  inconveniences,  it  is  probably  the  very  best  treatment  available  for  this 
malady.    In  the  recumbent  posture  the  spine  is  at  rest,  and  the  muscles 
relaxed,  the  evils  of  the  pressure  of  the  diseased  surfaces  against  one  another 
are  minimized  or  removed,  and  the  very  least  inducements  are  offered  for  the 
malady  to  progress.    In  all  rapid  and  acute  cases,  this  plan  of  treatment 
should  be  strictly  carried  out,  and  should  be  the  only  means  adopted.  In 
other  cases  it  is  well,  under  all  circumstances,  to  commence  the  treatment  by 
a  period  of  enforced  recumbency,  and  to  allow  this  measure  to  be  a  prelimi- 
nary to  further  treatment  by  instruments,  jackets,  etc.     Many  surgeons 
would,  however,  urge  that  recumbency  should  be  the  treatment  of  all  forms 
of  Pott's  malady,  and  should  constitute  the  only  local  measure.  Without 
o-oing;  as  far  as  this,  it  must  be  regretted  that  this  simple  expedient  is  not 
more  extensively  and  practically  resorted  to,  and  that  more  means  are  not 
afforded  in  hospitals  for  its  employment.    When  this  mode  of  treatment  is 
adopted,  the  patient  should  be  made  to  lie  upon  a  firm,  well-padded  mattress, 
with  the  spine  as  straight  as  possible,  and  with  the  head,  trunk,  and  limbs 
on  the  same  plane.    Any  but  slight  and  necessary,  movements  must  be  for- 
bidden and  the  more  recent  and  acute  the  case,  the  more  essential  is  it  that 
absolute  rest  shall  be  enjoined.    To  effect  this  end  in  the  case  of  children, 
Mr.  Fisher^  has  devised  a  "  bed-frame"  that  answers  its  purpose  veiy  weii. 
It  consists  of  two  flat  iron  bars,  each  with  a  crutch  and  strap  for  the 
shoulders  at  one  end,  and  a  third  or  transverse  bar  that  serves  to  connect 
the  crutch-bars  to  the  head  of  the  bed.    The  latter  bars  are  also  secured  to  the 
sides  of  the  bed  by  bandages.   The  shoulders  being  strapped  to  the  frame,  and 
the  lower  limbs  kept  still  by  a  weight,  any  movement  of  the  spme  is  almost 
impossible.     The  American  "box-splint"  for  fractured  femur  in  children 
answers  equally  well,  if  carefully  secured  to  the  bed,  and  steadied  also  by  a 
weip:ht  applied  to  the  lower  end  of  the  splint.   The  duration  of  the  treatment 
must  depend  upon  the  nature  of  the  case  and  other  circumstances,  and  m  the 
majority  of  instances  is  to  be  estimated  by  months  rather  than  by  weeks. 
The  obiections  to  prolonged  recumbency  are  of  course  obvious.    I  he  treat- 
ment is  long  and  irksome,  and  difficult  to  carry  out  efficiently;  b^t  Mr. 
Howard  Marsh,  and  others  who  advise  its  practice,  have  pointed  out  that  ttie 
objections  raised  are  somewhat  exaggerated,  and  that  the  difficulties  are  by 
no  means  insurmountable.^  i.  • 

(2)  Mechanical  Appliances.— A  YSi^t  number  of  instruments  Iiave  been  in- 
vented to  meet  the  various  indications  for  local  treatment  The  objections 
to  most  of  these  appliances  are  the  following:  They  are  heavy  and  often 
irksome,  possess  but  little  adaptability,  and  must  be  changed  or  altered  as 
the  child  increases  in  age.  The  expense  would  forbid  their  use— even  it  con- 
sidered desirable— to  any  extent  in  hospitals.  For  the  most  part  they  take 
their  lower  point  of  support  from  the  pelvis ;  but  the  pelvis  of^  a  child  is  so 
small  comparatively,  that  this  basis  is  often  delusive,  and  it  is,  moreover, 
unstable.  The  result  is  that  few  of  these  instruments  are  of  any  use,  and 
that  a  large  number  do  positive  harm.  The  least  objectionable  form  ot  in- 
strument is  that  where  the  lower  support  is  taken  from  a  broad,  rigid  band, 
well  moulded  to  the  hips  and  pelvis.  The  body  and  spinal  column  above  the 
seat  of  disease  are  supported  by  crutch  bars  that  pass  from  this  band  to  the 

«  Treatment^of  a^n^^  tJaries  in  Childhood.    British  Medical  Journal,  vol.  ii.  p.  769.  1881. 


pott's  disease  of  the  spine. 


545 


Fig. 


Taylor's  apparatus  for  the  treatment 

of  Pott's  disease  of  the  spine. 


axill?e,  and  that  can  be  lengthened  or  shortened  at  pleasure.  The  best  ex- 
amples, however,  are  somewhat  cumbrous. 

[A  better  form  of  apparatus  than  that  described  by  the  author  is  such  as 
is  shown  in  Fig.  899,  the  principal  support  being  given  by  iron  uprio-hts  on 
either  side  of  the  vertebral  column.    The  cut  ^ 
illustrates  the  spinal  brace  devised  by  Dr.  C.  F. 
Taylor,  of  New  York,  which,  with  various 
modifications,  is  extensively  employed  in  this 
country.] 

(3)  The  use  of  rigid  Jackets  with  or  without  Sus- 
pension.— By  the  introduction  of  his  now  well- 
known  ''jacket,"  Professor  Sayre  has  caused 

almost  a  revolution  in  the  treatment  of  Pott's 

disease  of  the  spine.  When  first  introduced,  this 

plan  of  treatment  was  very  widely,  blindly,  and 

enthusiastically  adopted,  and  was  regarded  by 

some  as  a  panacea  for  all  deformities  of  the  back. 

Since  that  time  a  certain  reaction  has  set  in,  and 

there  are  now  not  a  few  who  condemn  the  use  of 

Sayre's  apparatus  as  of  little  use,  and  as  at  least 

inferior  to  other  modes  of  treatment.    As  is 

usual  in  similar  cases,  the  truth  probably  lies 

between  these  two  extremes,  and  I  feel  convinced- 

that  Sayre's  method  affords  an  admirable  remedy 

for  Pott's  disease,  but  at  the  same  time  a  remedy 
that  must  be  properly  and  carefully  restricted  iia 
its  use.  The  details  of  Sayre's  method  are  too 
well  known  to  require  minute  description.  The 
main  features  are  simply  these— extension  is  applied  to  the  spine  by  means  of 
suspending  the  body  (Fig.  900),  and  while  in  the  extended  posture  a  rio:id  jacket 
of  plaster  of  Paris  is  applied  to  the  trunk.  The  body  is  suspended  ^Dy  means 
of  a  collar  beneath  the  chin  and  occiput,  and  by  bands  beneath  the  axillae;  a 
tripod  stand  is  used,  and  the  suspending  force  is  directed  throuo;h  a  series  of 
compound  pulleys.  (Fig.  901.)  The  first  point  to  be  discussedln  this  mode 
of  treatment  is  the  matter  of  suspension.  By  means  of  it  the  diseased  sur- 
faces of  contiguous  vertebrae  are  drawn  asunder,  muscular  contraction  is  over- 
come, and  the  column  is  restored— as  regards  its  curvatures— to  somethino- 
more  closely  approaching  the  normal.  Facts,  however,  are  greatly  needed 
that  will  throw  more  light  upon  the  precise  effect  of  suspension  upon  the 
diseased  part.  Fisher  suspended  the  cadaver  of  a  child  who  had  suffered 
from  Pott's  malady.  The  whole  of  the  body  of  the  first  lumbar  vertebra 
had  been  destroyed  by  disease,  and  the  contiguous  vertebrae  were  eroded. 
When  in  the  recumbent  posture,  the  diseased  parts  were  in  contact,  but  on 
suspension  they  became  separated  no  less  than  a  quarter  of  an  inch. 

It  must  be  remembered  that  the  extending  force  is  the  weight  of  the  body 
below  the  seat  of  disease,  and  that  this  force  will  be  the  greater  as  the  carious 
part  IS  higher  up.  It  will  also  increase  with  the  age  of  the  patient  and  the 
development  of  the  lower  limbs,  and  will  be  much  influenced  by  the  extent 
of  disease  m  the  column,  the  destruction  of  lio-aments,  the  amount  of  repair, 
and  the  degree  of  muscular  contraction.  Sayre  has  pointed  out  the  increase 
m  the  patient's  height  that  is  to  be  observed  during  suspension  in  cases  of 
"angular  curvature,"  but  it  must  not  be  imagined  that  this  increase  is  due 
solely  to  a  separation  of  parts  at  the  seat  of  disease.  Were  it  so,  the  ad- 
vantages of  suspension  would  be  very  doubtful.  He  mentions,  for  example, 
the  case  of  a  man  aged  19,  with  Pott's  disease,  who  gained  three-fourths  of 
VOL.  IV. —  35 


546 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


au  inch  ill  hei-ht  on  suspension.  The  production  of  a  gap  of  this  width  in 
the  anterior  part  of  the  spinal  column  would  be  a  very  questionable  advantage. 
The  increase  in  height,  under  such  circumstances,  is  due,  to  a  great  extent,  to 


Fig.  900. 


Fig.  901. 


Suspension  of  patient  for  application  of 
rigid  jacket  by  Sayre's  method. 


Tripod  tor  suspending  patient  in  applying  rigid 
jacket. 


the  stretchina;  of  the  column  and  unfolding  of  its  natural  curves;  and  it  is 
observed  in  the  normal  spine  of  any  individual  suspended  according  to  Sayre  s 

Thethject  of  the  rigid  jacket  is  to  steady  the  spine,  and  to  retain  it-  as  nearly 
as  possible,  in  the  position  which  it  assumes  during  extension     It  a  ras  at 
g  ving  phy'siolodcil  rest  to  the  part,  it  minimizes  the  efle<^  %°f  ^^^^^  .  ^"^ 
fiolent  movements,  and,  by  preventing  mutual  pressure  and  f^twn  ot  he 
diseased  surfaces.it  is  presumed  that  its  use  wil  arres  the  pi'ogi^^ 
malady  and  favor  the  process  of  repair    It  is  claimed, 
"acketf  that  it  is  inexpensive,  readily  applied,  and  composed  ot  mato-mls  tha 
•an  be  anywhere  obtained;  and,  lastly,  much  has  been  said  m  fawi  ot  ts 
simplicit?,  its  comparative  lightness,  and  the  comfort  which  it  aflords  the 
patient. 


pott's  disease  of  the  spine. 


547 


Many  objections  have,  as  already  mentioned,  been  made  to  Sayre's  treat- 
ment, both  as  a  whole  and  in  its  details.  The  objections  to  the  main  princi- 
ples of  the  method  may  now  be  briefly  discussed.  It  has  been  uro;ed  that 
suspension  pulls  asunder  the  diseased  parts,  and  that,  the  jacket  maintaining 
them  in  that  position,  a  cure  by  anchylosis  of  the  anterior  segments  of  the 
<column  is  positively  prevented.  This  objection  is  answered  by  asserting  that 
the  treatment  should  never  be  so  carried  out  as  to  cause  an  extensive  and  per- 
manent gap  in  the  column,  but  that  the  surfaces  should  be  just  prevented  from 
exercising  injurious  pressure  and  injurious  friction  the  one  upon  the  other. 
This  exposes  the  real  weakness  of  the  scientific  aspect  of  Sayre's  method,  for 
who  can  tell  when  the  extension  is  sufficient  just  to  prevent  injurious  pressure, 
but  not  to  cause  an  injurious  gap  ?  This  question  is  an  important  one,  and 
urgently  demands  an  answer.  It  has  been  urged,  moreover,  that  the  jacket 
is  not  capable  of  supporting  the  column  as  maintained  by  Sayre  and  others. 
This  objection  has  especial  reference  to  children,  and  it  is  declared  that  so  com- 
paratively slight  is  a  child's  pelvis  that  it  affords  no  proper  basis  for  the  support 
of  the  column.  It  is  asserted  also  that  the  hold  which  the  jacket  obtains 
upon  the  thorax  is  not  sufficient  to  support  the  weight  of  the  body  above  the 
seat  of  disease.  In  these  objections  it  is  assumed  that  the  Sayre's  jacket,  tak- 
ing its  fixed  point  from  the  pelvis,  holds  up  the  column  in  the  same  manner 
as  would  the  crutch  bar  of  the  steel  apparatus  for  Pott's  disease.  This  is  not 
the  case,  and  the  manner  in  which  the  rigid  jacket  supports  the  spine  is  more 
correctly  to  be  compared  to  the  manner  in  which  the  four  splints  around  an 
arm  support  and  maintain  position  in  a  fractured  humerus. 

Some  of  the  details  of  this  treatment  may  now  be  considered.  In  suspend- 
ing a  child,  the  collar  alone  is  usually  sufficient,  and  by  its  use  very  direct 
traction  upon  the  spine  can  be  obtained.  In  the  cases  of  elder  children  and 
adults,  the  axillary  bands  are  needed  in  addition.  A  collar  containing  an  air 
pad  has  been  introduced,  that  renders  the  extending  process  less  irksome  to 
the  patient.  As  to  the  amount  of  the  suspension,  the  rules  laid  down  by  Mr. 
Fisher  in  his  "  Essay"  are  I  think  the  best  and  the  most  carefully  considered.^ 
He  details  three  degrees  of  suspension.  In  the  first  degree,  the  patient  is 
suspended  until  the  toes  just  touch  the  ground.  He  maintains  that  this 
should  be  the  ^extreme  degree  of  extension,  and  urges  that  the  patient  should 
never  be  drawn  entirely  off  the  floor.  He  advises  this  amount  of  extension 
for  children  under  12,  with  limited  destruction  of  the  vertebra,  and  for  children 
under  5  m  whorn  more  extensive  disease  exists.  In  the  second  degree  of  ex- 
tension, the  patient  is  drawn  up  until  the  heels  are  raised  about  two  inches 
from  the  ground,  the  "  forepads"  of  the  feet  being  left  for  the  patient's  support. 
I  his  IS  advisable  in  more  advanced  cases  of  disease,  in  children  under  12,  and 
in  severe  cases  in  those  under  5.  In  the  third  degree,  the  body  is  raised  until 
the  heels  are  just  on  the  point  of  being  lifted  from  the  ground.  This  amount 
of  suspension  is  advised  for  all  cases  in  aduUs,  or  in  children  over  12,  and  in 
severe  examples  of  the  disease,  between  the  ages  of  12  and  5.  Sayre  simply 
advises  that  the  patient  be  drawn  up  "until  comfortable,"  and  is  an  advocate 
for  complete  suspension.  It  is  certain  that  patients  often  experience  much 
relief  on  suspension,  but  that  fact  can  hardly  aflford  a  proper  basis  for  esti- 
mating the  amount  of  force  to  be  used.  A¥hen  the  jacket  has  been  applied, 
the  patient^  must  be  carefully  placed  in  the  recumbent  posture  Avhile  the 
plaster  is  still  w^et,  and  this  practice  should  meet  the  objection  of  those  who 
assert  that  the  jacket  may  maintain  too  wide  a  gap  between  the  diseased  parts. 
In  the  place  of  suspension,  the  jacket  may  be  applied  in  the  recumbent 


1  Op.  cit.,  p.  31. 


548  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

posture,  as  advised  by  Dr.  Walker,  of  Peterborough  ;i  or  during  horizontal  ex- 
tension or  extension  by  an  inclined  plane.  I  would  most  strongly  advise  the 
application  of  the  jacket  while  the  patient  is  in  the  prone  position,  extension 
beincv  maintained  by  the  inclined  plane  upon  which  he  lies.  The  prone  pos- 
ture itself  tends  to  lessen  the  deformity,  and  to  remove  the  diseased  parts  trom 

mutual  pressure.  ^  ,     .  ip         i  i 

Some  few  details  in  the  application  of  the  jacket  itself  may  be  here  men- 
tioned    The  vest  Avorn  next  to  the  skin  must  be  drawn  well  down  during 
the  application  of  the  plaster  bandages,  and  to  effect  this  end  Sayre  advises 
it  to  be  fixed  temporarily  beneath  the  perineum.    The  bandages  are  made  ot 
some  loosely-w^oven  material,  such  as  crossbarred  muslm,  mosquito-nettmg, 
or  crinoline,  and  are  advised  to  be  about  3  yards  long  and  trom  2^  to  6 
inches  wide.    The  plaster  is  to  be  rubbed  into  the  bandages,  which  are 
to  be  rolled  up  and  then  dipped  into  a  basin  of  water  before  use.    As  the 
plaster  so  soon  spoils,  it  is  well  for  the  bandages  to  be  prepared  on  the  spot 
for  each  case  as  required.    During  the  application  of  the  bandages,  an  assist- 
ant should,  with  a  moist  sponge,  keep  the  plaster  smooth,  and  naay  add,  with 
his  hands,  a  little  dry  plaster  here  and  there  where  required     feayre  ad- 
vises the  use  of  longitudinal  strips  of  tin,  that  are  to  be  included  m  the 
folds  of  the  bandage.    They  certainly  add  to  the  rigidity  of  the  jacket  with- 
out s-reatly  increasing;  its  weight.    Little  pads  of  cotton-wool  are  to  be  placed 
ovef  the  iliac  spines  Snd  any  other  bony  prominences.   In  the  case  of  females, 
a  pad  should  be  placed  over  the  breasts,  to  be  removed  when  the  jacket  is 
ri^id    The  "dinner-pad"  must  not  be  omitted.    This  consists  of  a  wedge- 
shaped  pad,  inserted  beneath  the  vest  over  the  lower  part  of  the  abdpmen 
with  the  thin  edge  of  the  wedge  downwards.    It  is  removed  when  the  jacket 
is  drv,  and  leaves  a  potential  space  between  the  jacket  and  the  skiii.  .When 
a  dischars-inp;  abscess  exists  ,  in  a  part  that  would  be  covered  by  the  jacket 
Savre  advises  an  opening  to  be  made  in  the  following  naanner :  '  A  pi?ce  ot 
oil-silk  having  been  placed  over  the  sinus,  a  hole  should  then  be  cut  m  the 
shirt,  in  order  to  indicate  the  size  of  an  opening  to  be  subsequeiitly  made  in 
the  plaster  jacket;  and  in  this  hole  should  be  set  a  folded  piece  of  pasteboard 
of  the  same  size,  and  carrying  a  long  sharp  pin  thrust  through  its  outermos^^^ 
leaf    mw,  each  turn  of  the  bandage  can  be  carried  over  the  pm  without 
forcino-  it  into  the  abscess  cavity  below,  and  the  surgeon  is  furnished  with  a 
^uide'in  making  an  opening  that  will  lead  directly  to  the  diseased  surface 
When  the  plaster  has  nearly  set,  the  bandage  should  be  cut  aw^  around  the 
pin  until  the  pasteboard  is  reached,  and  an  opening  niade  of  sufficient  size  to 
allow  of  its  easy  removal.    The  oil-silk,  which  is  then  exposed,  should  be 
starred,  or  cut  into  strips  from  the  centre,  so  that  when  the  strips  are  reversed 
they  will  cover  the  edges  of  the  opening  m  the  plaster,  where  they  can  be 
p-lu'ed  down  with  p;um-shellac."^  , 
^  When  once  applied,  the  jacket  may  be  kept  on  for  one,  two,  or  three 
months,  or  until  it  becomes  so  weakened  as  to  be  useless.    In  some  of  bayre  a 
cases  the  jacket  was  kept  on  for  periods  varying  from  seven  to  twelve  months. 
This  practice  is  to  be  condemned  upon  the  grounds  of  the  simplest  hygiene, 
and  I  think  that  in  no  case  should  the  same  jacket  remain  on  the  patient  tor 
a  longer  period  than  twelve  weeks.    The  difficulty  as  to  cleanliness,  m  cases 
wherl  jackets  are  long  retained,  is,  to  some  extent,  met  by  the  i"genio»8  plan 
<,f  drawing  the  old  undershirt  off  while  a  new  one  is  drawn  on  without  dis- 
turbing thi  plaster  jacket.    This  is  effected  by  attaching  the  new  shirt  to  the 


.  See  British  Medical  Journal,  Dec.  1878.     For  an  account  of  Mr.  WiUett's  method  of  suspen- 
sion  in  tlie  prone  posture,  see  St.  Bartholomew's  Hospital  Reports,  vol.  xiv. 
'  Spinal  Disease  and  Spinal  Curvature,  p.  19.  London, 


pott's  disease  of  the  spine. 


549 


iower  border  of  the  old,  when,  as  the  old  vest  is  drawn  up  over  the  head  and 
removed,  the  new  garment  is  made  to  occupy  its  place. 

The  jacket,  as  already  noted,  must  not  be  used  in  early  or  acute  cases ;  and 
it  is,  of  course,  useless  when  good  consolidation  of  the  part  has  ensued.  It  is 
inadmissible,  also,  in  many  cases  where  lung  or  heart  complications  exist, 
and  in  instances  where  an  abscess  projects  in  any  part  that  would  be  covered 
by  the  jacket.  The  treatment  also  would  appear,  for  many  reasons,  to  be 
inadvisable  in  quite  young  children,  although  Mr.  Golding  Bird  has  applied 
Sayre's  jacket  with  success  to  an  infant  under  twelve  months  of  age.^  There 
are  many  objections  to  the  use  of  plaster  of  Paris  for  the  rigid  casing.  The 
plaster  is  apt  to  rub  out  of  the  bandages ;  it  can  rarely  be  applied  so  evenly 
as  to  exercise  everywhere  even  pressure  and  support;  it  is  heavy ;2  and, 
lastly,  it  keeps  the  part  from  view  for  a  long  time,  and  often  prevents  serious 
complications  from  being  detected.  An  abscess,  that  was  not  suspected  when 
the  jacket  was  applied,  has  shown  itself  for  the  first  time  by  an  escape  of  pus 
beneath  the  casing,  and  extensive  excoriations  also  have  occurred  that  might 
obviously  have  been  prevented  had  not  the  jacket  been  immovable.  Many 
of  these  objections  are  met  by  the  use  of  the  poro-plastic  jacket.  These 
jackets  are  made  from  a  prepared  felt,  and  are  moulded  upon  a  block  so  as  to 
form  corsets  of  various  sizes  suitable  to  patients  of  all  ages.  The  patient  is 
suspended  in  the  usual  way,  and,  wet  clothes  having  been  wrapped  about  the 
body,  a  corset  of  proper  size  is  moulded  to  the  figure.  This  moulding  is 
readily  effected,  inasmuch  as  the  jacket  is  rendered  very  pliable  by  a  momen- 
tary immersion  in  boiling  water.  It  is  to  avoid  the  injurious  contact  of  the 
heated  jacket  that  wet  clothes  are  applied  to  the  body  duritig  the  moulding 
process.  The  felt  soon  "sets"  again.  The  corset  having  been  properly 
shaped,  is  then  laced  down  the  front,  and,  although  it  forms  a  perfectly  rigid 
casing  for  the  body,  can  yet  be  removed  as  often  as  is  needed,  and  as  readily 
reapplied.  It  has  the  further  advantages  over  plaster  of  Paris,  of  being  much 
lighter,  firmer,  and  more  equable  in  its  support,  and  of  requiring  a  shorter 
period  of  suspension. 

Agnew  describes  a  jacket  of  half-tanned  leather,  which  is  thus  applied : 
The  child  is  suspended,  and  a  Sayre's  jacket  applied  in  the  usual  way.  The 
patient  is  kept  suspended  until  the  plaster  is  dry,  and  the  jacket  is  then  cut 
down  in  the  middle  line  in  front,  and  removed.  From  this  jacket  a  cast  in 
plaster  of  Paris  is  taken,  and  upon  this  the  leather  corset  is  moulded.  The 
corset  is  strengthened  by  longitudinal  strips  of  steel,  and,  when  applied,  is 
laced  down  the  front.  I  fail  to  see  the  advantage  of  this  apparatus  over  the 
simple  poro-plastic  jacket.  Its  use  involves  much  trouble  and  labor,  and 
great  inconveniences  to  the  patient,  not  the  least  of  which  is  the  prolonged 
suspension. 

The  treatment  of  Pott's  disease  varies  according  to  its  situation.  When 
the  caries  is  in  a  part  of  the  spine  below  the  third  or  fourth  dorsal  vertebra, 
a  jacket  of  some  kind  applied  in  the  suspended  posture  may  be  used  in  the 
manner  already  detailed.  But  when  the  disease  is  at  or  above  the  third  dor- 
sal vertebra,  suspension  is  no  longer  of  use,  and  the  jacket  alone  would  be  also 
of  no  avail.  In  such  cases  the  head  must  be  fixed,  and  the  upper  part  of  the 
column  kept  rigid  and  extended  by  some  form  ot  "jury-mast."  (Fig.  902.) 
This  jury-mast  consists  essentially  ot  a  rigid  bar  of  malleable  iron  or  steel, 
that  is  placed  along  the  back  (being  moulded  to  its  curve),  and  extends  some 
way  above  the  head.    To  the  summit  of  the  bar  an  apparatus  is  fixed,  that 

^  Trans.  Internat.  Med.  Congress,  1881,  vol.  iv.  p.  161. 

*  The  jacket,  as  applied  to  quite  young  children,  may  weigh  five  or  six  pounds.  (^Trans, 
Internat.  Med.  Congress,  vol.  iv.  p.  Id8.) 


»50 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


Fig.  902. 


keeps  the  head  extended  and  the  affected  spine  at  rest.  In  Sayre  s  "  jury- 
mast,"  the  head  is,  as  it  were,  suspended  by  the  apparatus :  extension  is  kept 
up  but  rotary  movements  of  the  head  are  permitted,  as  is  also  some  lateral 
motion  A  better  apparatus  is  that  advocated  by  Fisher,  which  difters  from 
Sayre's  instrument  in  so  far  that  it  not  only  maintains  the  extended  position, 
but  at  the  same  time  prevents,  by  its  rigidity,  all  movements  of  the  head  and 

.  cervical  spine.  In  any  case,  the  vertical  bar  is 
fixed  below,  either  to  a  Sayre's  plaster  jacket  ap- 
plied in  the  usual  way,  or  to  a  poro-plastic  corset. 
In  the  former  case  it  is  retained  by  being  included 
in  the  folds  of  the  plaster  bandages,  and  in  the 
latter  it  is  fixed  to  the  corset  by  means  of  rivets. 
In  either  case  the  necessary  firmness  needed  for  the 
support  of  the  bar  is  given  by  several  transverse 
pieces  of  metal  attached  to  the  lower  part.  There 
can  be  little  doubt  but  that  the  latter  method  of 
fixing  the  jury-mast  is  infinitely  the  more  advanta- 
geous. In  these  cases  of  disease  above  the  third 
or  fourtli  dorsal  vertebra,  recumbency  is  almost 
imperative  as  a  prelimiuary  measure,^  and  should 
be  insisted  on  as  long  as  the  mischief  is  acute  and 
progresshig  actively. 

The  general  treatment  of  the  malady  needs  little 
detail.  The  patient's  health  must  be  attended  to : 
change  of  air,  especially  to  the  seaside,  is  to  be  ad- 
vised, and  a  liberal  diet  should  be  ordered  in  all 
cases  where  such  a  diet  is  obtainable.  If  the  state 
of  the  digestive  organs  does  not  forbid  its  use,  cod- 
liver  oif  should  be  given  throughout  the  whole 
course  of  the  disease,  especially  when  the  i>atient 
is  a  child  and  scrofulous.  Among  other  drugs, 
iron,  iodine,  phosphorus,  and  quinine  are  of  service,  and  one  of  the  most 
suitable  drugs  for  children  is,  perhaps,  the  compound  syrup  of  the  phosphate 

^^ThTtreatment  of  the  abscess  is  a  subject  of  much  difference  of  opinion,  and 
on  this  matter  the  reader  is  referred  to  the  article  on  Abscesses  m  a  previous 
volume.*  As  far  as  my  own  experience  goes,  I  should  advise  an  evacuation 
of  the  matter  by  the  aspirator  at  as  early  a  period  as  possible,  and  I  do  not 
think  that  facts  support  the  practice  of  temporizing,  with  the  hope— which  is 
always  very  meagre— that  the  pus  will  be  absorbed.  When  the  collection 
re-forms  after  the  puncture,  it  may  be  again  aspirated,  and  this  procedure 
may  be  repeated  a  great  many  times.  After  each  operation,  the  skin  about 
the  puncture  should  be  kept  for  a  while  painted  with  collodion,  and  m  any 
case  every  care  should  be  taken  to  protect  the  parts  from  friction  and  inju- 
rious pressure.  .  •      r-.i  v 

In  the  majority  of  cases,  the  skin  at  the  most  prominent  point  of  the  abscess 
will  become  greatly  thinned,  and  possibly  inflamed,  and  the  condition  wiU 
be  such  that  the  collection,  if  left  any  longer,  will  discharge  itself  through 
the  integuments.  In  anticipation  of  this,  a  free  opening  should  be  made 
into  the  abscess  under  antiseptic  precautions,  and  the  wound  should  be  dressed 
antiseptically  until  such  time  as  antiseptic  measures  are  considered  unneces- 
sary or  unadvisable.  At  each  dressing,  it  is  well  that  the  abscess-cavity 
should  be  gently  syringed  with  a  weak  carbolic  solution  (1  to  100  parts). 


Jury-mast,  for  support  of  tead  in 
cases  of  Pott's  disease  above  the 
third  dorsal  vertebra. 


See  Vol.  I.,  page  760. 


DISEASE  OF  THE  ATLO-AXOID  REGION. 


551 


If  tho  opening  be  m  the  loins  or  back,  or  in  any  part  that  would  be  covered 
or  interfered  with  by  any  jacket  or  mechanical  apparatus,  then  should  such 
appliances  be  discontinued,  and  the  recumbent  position  be  insisted  on.  When 
the  discharge  has  diminished,  a  jacket  may  be  applied  with  a  hole  in  such 
part  ot  it  as  corresponds  to  the  sinus.  This  aperture  may  still  be  dressed 
antiseptically,  and  the  patient  allow^ed  to  get  up.    [See  page  560.] 

Disease  of  the  Atlo-axoid  Region. 

Diseases  of  the  bones  and  joints  in  this  region,  although  they  differ  in  no 
way  pathologically  from  like  diseases  in  other  parts  of  the  column,  are  yet 
conveniently  considered  apart  on  account  of  the  distinctive  clinical  features 
which  they  present.  The  special  features  of  disease  in  this  part  depend  upon 
the  peculiar  structure  and  outline  of  the  bones  themselves  as  compared  with 
the  other  vertebrae,  upon  the  peculiarity  of  the  joints  between  them,  the  free 
and  elaborate  movements  in  those  joints,  and  the  very  close  proximity  of 
that  most  important  part  of  the  cerebro-spinal  system,  the  medulla  oblongata. 

Pathological  Anatomy. — The  parts  concerned  in  this  region  are  the  atlas, 
the  axis,  and  the  condyles  of  the  occipital  bone,  together  with  the  atlo-axoid 
and  occipito-atloid  joints.  The  disease  in  these  parts  may  assume  very  vari- 
able aspects.  As  a  rule,  it  consists  essentially  of  an  arthritis  of  one  or  other 
of  the  joints  just  named.  This  arthritis  is  nearly  always  associated  w^ith 
gross  bone-mischief,  and  ma}^  be  attended  with  very  extensive  necrosis  or 
caries,  of  either  the  atlas  or  the  axis,  or  both.  There  are  cases  wdiere  a  caries 
or  a  necrosis  of  these  bones  has  appeared  to  exist  independently  of  any  joint- 
mischief,  and  that  such  a  condition  may  occur,  is  a  matter  beyond  doubt. 
But  such  cases  are  not  common.  Such  is  the  arrangement  of  the  articula- 
tions in  this  region  that  external  bone-disease  is  scarcelj^  possible  independent 
of  joint-mischief,  and  in  any  case  where  a  fairly  extensive  necrosis  or  caries 
exists,  it  may  be  safely  concluded  that  some  one  or  other  of  the  neighboring 
articulations  is  involved.  In  any  case  the  mischief  most  usually  com- 
mences in  the  joint,  but  it  may  commence  in  the  bone,  and  this  esjDecially 
applies  to  cases  where  the  anterior  portions  of  the  atlas  or  axis  are  carious  or 
necrosed. 

There  is  nothing  peculiar  about  the  bone-affection  or  joint-affection  as  it 
appears  in  this  region.  The  caries  and  the  necrosis  are  of  the  same  nature  and 
disposition  as  caries  and  necrosis  elsewhere.  The  joint-malady  usually  assumes 
the  form  known  elsewhere  as  "  w^hite  swelling."  It  is  nearly  always  chronic,  is 
apt  to  lead  to  "  pulpy  degeneration"  of  the  soft  parts  involved,  is  prone  to  in- 
duce extensive  mischief  in  the  cartilages  and  bones,. and  is  usually  associated 
with  suppuration.  Deformity  of  the  affected  joint  from  partial  dislocation  is 
common,  as  is  also  extension  of  the  suppuration  and  the  formation  of  sinuses ; 
and  lastly,  the  malad}^  may  end  in  a  more  or  less  complete  anchylosis.  In- 
deed, in  all  their  features — not  excluding  their  etiology — a  large  number  of 
the  joint-affections  in  this  part  are  identical  in  their  general  pathological 
features  with  the  wdiite  swellings  or  strumous  joint-diseases  of  other  regions. 

Sometimes  the  disease  in  this  segment  of  the  column  may  follow  upon 
injury  alone,  and  then  the  pathology  of  the  articular  or  osseous  changes  is 
identical  with  that  of  like  changes  elsew^iere  that  depend  upon  a  like  cause. 
The  same  remark  applies  to  those  instances  of  atlo-axoid  disease  that  are 
considered  to  be  due  to  syphilis;  of  the  two  joints  mentioned,  the  atlo-axoid 
articulation  would  appear  to  be  more  frequently  involved  than  that  bet\^^een 
the  atlas  and  occiput,  but  on  this  point  there  are  some  differences  of  opinion. 


552  MALFOKMATIONS  AND  DISEASES  OF  THE  SPINE. 

In  diseases  of  the  atlo-axoid  joint,  some  displacement  of  the  bones  is  very 
common,  and  indeed  usual.    This  takes  the  form  of  a  shdmg  forward  of  the 
atlas  upon  the  axis.    It  may  be  presumed  that  this  displacement  is  permitted 
bv  a  softeninff  of  the  ligaments  around,  and  especially  of  the  transverse  and 
odontoid  ligaments.    The  odontoid  process  thus  encroaches  upon  the  spinal 
canal,  and  the  most  serious  results  of  this  disease  are  apt  to  follow  therefrom. 
The  atlas  may  slide  symmetrically  forwards,  but  more  usually  the  displace- 
ment is  more  or  less  unilateral,  one  lateral  mass  of  the  atlas  being  in  advance 
of  the  other.    The  displacement  is  usually  very  slow  in  its  occurrence,  and  any 
sudden  displacement  in  this  direction  causes  instantaneous  death,    it  tpllows 
from  the  deformity  that  a  very  sharp  bend  is  given  to  the  cord  opposite  the 
seat  of  mischief,  and  it  is  a  matter  of  much  interest  to  note  to  what  extent 
the  spinal  canal  maybe  encroached  upon  without  a  fatal  result  ensumg  there- 
from    Thus,  Sir  James  Paget  has  recorded  an  instance  of  disease  in  this 
region,  where  the  atlas,  and  with  it  the  occiput,  had  slid  so  far  forward  on  the 
axis  that  the  spinal  canal  was  more  than  bisected  by  the  posterior  arch  of  the 
atlas.    The  odontoid  process  had  remained  with  the  axis.    The  bones  were 
S-reatly  anchylosed  in  this  position,  so  that  the  condition  must  have  existed 
long  enough  for  this  tardy  mode  of  cure  t6  be  effected.     In  some  cases  the 
odontoid  process  may  become  separated  from  the  body  of  the  axis,  and 
adhering  to  the  atlas,  may  be  carried  forward  with  that  bone  when  it  is 

Dislorations  at  the  occipito-atloid  joint  from  disease  are  very  rare.  Accord- 
ing to  Follin  and  Duplay,  they  may  be  bilateral  or  unilateral,  and  consist  as 
a  rule,  of  a  displacement  of  the  occipital  bone  backwards.  In  only  one  recorded 
instance  was  this  bone  displaced  forwards.'  „   •      i  i-v^ 

When  caries  and  necrosis  exist  in  this  part,  they  usually  involve  the  anterior 
portions  of  the  bones,  the  parts  most  commonly  implicated  being  the  anter  or 
arch  of  the  atlas,  the  body  of  the  axis,  and  the  odontoid  process  The  airterior 
arch  of  the  atlas  and  the  odontoid  process  have  separated  almost  entire,  as 
sequestra,  and  considerable  portions  of  the  body  of  the  second  vertebra  have 
been  lost  in  like  manner.  Or  these  parts  may  either  alone  or  co^omtly  be 
more  or  less  carious,*  and  in  one  case,  to  be  again  alluded  to,  no  tiace  ot  tne 
odontoid  process  was  to  be  found  after  death.  _      i  .  l  +>,e  nrnness 

In  some  cases  where  the  joints  are  the  parts  mainly  involved,  the  process 
may  run  its  course  and  end  in  cure  without  any  abscess  appearmg,  although 
some  evidences  of  suppuration  are  usual.  .  The  suppurative  process  set  up  by 
the  disease,  no  matter  whether  primarily  in  jomt  or  in  bone  tends  to  invade 
the  adjacent  soft  parts,  and  the  abscess  formed  ma,y  present  at  the  s^^des  or  at 
the  back  of  the  neck.  Having  reached  the  connective-tissue  I'^yej^  f  i^^^k 
the  abscess  may  extend  in  a  downward  direction  and  appear  a  <^istant  part 
Thus,  Smith,  of  Dublin,  records  a  case  m  which  an  abscess  proceeding  trom 
occipito-atloid  disease  presented  itself  in  tbe  supra-clavicular  fossa,^^^^^^ 
matily  opened  into  the  lung.  Bryant  describes  a  case  in  wh  ch  the  abscess 
formed  behind  the  sterno-mastoid  muscle,  and  m  which  from  the  opening  in 

heTkIn  that  was  formed,  a  piece  of  the  lamina  of  ^^^rteb- was  discharge^^ 
Very  commonly,  the  abscess  presents  itself  in  the  tiss'ie  behmd  the  pharj  nx 
(retro-pharyngeal  abscess),  and  this  is  especially  the  case  in  i°^tan°«8  o^^^^^^ 
kiseasi  in  the  anterior  parts  of  the  upper  cervical  vertebra.    This  retro-ph.1- 


1  Med.-Chir.  Trans.,  vol.  xxxi.  p.  286,  1848. 

2  Shaw,  Holmes's  System  of  Surgery,  2d  ed.,*vol.  iv.  p.  140. 


8  Traite  616mentaire  de  Path.  Ext.,  tome  in.  p.  l6,  iab».   _         ,,.,^^1^.  .nd  the  ed-e  of  the 
4  See  case  by  Dr.  Ogle,  where  the  atlas,  the  axis,  the  occipital  condyles,  and  the  ea^e 
foramen  magnum  were  all  carious.    Trans.  Path.  Soc,  vol.  xv.  p.  19. 
»  Manual  for  the  Practice  of  Surgery,  2d  ed.,  vol.  i.  page^Tb. 


DISEASE  OF  THE  ATLO-AXOID  REGION. 


553 


ryngeal  abscess  may  burrow  down  behind  the  pharynx  and  reach  even  to  the 
mediastinum.  In  other  cases  the  pus  may  go  towards  the  spinal  canal,  and 
may  form  a  collection  between  the  dura  mater  and  the  bone :  or  having 
pierced  that  membrane  it  may  enter  the  arachnoid  space,  and  lead  to  a 
rapidly  fatal  result.  FoUin  and  Duplay  assert  that  the  vertebral  artery  may 
be  opened  by  the  suppurative  process,  and  such  a  hemorrhage  take  place 
into  the  spinal  canal  as  to  lead  to  compression  of  the  cord.  As  in  Pott's  dis- 
ease, the  mischief  may  progress  to  a  fatal  issue  without  remission,  or  a  cure 
may  follow  without  any  previous  evidence  of  abscess,  or  a  like  good  result 
may  follow  after  the  abscess  has  appeared,  and  that  too  after  it  has  discharged 
itself  through  the  skin. 

In  cases  where  anchylosis  has  taken  place,  the  outlines  of  the  bones  involved 
may  be  very  confused,  and  the  deformity  remarkable.  In  a  case  noted  by 
Sir  Wm.  Lawrence,  the  atlas,  axis,  and  occipital  condyles  were  fused  together 
in  one  "firm  mass.  The  bones  had  been  partially  dislocated  from  one  another, 
and  the  odontoid  process  was  thrust  so  far  into  the  foramen  magnum  as  to 
really  occupy  the  cranial  cavity.^  In  a  specimen  described  by  Dr.  Lochee 
and  Mr.  C.  H.  Moore,  the  four  upper  cervical  vertebrae  and  the  occipital 
condyles  were  fused  together.  The  bones  were  all  much  compressed  and 
distorted,  and  their  outlines  very  confused.  There  was  no  trace  of  the  odon- 
toid process.  The  bodies  of  the  two  upper  cervical  vertebrae  had  invaded 
the  foramen  magnum,  and  were  practically  in  the  cranial  cavity.  The  spinal 
canal,  at  the  seat  of  disease,  was,  as  may  be  imagined,  much  diminished 
in  capacity .2  Lastly,  it  is  to  be  noted  that  the  spinal  cord  may  be  compressed 
or  crushed  by  fragments  of  bone  separated  in  the  progress  of  the  disease. 

Etiology. — The  etiology  of  disease  in  this  region  is  very  similar  to  that 
of  Pott's  malady.  The  disease  occurs  mostly  in  childhood  and  youth,  and  is 
ascribed  in  the  bulk  of  instances  to  the  influence  of  scrofula.  It  is  rare  in 
those  of  mature  age,  and  very  rare  in  the  old.  The  mischief  may  also  follow 
after  iujury,  and  this  would  seem  to  be  one  of  its  most  frequent  causes  in  those 
cases  that  appear  late  in  life.^  Cold,  unwonted  use  of  the  part — as  in  carry- 
ing weights  upon  the  head,  etc. — rheumatism,  gout,  etc.,  have  been  somewhat 
vaguely  regarded  as  active  causes  in  producing  disease  of  the  upper  cervical 
spine.  Syphilis  would  appear  to  be  a  frequent  cause  of  the  disease,  and  espe- 
cially of  that  form  of  it  that  principally  attacks  the  bone.  There  are  several 
recorded  cases  where  disease  of  the  upper  vertebrae  has  followed  upon  deep 
ulcer  of  the  pharynx,  and  it  is  very  probable  that  all  these  examples  have 
been  due  to  syphilis. 

Symptoms. — The  symptoms  of  spinal  disease  in  this  region  may  be  conve- 
niently arranged  under  the  heads,  (1)  Pain,  (2)  A  certain  rigidity  of  the  neck, 
(3)  Swelling,  (4)  Deformity,  (5)  Signs  of  abscess,  and  (6)  Evidence  of  pressure 
upon  the  cord. 

(1)  Pain  is  very  often  one  of  the  first  signs  of  the  malady  under  considera- 
tion. This  pain  is  mostly  complained  of  along  the  course  of  one  or  more  of  the 
following  nerves :  the  great  occipital,  the  small  occipital,  the  great  auricular, 
the  superficialis  colli,  and  the  descending  branches  of  the  cervical  plexus,  viz., 
the  sternal,  clavicular,  and  acromial  nerves.  It  is  necessary  to  remember  that 
the  first  cervical  nerve  escapes  between  the  occiput  and  the  atlas,  the  second 
between  the  atlas  and  the  axis,  and  the  third  beneath  the  latter  bone.  So 

'  Med.-Chir.  Trans.,  vol.  xiii.  1827.  2  Lancet,  voL  vii.  1867,  p.  637. 

'  See  example  of  occipito-atloid  disease,  ending  ii>  anchylosis,  in  a  man  aged  sixty-four.  It 
followed  upon  a  fall  on  the  head.    There  was  no  fracture.    Med.-Chir.  Trans.,  vol.  xxiv.  1841. 


00- 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


that  in  disease  of  this  region  of  the  cohimn,  the  first  three  cervical  nerves 
may  reaclilv  be  implicated,  and,  as  the  branches  above  named  are  all  sensory 
nerves,  theVlistribution  of  the  pain  may  be  very  definite.    The  two  occipital 
nerves  are  branches  of  the  second  cervical ;  the  great  anricular  and  super- 
ficialis  colli,  of  the  second  and  third  cervical;  and  the  descending  nerves,  of 
the  third  and  fourth  cervical.    Thus  the  two  occipital  nerves  are  the  two  • 
most  likely  to  be  irritated,  too-ether  with  those  parts  of  the  great  auricular 
and  superficialis  colli  that  are  formed  by  the  second  cervical.    The  third 
nerve  can  only  be  implicated  when  the  disease  extends  to  the  lower  part  of 
the  axis.    The  distribution  of  pain,  therefore,  may  be  of  some  value  in 
localizino-  the  mischief.    As  the  upper  cervical  nerves  lie  close  to  che  bone 
where  tlfev  issue  from  the  spinal  canal,  it  can  well  be  imagined  that  they  are 
earlv  and  readily  affected  by  any  inflammatory  changes  in  those  bones.  Thus, 
then,amoDo;  the  first  signs  of  disease  in  this  region  is  pain  about  the  back  of 
the  head  aiid  upper  part  of  the  neck,  or  about  the  sides  of  the  neck  and 
sometimes  in  the  ear,  or  less  frequently  about  the  shoulders  aud  upper  part 
of  the  chest.   The  pain  varies  in  intensity  in  different  cases,  is  commonly  neu- 
ralo'ic  in  character,  and  often  very  severe.    It  is  made  worse  by  any  pressure 
upon  the  head  that  brings  the  occipital  condyles  forcibly  on  to  the  spine,  and 
by  movements  that  concern  the  joints  of  the  first  two  cervical  vertebrae.  It 
is  often  increased  also  by  any  sudden  movement  or  any  joltmg  of  the  column. 
Hilton  says  that  the  pain  in  disease  of  the  lower  cervical,  the  dorsal,  and  the 
lumbar  spine,  is  "  almost  always  symmetrical,"  but  that  m  disease  involving 
the  first  two  joints  of  the  column  it  is  unilateral :  and  that  this  feature  serves 
to  point  out  which  side  of  the  vertebrfe  is  involved.i 

In  all  cases,  a  certain  amount  of  stiffness  in  the  neck  becomes  apparent, 
and  is  among  the  earliest  and  the  most  striking  symptoms  of  the  disease. 
The  movements  that  are  limited  will  depend  to  some  extent  upon  the  parts 
involved.  If  the  occipito-atloid  joint  be  alone  implicated,  all  nodding  move- 
ments of  the  head  will  be  arrested,  while  some  rotation  of  the  head  will 
still  be  possible.  If,  however,  the  disease  involve  only  the  atlo-axoid  articu- 
lation, then  will  all  rotary  movements  be  checked,  while  the  nodding  mo- 
tion may  still  be  effected.  As  a  matter  of  fact,  however,  both  ot  these 
movements  are  usually  more  or  less  arrested  m  disease  of  this  region,  no 
matter  how  limited  it  may  be.  The  parts  are  so  intimately  related  that 
movement  of  one  joint  can  hardly  fail  to  disturb  the  other  joint,  and  while 
nodding  movements  may  possibly  be  effected  without  great  discomfort  m 
atlo-axoid  disease,  it  is\^ery  improbable  that  rotary  movements  could  be 
made  with  a  like  ease  should  the  malady  attack  the  upper  of  the  two  arti- 
culations. In  most  cases,  the  greater  part  of  the  whole  of  the  cervical  spine 
is  rio-id.  If  the  patient  be  asked  to  turn  his  head,  he  effects  the  movement 
by  rotation  of  the  dorso-lumbar  spine,  or  by  turning  of  the  entire  body ;  and 
any  nodding  movement  of  the  head  he  replaces  by  a  bending  or  bowing 
movement  of  the  trunk. 

(3)  Swelling  about  the  nape  of  the  neck  soon  becomes  obvious,  and  this  may 
be  such  as  to  obliterate  the  suboccipital  fossa.  It  varies  greatly  m  amount 
in  different  cases.  The  swelling  may  involve  some  part  of  the  side  ot  the 
neck,  appearing  very  deeply  seated,  or  it  may  occur  in  the  post-pharyngeal 
region.  In  the  latter  reo:ion  it  may  cause  early  dysphagia.  I  he  more  super- 
ficial swelling  may  be  associated  with  some  tenderness,  and,  m  thm  subjects 
and  in  acute  cases,  with  some  decided  increase  in  the  temperature  of  the  skm. 

(4)  After  the  disease  has  existed  for  a  variable  period,  some  deformity  usu- 
ally becomes  obvious.    Before  this,  however,  takes  place,  the  patient  will 

1  Lectures  on  Rest  and  Pain,  third  ed.,  1880,  page  92. 


DISEASE  OF  THE  ATLO-AXOID  REGION. 


555 


possibly  have  adopted  a  carriage  more  or  less  typical  of  lesion  in  the  region 
of  the  column  now  under  notice.  The  head  may  be  kept  bent  forwards,  or 
backwards,  or  to  one  side,  or  in  the  position  of  rotation  ;  the  first  mentioned 
position  is  the  most  common.  Sometimes  the  patient  may  appear  to  be  un- 
able to  support  the  head  by  means  of  the  usual  muscles ;  he  prefers  the  re- 
cumbent posture,  with  his  head  sunken  in  a  pillow,  and,  if  required  to  get  up, 
will  support  his  head  Avith  his  hands.  The  actual  deformity  as  a  rule  de- 
pends upon  the  sliding  forwards  of  the  atlas  upon  the  bone  beneath.  When 
this  occurs,  the  chin  and  face  are  advanced,  and  are  stifly  poked  forwards.  The 
roundness  of  the  upper  part  of  the  back  of  the  neck  is  lost.  The  spine  of  the 
axis  becomes  prominent,  and  may  be  readily  felt  or  seen.  This  deformity 
when  present  is  very  characteristic,  and  is  well  represented  by  Mr.  Shaw  in  a 
drawing  in  his  monograph  already  referred  to.  The  displacement,  Avhen  in 
any  way  well  marked,  may  be  sometimes  felt  by  examination  of  the  part 
through  the  upper  and  posterior  part  of  the  pharj'nx. 

(5)  The  disease  may  run  its  entire  course,  and  end  in  cure,  without  any 
abscess  appearing  externally.  As  a  rule,  however,  abscess  does  appear,  although 
that  appearance  may  be  long  delayed.  The  purulent  collection  may  present 
itself  at  the  back  or  side  of  the  neck.  In  the  latter  position  it  will  be  deep- 
seated,  and  may  cause  severe  symptoms  and  great  difficulty  in  diagnosis.  Such 
an  abscess  will,  however,  have — apart  from  the  spinal  disease — no  especial  cha- 
racters that  separate  it  from  other  deeply-seated  cervical  abscesses.  In  some 
cases  (and  in  those  particularly  that  depend  upon  necrosis  of  the  anterior 
parts  of  either  of  the  two  upper  vertebrae)  the  purulent  collection  may  appear 
as  a  "  post-pharyngeal  abscess."  An  abscess  in*  this  situation  may  cause  very 
obscure  and  very  severe  symptoms.  In  a  case  already  associated  with  evi- 
dences of  disease  in  the  upper  cervical  region,  a  swelling  appears  behind  the 
]3harynx,  that  may  in  time  increase  so  as  to  push  forward  the  soft  palate,  or 
may  extend  so  low  down  as  to  be  obvious  from  the  mouth.  This  swellino'  is 
associated  with  much  pain  and  distress,  with  considerable  difficulty  in  deglu- 
tition, and  often  with  alarming  dyspnoea.  The  cause  of  this  dyspnoea  has  in 
more  than  one  recorded  case  been  overlooked,  and  tracheotomy  proposed  or 
practised  for  its  relief.  Very  often  the  abscess  presents  itself  at  the  same  time 
at  the  side  of  the  neck.  TJaus,  Mr.  Hilton^  records  a  case  of  a  child,  aged  twelve 
months,  who  in  addition  to  the  post-pharyngeal  swelling  had  an  abscess  that 
extended  to  the  angle  of  the  jaw,  pushing  forwards  the  trachea  and  carotid 
vessels,  and  lifting  up  the  sterno-mastoid  muscle.  The  collection  was  opened 
in  the  neck,  and  the  pharyngeal  tumor  at  once  subsided.  Sir  James  Paget^ 
gives  an  instance  where  the  post-pharyngeal  abscess  was  complicated  by  an 
extension  of  suppuration  to  the  parotid  region,  associated  with  rigidity  of  the 
jaw.  The  collection  opened  spontaneously  through  the  pharynx,  and  a  severe 
hemorrhage  followed.  The  hemorrhage  recurred  and  proved  fatal.  The 
autopsy  showed  caries  of  the  anterior  arch  of  the  atlas,  and  an  abscess-cavity 
about  the  carotids,  and  between  the  tonsil  and  the  parotid  gland.  The  source 
of  the  bleeding  was  not  discovered.  The  post-pharyngeal  abscess  may  open 
into  the  pharynx,  or  may  discharge  itself  through  the  integuments  of  the  neck, 
but  an  opening  in  the  former  situation  is  the  more  common.  The  bursting 
of  the  abscess  into  the  pharynx  may  cause  death  by  asphyxia,  the  matter 
finding  its  way  into  the  larynx.  Or,  independent  of  its  bursting,  the  collec- 
tion may  cause  death  by  asphyxia,  that  end  being  brought  about^by  pressure. 

Several  cases  are  recorded  where  the  mischief  in  the  bones  has  been  second- 
ary to  an  ulcer  of  the  pharynx,  and  in  all  these  instances  the  disease  would 
appear  to  have  been  due  to  tertiary  syphilis.    The  following  was  a  case  of 


1  Op.  cit.,  page  135. 


2  Holmes's  System  of  Surgery,  2d  ed.,  vol.  i.  p.  133. 


556  MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 

this  kind'i  The  patient,  a  man  aged  35,  had  an  extensive  syphilitic  ulcer 
of  the  pharynx,  that  had  destroyed  the  soft  palate  and  exposed  the  anterior 
arch  of  the  atlas.  This  process  of  bone  necrosed  en  masse.  Other  instances 
of  pharyno-eal  ulcer  associated  with  bone-disease  in  the  cervical  spine  are  evi- 
dentlv  secondary  to  the  osseous  lesion,  and  due  to  extension  forwards  of  the 
destructive  process.  Through  these  ulcers,  or  through  the  abscesses  alter 
evacuation  of  their  contents, ^sequestra  have  been  discharged  or  removed  by 
operation.  Thus,  in  the  case  just  mentioned,  the  whole  of  the  anterior  arch  ot 
the  atlas  was  removed  through  the  pharynx  as  a  sequestrum.  Mr.  Keate  has 
o-iven  an  account  of  a  like  operation.  Mr.  Bryant^  records  the  case  ot  a 
woman  who  coughed  up,  as  a  sequestrum,  the  odontoid  process,  and  who, 
nevertheless,  made  a  good  recovery.  The  same  surgeon  has  also  seen  the 
anterior  half  of  the  atlas,  with  its  articular  facets,"  expectorated,  and  a  cure 
follow  its  elimination.  Mr.  Hilton  also  details  the  case  of  a  patient  who 
coughed  up  the  anterior  arch  of  the  atlas,  the  sequestrum  having  escaped  by 
way  of  a  pharyngeal  ulcer.* 

(6)  The  symptoms  that  depend  upon  implication  of  the  cord  and  the  upper 
svincd  nerves  are  very  varied.    Some  of  these  symptoms  have  already  been 
alluded  to  in  dealing  with  the  matter  of  pain,  and  I  now  propose  to  consider 
some  of  the  graver  evidences  of  this  complication.    The  period  at  which 
these  symptoms  make  their  appearance  is  very  uncertain.    The  disease  may 
run  its  entire  course,  and  end  in  cure,  without  cord-symptoms  of  any  kind 
having  been  observed ;  or,  on  the  other  hand,  such  symptoms  may  be  among 
the  earliest  evidences  of  the  malady.    The  first  evidences  ot*  these  nerve-com- 
plications may  be  very  trifling  and  obscure,  while  in  not  a  few  cases  the  first 
and  only  sio-n  of  injury  to  the  cord  has  been  sudden  death.    Such  instances  of 
sudden  death  are,  probably  in  all  examples,  due  to  a  giving  way  of  the  trans- 
verse and  odontoid  ligaments,  whereby  the  atlas,  bearing  the  entire  weight 
of  the  head,  slides  forward  upon  the  axis,  and  thus  crushes  the  lower  part  ot 
the  medulla.    In  most  instances,  however,  the  symptoms  develop  very  slowly, 
and  proceed  from  bad  to  worse  in  progressive  cases.    There  may  at  lirst  be 
tindinp;  or  darting  pains  in  one  or  other  of  the  limbs,  usually  m  the  upper 
extremities.    This  may  be  followed  by  a  feebleness  that  may  pass  on  to  more 
or  less  complete  paralysis.    Some  few  cases  are  recorded  where  pam  and 
weakness  have  appeared  in  both  arms  and  in  both  legs  at  once.    The  para- 
lytic symptoms  may  be  preceded  by  spasmodic  contractions  of  various 
muscles,  and  by  convulsive  movements  of  the  limbs.    In  the  case  recorded 
bv  Dr  Lochee  and  Mr.  C.  H.  Moore,  and  quoted  above,  the  fingers  and  wrists 
were  contracted  in  the  flexed  position,  and  a  like  continuous  spasm  was  noted 
in  the  feet ;  there  was  muscular  weakness,  but  no  paralysis.    In  a  case  seen 
bv  Mr  Shaw,  "  the  muscles  became  affected  with  tonic  spasm ;  the  whole 
body  was  so  rigid  that  on  turning  the  patient  in  bed  she  rolled  with  the  stift- 
ness  of  a  corpse  having  rigor  mortis;  that  condition  lasted  for  a  month, 
it  gave  place  gradually  to  ordinary  paralysis,  from  which  she  eventually 
recovered."^    The  paralysis  may  vary  greatly  m  extent ;  it  is  arrt  to  be  genera 
rather  than  local,  and  although  some  patients  become  paraplegic  merely,  and 
others  exhibit  no  more  extensive  paralysis  than  loss  of  power  m  one  arm,  yet 
the  bulk  who  show  motor  defects  show  those  defects  over  an  extensive  series 
of  muscles,  and  exhibit  a  condition  that  varies  from  general  muscular  weak- 
ness to  general  paralysis  of  parts  below  the  neck.    Sensation  is  much  less 
frequently  impaired  than  motion,  and  would  appear  to  be  scarcely  ever  im- 

.  Med.^hiru.g,  Trans    vol.  xxxii.  p.  64.    1849.  ^  ^^^tt  u"'  '''' 

^  Op.  cit.,  vol.  1.  p.  281.  ^        '  ^ 

6  Loc.  cit.,  p.  145. 


DISEASE  OF  THE  ATLO-AXOID  REGION. 


557 


paired  without  motor  defects  ;  but  with  extensive  paralysis  there  may  be  con- 
siderable anaesthesia.  In  the  cases  of  wide-spread  paralysis,  there  is  usually 
loss  of  control  over  the  bladder  and  rectum. 

A  fatal  termination  may  be  preceded  by  certain  cerebral  symptoms — ver- 
tigo, headache,  vomiting,  convulsions,  and  epileptiform  attacks  ;  or  death  may 
be  sudden,  from  a  suddeu  crushing  of  the  cord  in  the  manner  above  detailed. 

In  addition  to  these  particular  symptoms,  the  patient  with  disease  of  the 
upper  cervical  spine  may  exhibit  certain  general  symptoms — such  as  fever, 
marasmus,  hectic,  fatty  and  amyloid  degeneration  of  viscera  from  long-con- 
tinued suppuration,  etc. 

Differential  Diagnosis. — In  the  diagnosis  of  disease  in  the  occipito-atloid 
and  atlo-axoid  regions,  the  following  sources  of  fallacy  must  be  eliminated: 
Muscular  rheumatism  in  the  cervical  region  may  cause  stiffness  of  the  neck, 
with  pain  on  movement,  and  has  been  mistaken  for  the  graver  malady.  The 
spinal  disease,  however,  is  most  common  in  the  young,  at  an  age  when  this 
form  of  rheumatism  is  quite  uncommon.  The  rheumatic  affection  is  associ- 
ated with  a  good  deal  of  tenderness  on  pressure,  a  symptom  absent  or  but 
slightly  marked  in  the  spinal  ailment.  Steady  pressure  of  the  head  vertically 
down  upon  the  vertebral  column  will  not  increase  the  pain  in  muscular  rheu- 
matism ;  nor  is  that  pain  as  much  aggravated  by  jolts  and  sudden  movements 
as  it  is  in  the  spinal  affection.  The  neck,  in  severe  muscular  rheumatism,  will 
be  quite  stiff,  but  in  the  more  deeply  seated  disease,  rotation  of  the  head  may 
remain  comparatively  free,  while  nodding  is  impossible,  and  vice  versa.  The 
rheumatic  affection  is  associated  with  no  deformity,  such  as  projection  of  the 
spine  of  the  axis.  It  may  be  attended  with  pains  in  the  limbs,  but  these  can 
easily  be  differentiated  from  the  nerve-pains  in  the  spinal  disease.  The  pro- 
gress of  the  case  and  the  effects  of  treatment  will  readily  remove  in  time  any 
difficulties  in  diagnosis. 

A  deep-seated  cervical  abscess^  associated  with  rigidity  of  the  neck,  pain  on 
movement,  etc.,  may  cause  error  in  diagnosis,  and  the  source  of  the  abscess 
may  be  wrongly  imputed.  The  simple  cervical  abscess  does  not  tend  to  cause 
rigidity  of  the  neck  until  it  is  well  advanced,  whereas  the  abscess  due  to 
spinal  disease  will  have  been  preceded  by  rigidity  of  the  parts  for  perhaps  a 
considerable  time.  In  the  simple  abscess,  the  neck  is  apt  to  be  drawn  to  one 
side,  a  position  uncommon  in  the  spinal  affection.  In  the  simple  abscess  the 
pain  is  not  apt  to  be  increased  by  carefully  applied  pressure  to  the  vertex ; 
there  will  be  an  absence  of  spinal  deformity,  of  post-pharyngeal  mischief,  and 
of  cord  and  nerve  symptoms.  Lastly,  the  source  of  the  non-spinal  abscess  may 
be  made  out,  and  a  positive  diagnosis  be  thus  established.  Torticollis^  phleg- 
mon of  the  neck^  and  glandular  disease  are  enumerated  by  some  authors  as 
affording  possible  sources  of  fallacy  in  diagnosis ;  but  the  points  of  resem- 
blance between  these  affections  and  the  spinal  malady  are  not  sufficiently 
close  to  merit  further  notice. 

Prognosis. — The  progress  of  the  disease  varies  considerably  both  as  to  the 
manner  and  the  rapidity  of  its  advance.  Within  a  short  time  from  the  com- 
mencement of  the  disease,  the  patient  may  be  bedridden ;  and,  on  the  other 
hand,  cases  are  met  with  like  one  recorded  by  Shaw,  where  a  patient,  a 
servant-girl,  continued  her  work  without  inconvenience  until  the  deformity, 
due  to  the  sliding  forwards  of  the  atlas  on  the  axis,  was  well  marked.  On 
the  whole,  the  prognosis  in  this  malady  is  grave,  the  seriousness  of  a  case 
depending  mainly  upon  the  implication  of  the  cord.  Although  the  majority 
of  the  deaths  from  this  disease  are  due  to  nerve-complications,  a  fatal  result 
may  be  brought  about  in  other  ways.    Thus,  the  patient  has  sometimes  died 


558 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


from  asphyxia,  owiiig  to  an  inability  to  cough  or  expectorate.  The  escape  of 
pus  into  the  larynx  from  a  post-pharyngeal  abscess  has  caused  death  by  a  like 
means.  The  rigidly  retained  recumbent  posture  has  led  to  fatal  hypostatic 
congestion  of  the  lungs  ;  and  other  patients  have  died  of  marasmus,  or  of  some 
of  the  evils  that  attend  upon  suppuration  and  discharging  sinuses.  The  least 
serious  form  of  paralysis  is  that  which  involves  the  upper  extremity,  espe- 
cially when  it  implicates  but  one  limb,  or  btit  a  part  of  one ;  the  most  grave 
form  appears  as  equal  paralysis  of  both  lower  extremities,  or  of  the  entire 
body.  It  is  well,  however,  to  remember  that  even  the  most  severe  forms  of 
paralysis  may  be  recovered  from  in  this  malady.  Thus  Shaw  cites  the  case 
of  a  man  aged  48,  wdth  disease  of  the  atlo-axoid  articulation,  who  was,  for 
six  months,  entirely  paralyzed  "  from  the  head  to  the  toes,"  and  who,  never- 
theless, made  a  perfect  recovery.  It  is  obvious  that  age  influences  the  prog- 
nosis considerably,  and  that  the  younger  the  patient  the  more  probable  is  a 
good  result,  other  things  being  equal. 

As  the  cure  is  by  anchylosis,  any  deformity  that  has  developed  must 

Eersist,  as  must  also  a  considerable  defect  in  the  range  of  movement.  Cases 
ave,  however,  been  recorded  here  and  there,  where  a  good  deal  of  movement 
has  been  recovered  after  extensive  disease  that  has  involved  the  bones  rather 
than  the  joints.  Thus,  in  a  case  where  nearly  the  entire  anterior  arch  of  the 
atlas  came  away  as  a  sequestrum,  the  patient  recovered  with  the  rotatory 
movements  of  the  head  almost  perfect,"  and  with  but  incomplete  limitation 
of  the  nodding  movements.^ 

Treatment. — The  general  treatment  of  these  cases  of  spinal  disease  needs 
no  comment.    The  local  treatment  should  be  such  as  to  insure  absolute  rest 
to  the  part,  and  to  prevent  displacement  of  the  bones.     These  ends  can 
only  be  properly  secured  by  a  rigidly  maintained  recumbent  posture.  The 
patient  should  be  placed  absolutely  flat  upon  his  back,  upon  a  Arm  and  level 
mattress.    Beneath  the  nape  of  the  neck,  a  small,  firm  cushion  should  be 
placed;  and  the  occiput  may  rest  either  upon  a  very  slight,  soft  pillow,  or 
upon  a  circular  pad,  so  hollowed  in  the  centre  as  to  relieve  the  more  promi- 
nent -part  of  the  occiput  from  any  injurious  pressure.    The  importance  of  the 
small,  hard  cushion  beneath  the  nape  of  the  neck— as  first  advised  by  Mr. 
Hilton — cannot  be  over-estimated.    Without  such  a  support,  the  recumbent 
position  becomes  almost  useless.    Mr.  Hilton  has  shown  by  a  reference  to 
anatomical  facts,  and  by  experiment  upon  the  dead  body,  that  this  little 
cushion  supports  the  axis  and  tends  to  lift  it  up.    By  this  means  the  glidmg 
forward  of  the  atlas  upon  this  bone  is  rendered  impossible,  compression  of 
the  cord  is  thus  avoided,  and  the  slight  flexure  given  to  the  spine  acts  by  way 
of  slight  extension  upon  the  diseased  parts.    The  head  should  be  kept  fixed 
in  the  position  indicated,  by  two  large  sand-bags,  placed  one  on  either  side  of 
the  head  and  neck.    In  cases  where  the  patient  is  restless  and  apt  to  move 
the  head,  immobility  may  be  secured  by  a  linen  cap  that  comes  well  forward 
on  to  the  forehead,  and  is  secured  under  the  chin  and  around  the  neck.  To 
the  front  of  this  cap,  linen  bands  are  attached  transversely,  and  secured  to  the 
sand-bags.    By  these  means  the  head  may  be  kept  secured  to  the  bed,  and 
none  but  the  most  trifling  movement  permitted.  This  position  should  be  main- 
tained strictly  for  as  many  months  as  may  be  required.    From  three  to  six 
months  will  be  suflicient  in  the  bulk  of  cases.   The  recumbent  posture  rigidly 
maintained  in  the  manner  just  indicated,  is  the  only  safe  position  for  a  patient 
with  active  disease  about  the  atlo-axoid  region.    Hilton  records  the  case  ot 
a  little  girl,  aged  5,  who  presented  very  severe  symptoms  in  connection  with 

I  Med.-Chir.  Trans.,  vol.  xxxii.  page  64. 


DISEASE  OF  THE  ATLO-AXOID  REGION. 


559 


this  spinal  disease.  The  recumbent  posture  was  ordered  and  maintahied  most 
rigidly.  In  14  days  the  child  had  remarkably  improved,  when  an  officious 
nurse,  in  direct  disobedience  to  orders,  thought  lit  to  ask  the  child  to  sit  up. 
Th3  child  did  so ;  the  head  fell  forwards,  and  the  patient  was  dead.^  The 
relief  that  the  recumbent  posture  often  gives  to  some  of  the  most  urgent 
symptoms  of  the  malady  is  well  shown  in  the  following  case,  also  recorded 
by  Mr.  Hilton.  The  patient— a  young  woman — when  seen  by  Mr.  Hilton, 
was  almost  pulseless,  was  unable  to  swallow,  was  scarcely  breathing,  and  not 
quite  conscious,  and  was  paralyzed  nearly  completely  in  both  arms  and  legs. 
She  was  propped  up  in  bed  by  pillows  at  her  back,  with  her  head  inclined 
somewhat  forwards.  Her  death  appeared  imminent.  She  was  at  once  laid 
flat  upon  the  bed,  with  a  pillow  beneath  the  nape  of  her  neck,  as  above  de- 
scribed. The  sense  of  suffocation  was  immediately  relieved,  and  the  severity 
of  the  other  symptoms  soon  diminished.  She  retained  the  recumbent  posture 
for  six  months,  and  then  left  the  hospital  cured. 

When  it  is  believed  that  firm  consolidation  has  taken  place,  the  patient 
may  be  allowed  to  get  up  ;  but  before  such  a  change  in  position  is  permitted, 
the  head  and  neck  must  be  fixed  in  some  rigid  apparatus.  This  apparatus 
may  consist  of  a  well-moulded  stock  of  gutta  percha,  leather,  or  poro-plastic 
felt,  and  should  be  well  secured  below  to  the  shoulders,  back,  and  chest,  and 
above  to^  the  chin,  lower  jaw,  and  occiput.  Or,  in  the  place  of  these  appli- 
ances, a  jacket  may  be  fitted  to  the  trunk,  and  a  jury-mast  applied  in  the 
manner  indicated  when  dealing  with  the  treatment  of  Pott's  disease.  The 
diseased  parts  should  be  thus  maintained  until  perfect  cure  has  resulted.  In 
no  case  should  any  of  these  instruments  be  used  as  a  preliminary  mode  of 
treatment,  to  the  disregard  of  the  recumbent  position.  In  all  cases  they 
should  be  merely  supplemental  or  secondary  to  the  treatment  by  posture. 
Those  vvdio  deprecate  prolonged  recumbency  urge  that  many  cases  do  well 
and  end  in  cure  when  this  measure  has  not  been  made  use  of.  But  it  must 
be  remembered  that  cases  of  cure  under  these  circumstances  are  exceptional, 
and  they  should  be  regarded  merely  as  fortunate  occurrences,  and  not  as  fur- 
nishing grounds  for  the  selection  of  a  mode  of  treatment.  It  is,  perhaps, 
needless  to  observe  that  attempts  to  reduce  the  dislocation,  such  as  have  been 
practised  by  some  surgeons,  are  quite  unjustifiable,  and  are  more  likely  to  end 
in  death  than  in  any  improvement. 

With  regard  to  the  abscess,  it  should  be  opened  at  the  earliest  opportunity, 
and  a  free  vent  given  to  the  pus.  This  especially  applies  to  post-pharyngeal 
collections.  These  abscesses  should  be  opened  by  a  small  puncture  that  may 
be  subsequently  enlarged,  and  the  operation  should  be  performed  while  the 
patient  is  in  the  recumbent  posture,  in  order  that  the  escaping  pus  may  run 
•down  into  the  gullet,  rather  than  into  the  larynx,  as  might  readily  occur, 
especially  when  the  subject  of  the  operation  is  a  child.  When  the  purulent 
collection  presents  itself  both  at  the  side  of  the  neck  and  behind  the  pharynx, 
It  may  be  well  to  open  it  in  the  former  situation,  according  to  the  method  ad- 
vocated  by  Hilton.^  This  surgeon  has  given  an  example  of  the  opening  of  an 
abscess  m  the  neck  that  presented  itself  also  behind  the  pharynx.  A  good  result 
followed.  Any  sequestra  that  may  be  exposed  by  the  opening  of  the  pharyn- 
geal abscess,  or  by  the  extension  of  a  pharyngeal  ulcer,  may  be  removed  by 
forceps,  provided  that  they  are  quite  loose.  Large  portions  of  both  the 
atlas  and  the  axis  have  been  removed  through  the  mouth  under  these  circum- 
stances. In  cases  due  to  syphilis,  a  specific  treatment  must  of  course  be 
adopted. 


1  Op.  cit.,  page  111. 


2  See  Vol.  I.,  page  761. 


560 


MALFORMATIONS  AND  DISEASES  OF  THE  SPINE. 


[Additional  Remarks  on  Spina  Bifida. 

Some  reference  should  be  here  made  to  the  Report  of  the  Committee 
appointed  by  the  Clinical  Society  of  London  to  investigate  the  subject  ot 
Spina  Bifida,  which  has  been  made  public  since  the  completion  ot  Mr. 
Treves's  article. 

This  committee  divides  cases  of  spina  bifida  into  three  classes,  viz.:  cases 
in  which  the  protrusion  involves  the  membranes  only  {spinal  meningocele), 
cases  in  which  the  cord  and  membranes  are  both  involved  {meningo-myelo- 
cele\  and  cases  in  which  the  cavity  of  the  sac  is  formed  by  the  central  canal 
of  the  cord  itself  {syringo- myelocele).  The  second  variety  is  the  most,  and 
the  third  the  least,  common.  In  meningo-myeloceles  the  spinal  cord  with 
its  central  canal  is  found  within  the  median,  vertical  portion  of  the  sac,  and 
at  this  part  there  is  no  covering  of  true  skin ;  from  this  intramural  portion 
of  the  central  nervous  system  arise  the  nerve-roots  by  which  the  sac  is  tra- 
versed.  A  somewhat  similar  classification  is  adopted  by  Prof.  Humphry, 
of  Cambrido-e,  who  recognizes  as  the  most  common  form  of  spina  bifida  the 
hydroracMs'" externa  anterior,  in  which  the  fluid  occupies  the  subarachnoid 
space  in  front  of  the  cord,  this,  with  the  nerves,  being  stretched  backwards 
and  outwards  upon  the  sac,  and  being  there  confluent,  together  with  the 
arachnoid,  pia  mater,  and  dura  mater,  or  their  representatives  m  the  thm 
membrane  which  forms  the  hindmost  part  of  the  wall  of  the  sac  ;  and  regard- 
ing as  rarer  varieties  the  hyclroraehis  externa  posterior,  or  hydro-meningoceie, 
-  in  which  the  fluid  is  found  behind  the  cord,  which  does  not  enter  the  sac, 
and  the  hydrorachis  interna,  or  hydro-myelocele,  in  which  the  fluid  occupies 

the  central  spinal  canal.  .i   .  xi     ^i,  i.^.^ 

The  Committee  of  the  Clinical  Society  believes  that  the  theory  best 
explaining  the  pathological  anatomy  of  spina  bifida  is  that  which  assumes 
a  primary  defect  of  development  of  the  mesoblast  from  which  aje  formed 
the  structures  closing  in  the  vertebral  furrow.  Three  analyses  of  the  fluid 
of  spin^e  bifid^e  made  for  the  committee  by  Halliburton  showed  uniformly  a 
decided  trace  of  sugar,  with  a  diminution  in  the  quantity  of  proteids,  which 
appeared  to  consist  entirely  of  globulin.  ...    ,    x  x-  ^-  -u-i^ 

Vith  reo-ard  to  the  treatment  of  spina  bifida,  the  committee  s  statistics,  while 
confirming  the  opinion  that  Morton's  iodo-glycerine  injection  affords  the 
most  successful  mode  of  treatment,  do  not  show  as  large  a  proportion  of  cures 
as  has  been  reported  by  that  author  himself,  benefit  havmg  been  obtained 
from  the  operation  in  only  39  out  of  71  cases.  Of  23  ^^^^^.^^f^  J^^^^ 
the  Committee  as  having  been  treated  by  excision,  16  are  said  to  have  been 
successful. 

Operative  Treatment  of  Pott's  Disease. 

Mr  Treves  has,  since  the  publication  of  this  article,  recorded  cases  in  which 
spinal  abscesses  were  opened,  with  antiseptic  precautions,  from  the  iom,  and 
the  aflected  vertebrae,  whether  carious  or  necrosed,  then  submitted  to  diiect 
treatment,  as  would  be  done  in  cases  of  bone-disease  of  f^^^^*  regions  bma- 
ilar  operations  have  also  been  performed  by  Bcecke  ,  By rd  R.  Davy,  an^  Mac- 
ewen.  The  latter  surgeon  reports  a  cure  by  trephining  the  vertebral  laminse 
for  the  paraplegia  of  Pott's  disease,  and  in  an  analogous  case  recorded  by 
Maydl,  the  patient  at  least  recovered  from  the  operation.] 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR 

APPENDAGES. 


E.  WILLIAMS,  M.D., 

PROFESSOR  OF  OPHTHALMOLOGY  IN  MIAMI  MEDICAL  COLLEGE,  CINCINNATI. 


Among  the  five  special  senses,  royal  importance  has,  at  all  times,  been  con- 
ceded to  sight.  The  value  of  the  eye,  in  the  animal  economy,  has  drawn  to 
its  diseases  a  never-flagging  interest.  As  we  approach  this  mystic  temple  to 
inquire  into  divine  secrets,  let  us  walk  lightly,  for  we  are  treading  on  holy 
ground.  Shut  off  the  light  of  the  eye,  which  is  the  cheer  of  the  soul,  and 
the  blackness  of  darkness  rusPies  in  to  overwhelm  the  stoutest  heart.  Had 
not  the  "  drop  serene  "  quenched  the  orbs  of  Milton,  his  ecstatic  invocation 
to  Light  coiild  never  have  been  conceived.  It  is  said  of  Shakespeare  that 
when  he  wrote  he  dipped  his  pen  in  his  own  heart.  That  is  the  main  secret 
of  his  immortality.  The  truly  scientific  spirit  is  ever  humble,  supremely 
desiring  to  know  and  to  tell  the  truth.  In  entering  on  our  favorite  study, 
shall  we  not  bring  to  bear  upon  it  an  earnest  and  honest  intelligence  ?  To 
this  end  a  brief  outline  of  the  structures  composing  the  organ  whose  injuries 
and  diseases  we  are  to  investigate,  must  inaugurate  our  work.  In  the  pinch- 
ing interests  of  brevity  we  must  assume  that  the  reader  has  an  adequate 
knowledge  of  the  anatomy  and  physiology  of  the  eye,  which  needs  only  to  be 
refreshed.  First  in  the  order  of  solid  importance,  let  us  take  up  the  cavity 
in  which  the  eye  is  securely  lodged,  and  successfully  discharges  its  functions. 


Anatomy  of  the  Eye. 

The  Bony  Orbits. — These  are  hollow  pyramids,  with  bases  presenting  for- 
wards and  outwards,  and  apices  backwards  and  inwards.  The  axes  of  the 
two  cavities  intersect  over  the  sella  turcica.  This  divergence  of  the  orbits 
affords  a  larger  field  of  vision  and  greater  circumspection.  The  most  firm 
and  resisting  part  is  the  bony  ring  that  forms  its  base.  The  prominence  of 
these  bony  guards,  with  the  nose  between  them,  protects  the  eyes  from  the 
disastrous  force  of  injuries.  The  upper  wall,  slightly  arched,  is  formed  by  the 
frontal  and  sphenoid  bones,  and  supports  the  anterior  lobe  of  the  brain.  In  its 
middle,  the  orbital  plate  is  very  thin,  and  liable  to  be  fatally  pierced  by  direct 
thrusts  from  nelow.  I  recall  the  case  of  a  man,  brought  to  the  hospital  with- 
out history,  and  delirious,  and  who  soon  died.  The  end  of  a  small  knife-blade 
was  found  broken  off' in  this  plate,  penetrating  and  causing  abscess  of  the  brain. 
On  this  wall  are  found  the  optic  foramen,  the  pit  for  lodging  the  lachrymal 
gland,  a  little  depression  for  the  trochlea,  and  a  supra-orbital  foramen  or  notch. 
The  inner  wall,  furnished  mainly  by  the  ethmoid,  is  smooth  and  parallel  with 

vol.  IV.— 36  (561) 


562         I>'JURIES  AND  DISEASES  OF  THE  EYES  A^D  THEIR  APPENDAGES. 

its  fellow,  completed  anteriorly  by  the  lachrymal  and  nasal  process  of  the  supe- 
rior maxillary.  Here  is  seen  the  vertical  groove  in  the  os  unguis  that  lodges 
the  lachrvmal  sac,  and  becomes  below  the  bony  nasal  duct.  The  lower  \yall, 
made  up  "chiefly  by  the  orbital  plate  of  the  superior  maxillary,  slopes  a  little 
downwards  and  outwards.  In  it  is  seen  the  groove  for  the  infra-orbital 
nerve.  The  outer  wall,  supplied  by  the  malar  and  sphenoid,  is  very  solid, 
slornno'  outwards,  and  oivins^  divergence  to  the  orbits.  The  scope  of  vision 
thus  afforded,  supplemented  V  rotatory  movements  of  the  head,  enables  us  to 
sweep  the  horizon  with  our  view.  . ,  i  i 

Xear  the  apex  of  the  cavity  we  find  two  large  fissures,  the  sphenoidal  and 
spheno-maxillary,  givins;  passage  to  vessels  and  nerves ;  the  former  com- 
municating with  the  cavity  of  the  cranium,  and  the  latter  with  the  zygomatic 
fossa.  The  motor  nerves that  supply  the  extrinsic  and  intrinsic  muscles  of 
the  eve  the  ophthalmic  branch  of  the  fifth  nerve,  some  filaments  ot  the 
sympathetic,  and  the  ophthalmic  vein,  all  pass  into  the  orbit  through  the 
sphenoidal  fissure.  The  infra-orbital  artery  and  nerve  pass  through  the 
spheno-maxillarv  fissure,  into  the  groove  in  the  floor  of  the  orbit,  in  blows 
on  the  temple,  blood  may  find  its  way  through  this  fissure  and  give  rise 
to  ecchymosis  of  the  conjunctiva.  I  once  saw  periostitis  following  the  ex- 
traction of  an  upper  molar  tooth,  the  pus  passing  through  this  fissure  into 
the  orbit,  and  pointing  at  the  lower  and  outer  margin,  below  the  angle  of 
the  eyelids.  In  fractures  of  the  base  of  the  skull,  the  crack  often  passes 
throuo'h  the  sphenoidal  fissure,  and  gives  rise  to  conjunctival  ecchymosis. 
It  may  likewise  traverse  the  optic  foramen,  contusing,  tearing,  or  compress- 
ino'  the  nerve,  and  o-iving  rise  to  serious  disturbances  of  sight.  A  sharp 
inftrument  mav  be  thrust  through  the  sphenoidal  fissure  with  fatal  injury 
to  the  brain.    A  royal  example,  in  the  case  of  Henry  the  Second,  of  ±  ranee, 

TrerLe*^of  the^  cavity,  with  its  fissures  and  foramina,  is  perceptibly 

diminished  by  the  periorbita  that  lines  it  throughout,  contmuous  at  the  base 
with  the  pericranium,  and  at  the  apex  with  the  dura  matei%  The  periorbita 
is  thin  and  somewhat  loosely  connected  with  the  bones,  being  easily  sepa- 
rated by  extravasations  of  blood  or  collections  of  pus.  - 

In  close  relation  to  the  orbit,  are  several  cavities  in  bones  the  largest  of 
which  is  the  antrum  in  the  superior  maxillary.    A  thm  translucent  plate  of 

bone  intervenes  between  it  and  the 
socket.  High  up,  it  opens  into  the 
nose,  and  is  lined  throughout  by 
mucous  membrane.  The  antrum 
is  large  enough  to  hold  a  musket- 
ball,  and  instances  are  on  record, 
in  which  bullets  have  lodged  there 
for  years.  The  frontal  sinus,  at 
the  upper  and  inner  part  of  the 
orbit,  communicates  freely  with 
the  superior  meatus  of  the  nose, 
through  the  infundihulum.  The 
numerous  air  cells,  in  each  mass  of 
the  ethmoid,  are  separated  from  the 
socket  only  by  a  thin  plate  of  bone, 
the  OS  planum.    (Fig.  903.) 

Tumors  and  accumulations  of 
various  kinds  in  these  cavities,  are 
likely  to  encroach  upon  the  orbit, 
dislodge  the  eye,  and  cause  exoph- 


Fig.  903. 


Frontal  section  of  an  adult  skull  through  the  middle  of 
the  orbits.  0.  Orbit ;  3^.  Naris  ;  A.m.  Antrum  maxillare  ; 
C.c.  Cranial  cavity.    (After  Merkel.) 


ANATOMY  OF  THE  EYE. 


563 


thalmus,  diplopia,  and  other  serious  troubles.  I  have  seen  several  cases  of 
cyst  m  the  ethmoid,  that  crowded  the  contents  of  the  orbit,  and  had  to  be 
treated  surgically,  to  save  the  eye.  Cases  of  fistula  of  the  frontal  sinus  pre- 
senting above  the  tendo  oculi,  have  been  sent  to  me  for  fistula  lachrymalis. 

Fig.  904. 


Horizontal  section  through  the  orbit  of  an  adult  male.  B.  Eyeball;  R.L.  External  rectus  muscle-  R.m  In- 
ternal  rectus  ;  F.  Orbital  fat;  N.o.  Opr.ic  nerve;  T.B.  Capsule  or  fascia  of  Tenon;  L.p.l.  External' palpebral 
ligament;  (y.Z.  Lachrymal  gland  ;  S.o.  Orbital  septum  ;  M.H.  Upper  part  of  Horner's  muscle  (tensor  tarsi)  ;  U.c. 
Reflexion  or  conjunctiva;  T.  Tarsal  cartilage;  M.o.p.  Orbicularis  palpebrarum  muscle;  P.m.o.  Internal  wall  of 
orbit;  C.e.  Ethmoidal  cells;  P.l.o.  External  wall  of  orbit;  M.t.  Temporal  muscle;  X  Junction  of  capsule  of 
Tenon  with  conjunctiva  of  globe;?/.  Fascial  termination  of  sheath  of  internal  rectus;  z.  Fascial  termination  of 
sheath  of  external  rectus.    X         (After  Gerlach.) 

The  bony  orbit  lodges  the  eye,  the  optic  nerve,  the  six  rotatory  muscles 
and  their  nerves,  sensory  nerves,  numerous  bloodvessels,  and  a  laro;e  amount 
of  cellulo-adipose  tissue,  which  gives  sof^  support  to  the  eyeball.   (Fig.  904.) 

Optic  ITerve.— The  optic  nerve,  entering  the  orbit  through  the  foramen  opti- 
cum,  and  measuring  about  4  mm.  in  diameter,  runs  forwards,  in  a  tortuous 
manner,  to  the  sclerotic,  slightly  below  and  inwards  from  the  posterior  pole 
of  the  eye,  which  it  pierces  in  an  opening  1.5  mm.  in  diameter.  Its  entire 
length,  within  the  orbit,  is  28  or  29  mm.  The  nerve  is  closely  embraced  bv  a 
neurilemma,  which  is  continuous  with  the  pia  mater,  and  which  sends  numer- 
ous septa  inwards,  to  divide  the  fibres  into  separate  bundles.    Through  these 


564         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

divisions,  the  nerve  trunk  is  freely  supplied  with  blood.  (Fig.  905.)  A  firmer 
external  sheath,  derived  from  the  dura  mater  at  the  optic  toramen,  envelops 

Fig.  905. 


Transverse  section  of  optic  nerve  a  little  in  front  of  the  entrance  of  the  central  vessels.  Vi.  Inner  sheath  or 
neurilemma  ;  Ve.  Outer  sheath  ;  A.  Lymph-space  between  the  two  sheaths,  a  continuation  of  the  arachnoideal 
space.    (After  Merkel.) 

the  nerve  and  neurilemma,  and  is  laxly  connected  with  the  latter  by  delicate 
fibrous  tissue.  The  two  sheaths  of  the  nerve,  thus  related,  become  more 
firmly  united  as  they  approach  the  sclera.  On  reaching  the  ball,  the  ex- 
ternal sheath  blends  with  the  sclera,  while  the  other  is  lost  m  the  choroid. 


Fig.  906. 


Fig.  907. 


T  A■r..^  «PrHon  of  the  entrance  of  the  optic  nerve  into  the  eyeball.  Cross-section  of  optic  nerve  at 

Longitudinal  section  ^fj^f^^^^^^^;  ^^^^^^  ^,,,,1,  .   y^,  j^^er         point  of  passage  through  lamiua 

0.  Substance  of  optic  '         /^^^^^^^^^^  1   Lymph-space  between         cribrosa.    S.  Sclerotic;  Vc.  Cross. 

:^:::L:^^s:;::rLt  :i::iz£::Lo..  ,  l...  , central  vesse..  (^ter 

(After  Merkel.) 

Constricted  in  passing?  through  the  sclera,  the  nerve  changes  its  color  from 
white  to  semitransparent  gray,  due  to  microscopic  modifications  in  the  nerve- 


ANATOMY  OF  THE  EYE. 


565 


fibres  as  they  lose  their  opaque  sheaths.  A  third  covering,  between  these 
two,  very  delicate,  and  in  close  relation  to  the  outer  or  dural  sheath,  is  now 
described.  All  the  tunics  of  the  brain  are  thus  represented  as  continued  in 
the  sheath  of  the  optic  nerve.  The  intervaginal  space,  continuous  with  the 
subarachnoid  spaces  of  the  brain,  is  liable"  to  serous  infiltration  from  the 
brain,  causing^  compression  of  the  nerve-trunk.  The  constriction  of  the 
nerve  in  piercing  the  lamina  cribrosa  of  the  sclera,  the  sudden  bending  of 
the  individual  fibres  as  they  pass  into  the  retina,  the  canal  in  its  axis  for  the 
central  artery  of  the  retina,  as  well  as  the  opening  in  the  choroid,  are  all  well 
seen  in  the  annexed  cut.  (Fig.  906.)  Fig.  907  shows  a  transverse  section  of  the 
optic  nerve.  The  central  artery  of  the  retina  pierces  the  sheath,  aLout  half  an 
inch  behind  the  eye,  passes  to  the  axis  of  the  cord,  and  follows  it  till  it  enters 
the  fundus  and  divides  into  its  retinal  expansions.  The  main  trunks  of  the 
I'etinal  arteries  and  veins  enter  and  emerge  from  the  centre  of  the  optic 
papilla. 

Eyeball.— In  form,  the  eyeball  is  very  nearly  a  globe,  whence  its  name.  The 
antero-posterior  diameter  measures  about  24  mm.,^the  horizontal  23.5  mm.,  and 
the  vertical  23  mm.  (Merkel).    Just  back  of  the  sclero- 
corneal  junction,  the  globe  is  retracted  as  by  a  tight  Fig.  908. 

cord.  (Fig.  908.)  ^  From  the  centre  of  the  cornea  to  the 
deepest  part  of  this  constriction,  the  curvature  is  greater 
than^  that  of  the  rest  of  the  globe.  The  back  half  of  the 
eye  is  much  more  uniform  in  curvature  than  the  front. 
The  shape  and  firmness  of  the  ball  are  maintained  by  the 
outer  tunic.  This  thick,  dense  coat  is  composed  of  two 
parts,  continuous  by  their  constituent  elements,  but  dif- 
fering greatly  in  their  physical  properties.  The  one, 
the  sclera,  is  opaque  like  tendon  ;  the  other,  the  cornea, 
is  clear  like  fine  glass.  The  sclera  forms  a  little  more  ""IZ^.TaJ^^^^^^^^^ 
than  four-fifths,  and  the  cornea  the  rest,  of  this  strong,  in- 
vesting coat.  The  sclera  is  thickest  posteriorly,  where  it  is  pierced  by  the 
optic  nerve,  and  reinforced  by  its  outer  sheath,  measuring  here  1  mm.  For- 
wards it  grows  thinner,  till  again  reinforced  by  the  expanded  and  laterally 
l)lending  tendons  of  the  four  recti  muscles.  The  sclera  is  a  dense,  fibrous, 
white  menibrane,  composed  of  fibres  of  connective  tissue,  rigidly  interwoven  in 
all  directions,  but  running  mostly  at  right  angles  to  each  other.  The  portion 
seen  in  front,  is  called  the  white  of  the  eye.  At  the  point  of  penetration  of 
the  optic  nerve,  the  sclera  is  thin  and  pierced  by  numerous  small  holes  for  the 
passage  of  the  bundles  of  optic  nerve  fibres.  This  weakened  ring  of  sclera, 
which  plays  such  an  important  part  in  glaucoma,  is  called  the  lamina  cri- 
brosa. It  is  that  which  gives  the  stippled  aiDpearance  to  the  optic  papilla, 
when  seen  with  the  aid  of  the  ophthalmoscope.  It  is  situated  a  trifle  below- 
the  horizontal  meridian,  and  4  mm.  to  the  nasal  side  of  the  posterior  pole. 
Its  diameter  is  about  1.5  mm. 

In  its  entire  outer  surface,  the  sclera  is  embraced  by  the  capsule  of  Tenon, 
to  Avhich  it  is  loosely  connected  by  elastic  tissue,  allowing  of  the  greatest 
freedom  of  motion.  The  ball  rotates  in  this  capsule,  much  as  the  head  of  the 
femur  moves  in  the  acetabulum. 

In  front,  the  sclera  encroaches  somewhat  on  the  cornea,  especially  above 
and  below.  ^  For  this  reason  the  cornea  appears  oval  horizontally,  when 
viewed  anteriorly,  but  circular  when  seen  from  behind.  ^N'ear  its  inner  sur- 
tace,  close  in,  front  of  the  iris  and  just  behind  the  sclero-corneal  junction, 
lies  the  circular,  flattened  canal  called  the  sinus  venosus,  the  canal  of 
Schlemm,  and,  by  Leber,  the  plexus  ciliaris.    Close  in  front  of  this  venous 


566 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


canal  or  canals,  the  opaque  sclera  is  suddenly  transformed  into  the  clear 
cornea'Ihe  line  of  unio!>  being  called  the  lirnbvxs  corner  or  the  sclero-corneal 
Zction.  The  horizontal  diameter  of  the  cornea,  m  front  n>easures_11.6  mm., 
while  the  vertical  is  11  mm.    The  anterior  surface  of  the  cornea  is  an  ellip- 
soid the  curvature  in  the  vertical  being  slightly  greater  than  in  the  horizontal 
mer  dian.    This  ffives  rise  to  a  slight  degree  of  norma  astigmatism.  _  In  the 
central  region,  tErough  which  direct  vision  takes  place,  the  anterior  and 
po  terior  surfaces  of  the  cornea  are  parallel,  the  thickness  measuring  0.9  mm., 
while  in  the  periphery  it  is  1.1  mm.  thick.    The  most  important  physical 
properties  of  the  cornea  are  its  great  transparency  and  firmness  of  texture. 
It  is  seldom  ruptured  by  blunt  force,  the  sclera  yielding  in  preference,  m  a 
line  parallel  to  and  close  behind  the  base  of  the_  cornea.    In  virtue  of  its 
epithelial  covering,  the  free  surface  of  the  cornea  ls  very  polished,  reflecting 
sharp  but  diminutive  images.    The  conjunctival  epithelium  is  continuous 
with  that  of  the  cornea.    As  on  a  basement,  this  smooth  epithelial  layer  rests 
on  the  condensed  corneal  tissue,  called  usually  Bowman  s  membrane  Poste- 
riorly the  cornea  is  lined  by  a  "glass"  lamel  a,  the  membrane  ot  Descemet 
Its  free  surface,  washed  by  aqueous  humor  is  .cohered  by  a  single  layer  ot 
endothelial  cells,  which  have  an  important  bearing  on  the  filtration  of  fluids 
through  the  cornea.    The  proper  tissue  making  up  the  mam  thickness  ot 
the  cornea,  is  contained  between  these  two  surface  membranes,  and  is  ot  a 
lamellated  character,  capable  of  being  resolved  into  a  greater  or  less  number 
of  layers,  according  to  the  delicacy  of  the  manipulation.    Each  lamina  is 
composed  of  vast  numbers  of  fine  elastic  fibres,  running  parallel  with  each 
other    The  layers  are  placed  upon  each  other  so  that  the  fibres  of  one 
lamina  will  lie  at  right  angles  to  those  of  the  next.    The  numerous  lamina 
m-e  knit  together  by-  fibres  passing  more  or  less  perpendicularly  through 
them    The  interspaces  between  the  superimposed  layers  and  their  elements 
are  filled  with  a  transparent,  gluey  substance  in  which  are  lodged  the  cor- 
neal cells,  and  through  which  pass  the  irregular  canals  that  circulate  trans- 
parent, nutritive  fluid.    The  cornea,  as  a  necessary  condition  of  its  great 
clearness,  is  non-vascular,  only  becoming  visibly  vascular  m  ^.on^<^V^^nce  of 
inflammation.    The  cornea,  in  the  deeper  layers  of  its  epithelium  and  m  its 
superficial  lamina,  is  very  freely  supplied  by  a  fine,  beautifu  BetworW 
sensory  nerve  filaments.    Its  common  sensihihty  is  due  to  this  liberal  supply 
from  the  fifth  nerve.    The  arcus  senilis  of  the  cornea,  which  is  seen  in  many 
old  persons,  and  rarely  in  the  young,  is  a  fatty  degeneration  of  its  elements 
in  a  narrow  strip  just  within  its  base.    The  sclera  gives  so  id  attachment  to 
the  rotatory  muscles  which  reach  it  by  piercing  obliquely  the  capsule  of 
Tenon.    The  four  straight  muscles  are  fixed  to_  the  anterior,  and  the  two 
oblique  to  the  posterior  hemisphere  of  the  sclerotic. 

Within,  the  sclera  is  lined  by  the  choroid  for  about _  two-thirds  of  its 
extent  The  two  are  loosely  connected  by  elastic  fibrillar  tissue,  covered  with 
endothelium,  and  forming  lymph  spaces  The  choroid  is  excessively  vascular, 
forming  a  reservoir  of  nutritive  material  for  all  the  inner  organs  of  the  globe. 
It  contlins,  in  addition  to  its  exquisite  vascularity,  fine  fibres  of  eo"nective 
tissue,  numerous  cells  filled  with  pigment  granules,  and  many  nerve  fibres. 
The  amount  of  pigment  in  the  cells  of  the  stroma  varies  from  great  abund- 
ance in  dark  races,  to  little  in  fair  persons,  and  none  in  albinos.  _ 

Posteriorly,  the  choroid  is  pierced  by  the  optic  nerve,  the  opening  corres- 
ponding with  the  optic  papilla  and  the  blind  spot  The  choroid  was  once  con- 
sidered the  seat  of  visual  impressions,  and  the  hole  m  it  was,  of  course  a  sufh- 
cfent  explanation  for  the  blind  spot!  If  divided  into  two  layers  the  outer 
contains  the  large  choroidal  vessels  (vasa  vorticosa,  etc.)  and  the  inner,  the  beau- 
Xl  chorio-cailllaris.    It  is  undoubtedly  to  this  rich  network  of  capillaries. 


ANATOMY  OF  THE  EYE. 


567 


Fig.  909. 


that  the  outer  percipient  elements  of  the 
retina  (the  rods  and  cones)  look  for  their 
functional  nutrition.  Anteriorly,  the 
choroid  thickens  into  a  wedge-shaped 
portion,  called  the  ciliary  body.  From 
the  ora  serrata  retinae  to  within  1  mm. 
of  the  sclero-corneal  junction,  the  thick- 
ness gradually  increases,  terminating  in 
the  ciliary  processes,  which  surround  the 
margin  of  the  crystalline  lens  without 
touching  it.  The  processes  are  about 
seventy  in  number,  and  make  a  beautiful 
picture  when  the  eye  is  divided  through 
the  equator  and  they  are  looked  at  from 
behind.  A  good  idea  of  them  and  of 
the  vasa  vorticosa  is  obtained  from  Fig. 
909.  Continuous  with  the  ciliary  pro- 
cesses, and  gaining  from  them  part 
of  its  peripheral  insertion,  is  the  iris. 
Passing  from  the  points  of  the  ciliary 
processes  to  the  margin  of  the  lens,  is  the 

folded  zone  of  Zinn,  or  suspensory  ligament.  .  The  Lens,  agglutinated  to  the 
hyaloid  fossa  of  the  vitreous,  and  fastened  by  this  ligament  to  the  ciliary 
processes,  makes  a  complete  septum  between  the  vitreous  behind  and  the 
aqueous  in  front.  (Fig.  910.) 


Sagittal  section  of  eyeball.  X  3.  The  retina  has 
been  removed  with  the  pigmeut  membrane,  etc. 
Cc.  Ciliary  body ;  Vv.  Vense  vorticosae,  visibl© 
through  the  inner  layer  of  the  choroid.  (After 
Merkel.) 


Fig.  910. 


Ck 

Sc. 


Meridional  section  of  anterior  half  of  human  eyeball.  Sclerotic;  Ch.  Choroid;  L.i.  Internal  limiting 
membrane  ;  M.c.  Ciliary  muscle;  L.a.  Annular  ligament;  P.c.  Ciliary  processes;  Z.  Ciliary  zone:  L  Iris;  L. 
Lens  ;  N.l.  Nucleus  of  lens  ;  C.  Cornea  ;  P.c.r.  Ciliary  portion  of  the  retina.    X  4.    (After  Gerlach.) 

On  the  outer  surface  of  the  ciliary  body,  next  the  sclera,  lies  a  thickened, 
grayish  ring,  from  3  to  4  mm.  wide— the  ciliarij  miiscle~hj  the  action  of  which, 
on  the  lens,  the  eye  is  focused  for  distinct  vision  at  different  distances.  This 
muscle  takes  its  fixed  attachment  from  the  inner  surface  of  the  sclera,  in  a 
circular,  tendinous  ring,  corresponding  to  the  inner  wall  of  the  canal  of 
Schlemm  (Fig.  911).  From  this  attachment  it  sends  some  tendinous  fibres 
to  the  iris,  and  large  numbers  to  the  radiating  and  circular,  non-striated  fibres 


568 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


of  the  ciliary  muscle.  This  muscle,  acting  from  the  sclero-corneal  junction^ 
draws  the  choroid  forwards  and  renders  it  tense,  moving  the  ciliary  processes 
likewise  forwards,  and  a  little  tow^ards  the  axis  of  vision.  Thus  the  sus- 
pensory ligament  is  relaxed,  and  the  anterior  surface  of  the  lens,  which  is 

Fig.  911. 


The  ciliary  muscle,  a  Cornea  ;  b.  Liraljus  cornese  ;  c.  Sclerotic  ;  d.  Iris  ;  e.  Space  of  Fontana  ;  /.  Meridional 
portion  of  ciliary  muscle  ;  g,  Radial  portion  of  the  same  ;  h.  Annular  muscle  of  Miiller ;  i  Anterior  tendon  of  ciliary 
muscle  ;  k.  Posterior  tendon  of  meridional  portion  of  same.    (After  Iwanoff  and  Arnold.) 

compressed  in  the  quiescent  state  of  the  muscle,  is  allowed  to  grow  more  con- 
vex, in  response  to  its  natural  elasticity.  It  is  thus  that  the  eye  is  accommo- 
dated for  near  vision,  by  an  active  process,  producing  relaxation. 

The  active,  muscular  curtain,  w^hich  regulates  the  amount  of  light  admitted 
to  the  eye,  the  iris,  is  fastened  at  its  periphery  by  fibres  from  the  ligamentum 
annulare  of  the  ciliary  muscle,  by  bloodvessels  passing  directly  between  it 
and  the  choroid,  and  by  the  ligamentum  pectinatum— bands  of  elastic  fibres 
thrown  over  from  the  membrane  of  Descemet  to  the  iris,  at  the  outer  mar- 
gin of  the  anterior  chamber.  The  spaces  between  these  trabeculse,  and  con- 
necting wath  the  aqueous  chamber,  allowing  perhaps  free  filtration  of  the 
intraocular  fluids,  are  now  called  Fontana's  spaces. 

In  the  surgical  pathology  of  the  eye,  the  ciliary  region,  including  the  outer 
rim  of  the  anterior  chamber,  plays  a  very  important  part.  The  iris  is  a 
membranous  septum,  circular  in  form,  passing  across  the  eye  close  m  front 
of  the  lens,  from  its  attachment,  1  mm.  behind  the  clear  margin  of  the  cornea, 
and  pierced  in  its  centre  by  the  pupil.  Its  tissue  is  delicate,  easily  torn,  and 
very  sensitive,  and  both  surfaces  are  bathed  with  the  aqueous  humor,  in  which 
it  moves  with  perfect  freedom.  In  its  stroma  are  two  antagonistic  sets  of 
muscular  fibres.  One  set  is  arranged  in  a  circular  band  around  the  pupil, 
on  the  posterior  surface,  and  aboutl  mm.  wide,  supplied  with  motor  force  by 
filaments  from  the  third  nerve.  The  other  muscle  passes  from  the  entire 
periphery  of  the  iris,  in  converging  directions,  to  the  sphincter  pupillse,  with 


ANATOMY  OF  THE  EYE. 


569 


which  its  fibres  are  interlaced.  This  is  the  dilator  of  the  pupil,  and  it  is 
endowed  by  filaments  from  the  sympathetic  nerve.  The  iris  tissue  is  abun- 
dantly supplied  with  bloodvessels  and  pigment  cells,  the  latter  more  exube- 
rant on  the  posterior  surface.  There  is  likewise  a  generous  distribution  of 
nerve-fibres,  sensory  and  motor,  all  the  elements  being  united  by  connec- 
tive tissue.  The  iris,  in  a  narrow  ring  around  the  pupillary  border,  rests 
against  the  anterior  lens  capsule,  over  which  it  slides  in  the  almost  constant 
movements  of  contraction  and  dilatation  of  the  pupil.  The  pupil  moves  in 
response  to  reflex  impressions,  made  by  light  on  the  retina. 

Lying  immediately  within  the  choroid,  and  extending  from  the  optic 
nerve  entrance  to  the  ora  serrata  retinae,  is  the  nerve-membrane,  the  retina. 
It  is  a  very  soft,  perishable  structure,  quite  transparent,  and  hence  invisible', 
except  by  the  bloodvessels  with  which  it  is  freely  supplied.  Ordinarily  per- 
fectly colorless,  it  becomes  of  a  purplish-red  by  a  sojourn  in  the  dark.  This 
color  is  soon  dissipated  when  the  eye  is  exposed  to  common  light.  Fascinat- 
nig  as  may  be  the  chemical  theory  of  vision,  it  is  by  no  means  certain  that 
actmic  action  has  anythuig  to  do  with  this  marvellous  function.  Three 
objects,  all  in  or  connected  with  the  retina,  are  positively  to  be  seen  by 
ophthalmoscopic  illumination :  the  optic  disk,  with  its  sharp  margins  and. 

Fig-  912.  Fig.  913. 


Equatorial  section  of  eyeball,  natural  size,  posterior 
segmenc.  Fu.  Optic  papilla ;  Ml.  Macula  lutea.  (After 
Merkel.) 

characteristic  vessels;  the  macula  hitea, 
in  the  direct  line  of  vision ;  and  the 
ramifications  of  the  retinal  vessels. 
The  disk  or  papilla  is  of  circular  form, 
1.4  mm.  in  diameter,  light  purplish- 
white  in  tint,  and  contrastmg  sharply 
with  the  deep-red  color  of  the  rest  of 
the  fundus  of  the  eye.  In  its  centre 
are  seen  the  main  trunks  of  the  central 
artery  and  corresponding  veins  of  the 
retina,  radiating  and  ramifying  in  all 
directions,  but  more  notably  towards 
the  inner,  upper,  and  lower  parts  of 
that  membrane.  The  arteries  are  easily 
distinguished  by  their  lighter  color  and 
somewhat  smaller  size.  About  4  mm. 
from  the  centre  of  the  papilla,  and  out- 
wards, is  seen  the  macula  lutea  with 
its^  fovea  centralis.  This  lies  in  the 
axis  of  direct  vision,  and  is  the  most 
exquisite  part  of  the  retina.  (Fig.  912.) 


Diagrammatic  section  of  the  human  retina,  showing  ita 
ten  layers.    (After  Schultze  and  Schwalbe.) 


o70 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


The  conducting  fibres  of  the  optic  nerve,  estimated  at  438,000,  unfolding 
in  the  papilla,  bend  suddenly  outwards  and  are  lost  in  the  retina,  constituting 
its  innermost  layer,  in  which  are  distributed  the  arteries  and  veins,  stu- 
died in  microscopic  sections,  there  are  ten  distinct  layers  m  the  thickness  ot 
the  retina.  (Fig.  913.)  The  tenth  of  these,  the  pigment  epithelium,  formerly 
described  as  belongmg  to  the  choroid,  and  in  which  are  buried  the  outer  ends 
of  the  rods  and  cones,  is  now  known  to  be  an  integral  and  very  important  part 
of  the  retina.  The  rods  and  cones  standing  perpendicularly  m  the  outer  layer  ot 
the  retina,  are  the  percipient  elements  ;  the  inner  layer  is  composed  of  nerve- 
fibres  which  are  conductors  ;  and  the  intermediate  structures  serve  to  connect 
these  two  essential  elements.  Filling  and  giving  solidity  to  the  globe  of  the 
eye,  and  with  the  cornea  forming  its  refracting  media,  are  the  aqueous  and 
vitreous  humors  with  the  crystalline  lens  between  them.  (Fig.  914.) 


Fig.  914. 


Diagrammatic  horizontal  section  of  tlie  eye.    (After  Merkel.) 

The  space  between  the  cornea  and  the  lens  is  the  aqueous  chamber  di- 
vided by  the  iris  into  the  anterior  and  posterior,  communicating  through  the 
pupil  The  depth  of  the  anterior  chamber  is  3.6  mm.  In  active  accommo- 
dation, the  lens  capsule,  becoming  more  convex  and  carrying  the  iris  tor- 
wards,  diminishes  sli-htly  the  depth  of  the  chamber.  It  is  now  positively 
certain  that  the  lens,  acted  on  by  the  ciliary  muscle,  is  the  instrument  of 
accommodation.   As  age  progresses  the  lens  hardens,  responding  less  and  less 


ANATOMY  OF  THE  EYE. 


571 


to  the  efforts  of  this  muscle,  and  the  patient  becomes  presbyopic  and  has  to 
use  glasses  for  reading,  except  when  myopic. 

The  popular  notion  that  flattening  of  the  cornea  is  the  cause  of  presbyopia 
has  no  foundation.  The  lens  is  a  double  convex  body,  held  in  its  position 
close  behind  the  iris,  by  the  suspensor}^  ligament  and  adhesions  of  its  poste- 
rior capsule  with  the  hyaloid  fossa.  In  young  persons  it  is  soft,  elastic,  and 
colorless ;  in  advanced  years  it  becomes  of  an  amber  color,  and  hard  like  a 
piece  of  dry  cheese.  The  anterior  surface  of  the  lens  is  less  convex  than  the 
posterior.  The  thickness  of  the  lens  in  its  axis  is  3.7  mm.,  and  its  equato- 
rial diameter  is  from  9  to  10  mm.  The  firmer,  central  part  of  the  lens  is  called 
the  nucleus,  and  the  outer  layers  the  cortical  substance.  It  is  composed  of 
numerous  layers  like  an  onion,  the  layers  being  formed  by  individual,  ser- 
rated lens-fibres.  The  lens  is  closely  invested  by  a  capsule,  of  which  the 
anterior  portion  is  thicker  and  more  resistant  than  the  posterior.  It  is  struc- 
tureless and  perfectly  clear,  and  resists  chemical  reagents  in  a'  remarkable 
way.  The  medium  of  connection  between  the  lens  and  the  capsule  is  a  thin 
layer  of  cells  from  which  the  lens-fibres  take  their  origin,  and  through  which 
its  nutrition  is  accomplished.  How  the  lens  is  held  in  its  position  has  been 
already  stated. 

Filling  up  all  the  interior  of  the  eye,  back  of  the  lens,  is  the  vitreous  humor, 
or  corpus  vitreum.  This  is  of  the  consistence  of  jelly,  hangs  together  in  a  mass 
when  lifted,  and  is  absolutely  transparent.  Hence  the  difiiculty  in  studying 
its  structure,  and  the  various  views  in  regard  to  it,  error  being  sometimes 
caused  by  the  chemical  reagents  used  in  hardening  it.  Liquefaction  of  the 
vitreous  takes  place  soon  after  death,  and,  in  many  pathological  conditions, 
during  life.  In  the  extraction  of  cataract,  a  healthy  vitreous  greatly  dimin- 
ishes the  risks  of  accident,  and  should  be  ascertained  as  certainly  as  possible. 
In  the  process  of  diseases  of  the  choroid,  especially,  the  vitreous  is  liable  to 
become  in  part  or  entirely  disorganized.  In  that  case  it  is  turbid,  with  float- 
ing corpuscles,  and  interferes  with  satisfactory  ophthalmoscopic  examination. 

Muscles  attached  to  the  Eyeball. — The  eyeball,  so  balanced  in  the  orbit 
as  to  yield  to  the  least  muscular  force,  is  rotated  in  the  various  directions 
by  six  muscles.  The  four  recti,  originating  by  a  common  tendon  at  the  optic 
foramen,  passing  directly  forwards  so  as  to  embrace  the  globe  and  fasten 
themselves  upon  it,  form  two  pairs.  The  superior  and  inferior  oblique 
constitute  the  third  pair.  The  favorable  way  in  which  the  eye  is  pivoted 
in  the  socket,  and  acted  on  by  these  muscles,  is  well  seen  in  Fig.  915. 
Of  the  four  recti,  the  internal  is  the  strongest  and  the  superior  the  weakest. 
Before  their  firm  insertion  into  the  sclera,  the  four  recti  become  tendinous, 
the  width  and  situation  of  their  insertions  being  easily  seen  in  the  cut. 
The  flattened  tendons,  the  relative  distance  of  their  insertions  from  the 
cornea,  and  the  peculiar  relations  of  the  tendons  to  the  capsule  of  Tenon, 
through  which  they  must  pass  to  reach  the  sclerotic,  have  been  very  critically 
studied  since  the  introduction  of  tenotomy  for  the  relief  of  squint.  The  most 
trustworthy  measurements  (Merkel)  of  their  points  of  attachment  from  the 
cornea,  are:  for  the  rectus  internus  6.5  mm.,  rectus  externus  6.8  mm.,  rectus 
superior  8.0  mm.,  rectus  inferior  7.2  mm.  The  width  of  the  tendons  varies 
from  7  mm.  to  9  mm.  These  tendons,  before  their  insertions,  send  numerous 
filaments  of  connective  tissue  to  the  sclera,  and  also  from  their  edges,  thus 
adding  firmness  and  breadth  to  their  proper  tendinous  attachments.  The 
globe  is  embraced  by  the  capsule  of  Tenon,  which  is  loosely  connected  to 
the  sclera,  and  in  which  the  eye  rotates.  It  blends  with  the  conjunctiva,  and 
ends  near  the  margin  of  the  cornea.  Behind,  it  is  connected  wd'th  the  ball  at 
the  seat  of  penetration  of  the  ciliary  nerves  and  vessels,  not  reaching  quite 


572         INJURIES  A^B  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


to  the  optic  nerve.  Coming  forward  through  the  cushion  of  orbital  fat,  the 
recti  muscles  pierce  this  capsule  obliquely  by  their  tendons,  and  are  loosely 
connected  with  it.    The  fascia  of  these  muscles  is  likewise  pretty  firmly 


Fig.  915. 


The  eye  in  its  normal  situation  in  the  orbit,  seen  from  in  front.  Lp.  Levator  palpebrae  superioris  ;  Ss,  Bl,  Ri, 
Em.  Attachments  of  the  straight  muscles  of  the  eyeball.  Tr.  Trochlea.  Os.  Tendon  of  the  superior  oblique  mus- 
cle.   Oi.  Inferior  oblique  muscle.    (After  Merkel.) 


connected  to  the  outer  surface  of  the  capsule  of  Tenon,  where  they  press  upon 
it  before  passing  through  to  reach  the  sclera.  It  is  this  arrangement  that 
prevents  a  complete  tenotomy  from  destroying  all  control  of  the  muscle  over 
the  eye.  It  still  rotates  the  eye  through  this  indirect  influence  on  the  capsule 
and  its  insertion  around  the  cornea. 

The  movements  produced  by  the  isolated  or  combined  action  of  these 
muscles,  are  rotations  around  a  fixed  point  in  the  axis  of  vision,  13.54  mm. 
behind  the  centre  of  the  cornea,  near  the  physical  centre  of  the  globe.  In 
moving  the  eyes  right  or  left,  in  the  horizontal  level,  one  muscle  only  in  each 
eye  is  called  into  play.  The  external  moves  the  cornea  directly  outwards, 
and  the  internal,  inwards.  In  moving  the  cornea  directly  upwards,  the 
superior  rectus  and  inferior  oblique  combine  in  their  action.  In  turning  the 
cornea  downwards,  the  inferior  rectus  and  superior  oblique  work  together. 
In  all  the  oblique  movements  of  the  eyes,  three  muscles  combine.  In  all 
movements  beloio  the  horizontal  level  of  the  eyes,  the  superior  oblique  is 
brought  into  play.  In  all  rotations  upwards,  the  inferior  oblique  is  active. 
The  single  action  of  the  superior  oblique  rotates  the  cornea  dow^nw^ards  and 
outwards,  that  of  the  inferior  oblique  upwards  and  outwards.  The  third 
nerve  (oculo-motor)  supplies  the  recti  muscles  (except  the  external),  the  infe- 
rior oblique,  and  the  levator  palpebrce  superioris.  The  fourth  (trochlearis) 
inspires  the  superior  oblique,  and  the  sixth  the  external  rectus. 

In  no  other  part  of  the  body  do  we  so  readily  detect  even  slight  muscular 
disturbances,  as  in  the  rotatory  movements  of  the  eyes.  Derangements  that 
elsewhere  would  never  be  noticed,  are  here  painfully  forced  on  the  attention 


ANATOMY  OF  THE  EYE. 


57B 


by  diplopia,  or  double  vision.  This  is  present  no  doubt  in  the  beginning  of 
all  cases  of  strabismus,  and  is  the  most  harassing  and  persistent  symptom  of 
muscular  paralysis. 

Eyelids  and  Lachrymal  Apparatus. — That  the  movements  of  the  eye  may 
meet  with  the  least  possible  resistance  from  friction,  the  anterior  half  of  the 
globe  and  the  inner  surface  of  the  lids  are  lined  by  a  smooth  mucous  mem- 
brane, constantly  lubricated  by  its  own  secretions.  To  provide  additional 
moisture,  and  keep  the  cornea  constantly  free  from  accumulations  of  the  waste 
epithelium,  the  secretions  of  the  lachrymcd  gland  come  into  play.  This  gland 
lies  in  the  pit  near  the  upper  and  outer  margin  of  the  orbit,  and  pours  its  fluid 
through  the  excretory  ducts  on  the  eyeball.  The  surplus  tears  And  their  way 
over  the  globe,  and  are  finally  carried  into  the  nose  by  the  tear  passages,  the 
canaliculi,  the  lachrymal  sac,  and  the  nasal  duct.  The  conjunctiva  extends  from 
the  free  edges  of  the  lids,  where  it  is  continuous  with  the  skin,  back  through 
the  fornix  to  the  globe,  and  thence  forwards,  over  the  sclera,  to  the  margin  of 
the  cornea,  the  latter  being  covered  by  the  continuous  epithelium.  It  is 
divided,  according  to  its  distribution,  into  the  tarsal  portion ;  the  reflected 
portion,  or  fornix ;  and  the  ocular  portion  that  covers  the  sclera.  The  tarsal 
division  is  firmly  united  to  the  inner  surfaces  of  the  tarsi,  above  and  below,  and 
is  dissected  off  with  difficulty.  The  reflected  portion  is  more  loosely  united  to 
the  structures  below,  and  readily  becomes  infiltrated  by  inflamniatory  products 
collecting  in,  and  especially  underneath  it.  The  ocular  covering  is  very  thin 
and  transparent,  and  is  also  connected  to  the  sclera  very  loosel}^  Infla'^nmia- 
tory  collections  under  it,  so  common  and  so  alarming,  are  called  chemosis. 
At  the  margin  of  the  cornea,  the  conjunctiva,  blended  with  the  capsule  of 
Tenon,  is  firmly  united  to  the  sclera.  Hence,  to  effectually  fix  the  eye  for 
surgical  operations,  it  must  be  seized  as  close  to  the.  cornea  as  possible. 
The  free,  smooth,  epithelial  covering  of  the  conjunctiva,  forms  the  surfaces 
that  glide  so  easily  and  comfortably  over  each  other  in  the  movements  of  the 
eyes,  and  in  winking.  The  conjunctiva,  especially  the  strip  lining  the  back 
portion  of  the  tarsus,  next  the  fornix,  is  traversed  by  many  deep  fissures  which 
communicate  freely,  and  into  which  the  epithelium  dips,  giving  it  an  uneven 
appearance.  These  fissures  were  formerly  described  as  papillae.  The  con- 
junctiva is  supplied  with  bloodvessels,  and  parts  are  infiltrated  with  lymph 
cells,  capable  of  enormous  increase,  and  causing  great  swelling  and  hyper- 
trophy in  inflammation.  It  is  likewise  freely  endowed  with  sensibility  by 
distributions  of  the  fifth  pair.  The  different  kinds  of  glands  that  open  on 
the  conjunctiva,  along  the  free  margin  of  the  lids,  on  the  limbus  conjunctivse, 
and  in  the  fornix,  properly  belong  to  other  structures  of  the  lid. 

The  eyelids  are  movable,  complicated  structures,  opening  and  closing  in  re- 
sponse to  muscles,  like  shutters.  Into  the  framework  of  each,  to  give  it  stiflf- 
ness,  enters  a  condensed  fibrous  structure  of  semilunar  shape,  called  the  tarsus. 
The  tarsus  of  the  upper  lid  is  longer  and  broader  than  that  of  the  lower.  The 
thick,  sharp-cut  edges  of  the  lid,  along  the  anterior  lip  of  which  the  eye-lashes 
are  implanted,  and  on  the  posterior  lip  of  which  the  Meibomian  ducts  are  seen, 
is  formed  chiefly  by  the  thick  tarsus.  Toward  the  upper  edge,  into  which  the 
levator  palpebrse  superioi-is  is  fastened,  it  grows  quite  thin.  Imbedded  in  the 
thickness  of  the  tarsus,  perpendicular  to  its  free  margin,  and  belonging  histo- 
logically to  the  skin,  are  the  Meibomian  glands,  long  tubes  with  acinous  attach- 
ments, and  opening  in  visible  points  along  the  inner  lip  next  the  conjunc- 
tiva. (Fig.  916.)  The  points  in  which  the  two  lids  unite  are  called  commis- 
sures. The  outer  commissure  is  sharp,  and  the  inner  rounded  out  to  receive 
the  caruncula  lachrymalis  of  the  conjunctiva,  behind  which  is  a  vertical, 
thickened  fold  of  conjunctiva  called  the  plica  semilunaris.    At  the  inner  com- 


574         INJURIES  AND  DISEASES  OF 
Fig.  916. 


The  eyelids  closed.  The  skin  over  both  tarsal  car- 
tilages removed,  so  as  to  make  the  tarsal  glands  visi- 
ble.   (After  Merkel.) 


THE  EYES  AND  THEIR  APPENDAGES. 

miss  ore  are  also  found  the  tear  ducts  for 
collecting  and  carrying  off  the  super- 
fluous tears  to  the  nose.  At  the  inner 
end  of  each  tarsus  are  the  openings  of  the 
canaliculi,  one  above  and  one  below. 
These  points,  surrounded  by  some  cir- 
cularly disposed  fibres  of  the  orbicu- 
laris muscle,  are  called  the  puncta 
lachrymalia.  The  small  canals  leading 
from  them  into  the  lachrymal  sac,  are 
the  canaliculi.  They  sometimes  unite 
before  reaching  the  sac,  and  at  other 
times  enter  it  separately.  Lying  in  the 
lachrymal  groove  of  the  os  unguis,  tra- 
versed near  its  middle  and  supported  by 
the  tendo  oculi  of  the  orbicularis  mus- 
cle, is  the  lachrymal  sac,  v^hich  passes 
by  the  nasal  duct  to  the  inferior  mea- 
tus of  the  nose.    In  a  healthy  state  the 

J.  917. 


JET 


^.    ,    -  f>,p  ipft  eve  with  the  neighboring  muscles.    Lm.  Median  palpebral  ligament;  E  F. 

"''""'ZpTo!tro.UU?L:lr9;rladr.tus  faMl  »upenorIs ;  ^.  Zyg»mati»us.    (After  MerUel.) 


ANATOMY  OF  THE  EYE. 


0/0 


puncta  are  held  gently  against  the  hall,  and  the  tear  passages  are  made  to 
perform  their  function  by  the  action  of  the  orbicularis  muscle.  Through  the 
puncta,  the  mucous  lining  of  the  eyelids  is  continuous  with  that  of  the  nose 
and  throat.  Lying  on  the  anterior  surface  of  the  eyelids,  between  the  skin 
and  the  tarsi,  and  extending  over  the  prominent  base  of  the  orbit,  is  the  sphinc- 
ter of  the  eyelids,  the  orbicularis  muscle.  Begirming  from  the  lower  edge  of 
the  tendo  oculi  and  the  adjacent  bone,  it  sweeps  around  the  outer  commissure 
and  comes  back  to  be  inserted  into  the  upper  edge  of  the  same  tendon.  It 
is  divided  into  the  palpebral  portion,  lying  on  the  tarsi  and  exclusively  used 
in  winking,  and  the  orbital,  called  into  voluntary  play  when  the  eyes  are 
firmly  closed.  This  muscle  is  supplied  by  the  portio  dura  of  the  seventh  pair, 
and,  with  its  relations,  is  beautifully  seen  in  Fig.  917.  Implanted  deeply  along 
the  anterior  lip  of  the  free  margin  of  the  lid,  with  their  bulbs  between  the  orbi- 
cularis fibres  and  the  surface  of  the  tarsus,  are  the  ciliae  or  eye-lashes.  Covering 
the  entire  muscle  and  continuous  with  the  skin  of  the  face,  is  the  thin  cuta- 
neous covering  of  the  eyelids,  with  its  loose  subcutaneous  tissue.  The  upper 
eyelid  is  provided  with  a  muscle,  the  levator,  to  lift  it,  while  the  lower  sub- 
sides over  the  projecting  globe  in  response  to  gravitation,  when  the  orbicularis 
is  relaxed. 

Optical  Defects  dependent  upon  Anatomical  Peculiarities  of  the 
Eye.— By  actual  measurement  the  eye  varies  in  size  very  much,  in  different 
persons.  The  optically  perfect  eye  measures  24  mm.  in  the  antero-posterior 
diameter,  and  is  called  emmetropic  or  normal.  In  such  an  eye  the  retina  lies 
in  the  focus  for  parallel  rays.  Distant  objects,  from  which  such  rays  only 
come,  are  sharply  imaged  upon  the  retina.  By  distant,  we  mean  from  18  feet 
off  to  infinitely  far,  as  the  stars.  If  the  eye  is  smaller  than  this  ideal  standard, 
measuring,  for  instance,  20  mm.  from  cornea  to  retina,  it  is  called  hyperopic. 
In  that  case  parallel  rays,  undergoing  the  same  refraction  by  the  cornea  and  lens, 
will  strike  the  retina  before  intersecting,  and  the  image  will  not  be  sharp. 
Hence  vision  of  remote  objects  is  imperfect,  as  long  as  no  voluntary  muscu- 
lar effort  of  accommodation  is  added.  Theoretically,  such  an  eye  could  only 
unite  convergent  rays  upon  the  retma  ;  but  in  nature  no  objects  exist  that  send 
off  such  rays,  because  none  are  beyond  an  infinite  distance.  Practically,  then, 
such  eyes  are  always  on  a  strain,  making  active  efforts  of  accommodation 
for  all  distances.  They  are  never  at  rest  except  in  sleep.  By  an  emmetro- 
pic eye,  remote  objects  are  seen  with  perfect  definition  without  any  accommo- 
dative muscular  action.  Hence  the  ciliary  muscle  is  at  absolute  rest,  except 
in  reading  and  near  w^ork.  This  difference  accounts  for  the  tired  and 
fatigued  feeling  of  hyperopic  eyes,  which  distresses  them  and  gives  the  physi- 
cian so  much  trouble  and  anxiety.  When  applied  to  close  work  especially, 
they  tire  easily,  and  are  called  weak  or  asthenopic.  The  pain  and  fatigue  result 
from  strain  of  the  ciliary  muscle,  and  the  trouble  is  called  accommodative 
asthenopia.  ^  It  is  in  hyperopes  that  we  so  often  find  convergent  strabismus. 
There  is  still  another  deviation  from  the  emmetropic  form,  and  that  is  the 
myopic  or  near-sighted  eye.  In  such  the  distance  from  cornea  to  retina  is 
increased,  so  that  parallel  rays  intersect  before  reaching  the  nerve  membrane. 
The  axis  of  vision  measures  25,  30,  or  even  more,  millimetres.  The  far- 
thest point  of  distinct  vision,  instead  of  being  at  an  infinite,  is  at  a  finite  dis- 
tance. It  comes  nearer  and  nearer,  as  the  degree  of  myopia  increases.  Be- 
yond the  far  point,  all  is  dim,  the  farther  the  worse.  Such  eyes  can  only  get 
sharp  imao^es  of  distant  objects  by  the  use  of  concave  lenses.  All  persons 
who  see  distant  objects  better  with  convex  lenses,  must  be  hyperopic.  Those 
whose  remote  vision  is  cleared  by  concave  glasses,  rnay  be  myopic.  Myopia 
occurs  rarely  in  old  people,  and  then  generally  with  incipient  cataract.  If 


576 


INJURIES  Ax\D  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


the  myopia  reaches  in  them  a  high  degree,  they  lay  aside  their  spectacles  for 
readiii  and  boast  of  second  sight.  Just  in  proportion  as  they  gam  in  read- 
ins:  without  glasses,  they  lose  in  distinctness  of  sight  for  distance,  and  must 
use  concaves.  Myopia  is  an  acquired  disease.  Hyperopia  congenital  de- 
fect In  myopia  the  eyeball  is  enlarged  and  strikingly  prominent.  ^  Around 
the*  posterior  pole  the  sclera  and  other  tunics  bulge  backwards,  giving  that 
T)art  of  the  dobe  an  egg  shape.  Diagnosis  of  the  refraction  ot  the  eye  is 
not  always  easy.  In  expert  hands,  the  most  direct  and  independent  means 
of  ascertaining  the  refraction  is  the  ophthalmoscope.  But  accuracy  in  this 
means  of  diagnosis  involves  not.  only  a  long  experience  but  an  absolute 
knowledp-e  of  the  refraction  of  the  observer's  own  eye.  It  the  ey^e  ot  the 
examiner  and  that  of  the  examined  are  both  emmetropic  then  an  absolutely 
sharp  ima2:e  of  the  fine  vessels  in  the  direct  fundus  will  be  obtained,  io 
do  this  and  get  a  large  magnifying  power,  the  eye  carrying  the  ophthalmo- 
scope must  approach  almost  to  contact  with  that  inspected.  ^  Ihis  is  the  ex- 
amination in  the  erect  image.  If  the  examiner's  eye  is  myopic,  or  hyperopic, 
it  must  be  rendered  emmetropic  by  the  proper  lens  m  the  eye-clip. 

If  no  distinct  image  of  the  fine  fundus  is  obtainable,  the  accommodation 
of  the  examiner  and  examined  being  relaxed,  then  there  is  either  hyperopia  or 
myopia.   If  a  convex  lens  added  to  the  clip  makes  the  details  c  ear,  there  is 
hyperopia.    If  a  concave  is  required,  it  must  be  myopia.    In  the  family  ot 
mydriatics  we  find  a  valuable  aid  in  ophthalmoscopic  diagnosis.    W  hen  atro- 
pine, hyosciamine,  or  duboisia  in  strong  solution,  is  applied  to  the  eye,  it  soon 
dilates  the  pupil  and  paralyzes  the  ciliary  muscle.  By  this  means  we  eliminate 
a  troublesome  factor,  the  accommodation,  and  have  the  eye  at  rest.  Moreover, 
when  the  accommodation  is  relaxed  in  this  way,  it  renders  the  use  ot  test- 
dasses  in  the  diagnosis  very  easy,  simple,  and  sure.    Atropinize  a  myope, 
and  it  will  aftect  his  distant  vision  little  or  none.    It  was  bad  before  and  is  so 
still    Do  the  same  for  an  emmetrope,  and  his  remote  vision  will  not  be 
seriously  changed.    It  was  good  before,  and  is  so  still.    The  only  change  is, 
that  he  can  no  longer  read  print  without  the  aid  of  a  strong  convex  lens. 
His  power  of  varying  the  refraction,  by  voluntary  contraction  of  the  ciliary 
muscle,  is  temporarily  lost.    Subject  a  hyperope  to  the  thorough  action  of 
atropine,  and  his  sight  for  distance  will  be  reduced,  more  or  less  seriously, 
according  to  the  degree  of  hyperopia.   Then,  if  a  convex  glass  brings  it  up  to 
what  it  was  before,^hyperopia  undoubtedly  exists,  and  Xh^  degree  measured 
by  the  strength  of  the  glass  required  to  give  perfect  sight  tor  distance.  Iliis 
is  the  most  certain  means  of  diagnosis,  and  in  all  doubtful  cases  should  be 
resorted  to  in  order  to  confirm  the  diagnosis  by  other  methods.    One  serious 
objection  to  the  use  of  the  ordinary  salts  of  atropia  for  this  purpose,  as  well  as 
for  facilitating  ophthalmoscopic  examinations,  is  the  long  time  (sometimes  a 
week  or  more)  that  the  eftects  last.    Happily,  the  homatropme  relaxes  the 
ciliary  muscle  quickly  and  thoroughly,  and  its  effect  soon  passes  away,  gene- 
rally inside  of  24  hours.    To  do  this  thoroughly  it  must  be  strong  (8  grains  to 
the  ounce),  and  dropped  in  freely  every  20  or  30  minutes  for  two  or  three 
.     times,         constitutional  effects  are  noticed,  as  m  the  similar  use  of  atropine 
or  duboisia.   Duboisia  is  quite  as  certain  in  its  eftects,  and  more  transient  than 
atropine.   Its  influence  does  not  pass  off  as  soon  as  that  of  homatropme,  and 
it  is  very  liable  to  produce  serious  constitutional  symptoms.   I  now  use  homa- 
tropine  almost  exclusively  for  testing  refraction  and  for  ophthalmoscopic 
examinations  ;  in  the  latter,  applying  a  much  weaker  preparation.  Hyper- 
opia may  be  entirely  latent,  or  altogether  manifest.    In  the  former  case,  it  is 
neutralized  by  the  strong  activity  of  the  ciliary  muscles,  as  m  children  and 
youiip;  people.     In  the  latter,  nearly  always  in  persons  in  advanced  lite, 
the  lens  becomes  so  hardened  that  the  ciliary  muscle  can  no  longer  over- 


DIAGNOSIS  OF  OCULAR  AFFECTIONS  WITHOUT  THE  OPHTHALMOSCOPE.  577 


come  the  hyperopia.  When  the  hyperopia  is  all  manifest,  the  simple 
use  of  the  mirror  and  of  the  test-glasses  is  all  that  is  required.  In  that  con- 
dition hyperopes  are  compelled  to  use  glasses  all  the  time,  or  else  to  see  very 
iniperfectly.  They  need*  one  pair  to  neutralize  the  hyperopia  and  to  walk 
with,  and  another,  stronger  pair  to  read  with.  Young  hyperopes,  whose  eyes 
have  been  trained  to  tolerate  the  glasses  the}^  need,  can  use  the  same  o-lasses  for 
walking  and  reading.  Their  accommodation  makes  up  for  the  ^increased 
refraction  needed  in  reading.  Another  anomaly  of  refraction  is  often  found, 
alone,  or  in  connection  with  hyperopia  or  myopia.  It  is  due  to  differences' 
of  curvature  in  the  different  meridians  of  the  cornea,  and  is  called  astigma- 
tism. ^  As  in  other  anomalies,  the  refraction  may  be  defective  or  excessive 
constituting  hyperopic  or  myopic  astigmatism.  Astigmatism  in  hio;h  de- 
grees impairs  the  sight  much  more  than  simple  hyperopia  or  myopia,^as  the 
effect  is  very  imperfectly  corrected  by  accommodation.  The  diagnostic  aids 
are  the  ophthalmoscope,  mydriatics,  and  tests  with  glasses  of^ylindrical 
surface,  convex  and  concave.  The  usual  test-types,  as  in  trying  for  hyperopia 
and  myopia,  a  system  of  lines  radiating  from  a  centre,  and  other  devices,  are 
resorted  to  in  order  to  facilitate  accuracy  of  diagnosis.  My  space  will  not 
allow  details  in  this  interesting  department  of  physiological  optics. 


Diagnosis  of  Ocular  Affections  without  the  Use  of  the  Ophthalmoscope. 

Medical  men  often  talk  flippantly  about  the  use  of  the  ophthalmoscope, 
flourishing  the  instrument  before  the  dazed  eyes  of  their  patients,  seeino^ 
nothing  and  not  even  knowing  how  to  interpret  that.  It  is  kept  as' one  oi 
many  professional  trappings,  and  has  its  reward.  As  a  blow-bugle,  in  the 
recruiting  oflice  of  rival  medical  schools,  it  has  an  important  place,  but  how 
tew  students  ever  look  through  it  with  discrimination !  A  few  weeks  of 
special  instruction  by  a  competent  teacher  will  alone  enable  the  student  to 
begin  the  intelligent  employment  of  it  in  diagnosis.  But  daily  and  perse- 
vering use  of  this  or  any  other  instrument  of  precision,  is  required  to  crive  it 
serious  importance.  I  do  not  exaggerate  its  difiiculities,  or  disparage  it?faith- 
ful  employment.  It  is  invaluable  in  the  differential  diagnosis  of  deep-seated 
lesions  of  the  eye,  as  well  as  in  the  study  of  disease  seated  elsewhere.  It 
would  be  as  rational  to  study  astronomy  by  the  aid  of  a  spj^-glass  when  Ave 
can  use  a  telescope,  as  to  discard  the  ophthalmoscope  in  the  critical  study  of 
fundamental  diseases  of  the  eye.  But  I  simply  state  the  above  well-known 
facts,  m  order  to  urge  the  importance  of  other  and  simpler  means  of  diao-- 
nosis,  which  are  too  much  neglected  by  the  general  practitioner.  I  w^ant  Fo 
show  how  many  valuable  things  he  can  find  out  by  the  aid  of  the  spy-^lass ! 

Cataract,  when  bad  enough  to  seriously  trouble  sight,  can  be  perfectly  made 
out  without  the  ophthalmoscope.  With  the  pupil  dilated  and  oblique 
Illumination,  no  doubt  need  exist.  Then  the  functional  tests  will  show 
whether  the  visual  defect  is  in  rational  proportion  to  the  changes  seen  in  the 
lens.  Is  the  cataract  mature,  and  the  propriety  of  an  operation  asked? 
i^  unctional  interrogation  of  the  retina  as  to  acuteness  of  perception,  and  the 
visual  field,  is  easily  made  and  satisfactory.  Glaucoma,  frequent  in  senile 
subjects,  may  be  fatally  mistaken  for  cataract.  And  yet  no  very  great  tact 
IS  required  to  settle  the  differentiation  without  the  use  of  the  qyq  mirror 
Ihe^  absence  of  definable  opacities  in  the  lens ;  careful  and  repeated  tests  of 
tension  ;  the  general  outward  appearance  of  the  eye,  including  the  episcleral 
circulation;  the  size  of  the  pupil,  its  activity  and  the  texture  of  the  iris; 
and  above  all,  trials  of  visual  acuity  and  the  integrity  of  the  field,  will  settle 
tne  question,   himple  cataract  runs  its  entire  course  without  pain.  Glaucoma 

vol.  IV. — 37 


578         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

seldom  does.  Indeed,  in  the  worst  cases  of  acute  glaucoma,  the  vitreous  is 
so  turbid  and  the  cornea  so  dull,  that  no  ophthalmoscopic  mspectiou  of  the 
fundus  is  possible.    Yet  our  diagnosis  need  be  none  the  less  positive 

Jn"L  in  all  forms  and  degrees  can  be  made  out,  beyond  a  doubt,  by  ordi- 
nary crutiny,  aided  by  atropine  and  oblique  illumination  It  cyclitis,  or 
choroiditis,  or  optic  neuritis  exist  with  it,  the  eye  is  usually  too  tender  to 
St  even  if  the  vitreous  be  clear,  to  admit  of  a  protracted  use  of  the  re- 
flfcto'r.  The  functional  tests  of  vision,  in  a  moderate  light  will  give  a  rea- 
sonable clue  to  the  integrity  of  the  fundus.  If  the  defect  ot  sight  be  out  of 
prCrtion  to  the  chanies  in  the  iris,  pupil,  and  aqueous  humor,  we  infer  a 
deel>seated  complication.  Increased  tension  in  such  a  case  means  glaucoma, 
and  the  reverse  indicates  cyclitis.  . 

Of  course,  all  alterations  of  transparency  and  shape  in  the  cornea  are  per- 
fectly ascertained  by  the  usual  means,  oblique  il  ummation  and  functional 
tSs  of  vTsion.  There  is  no  excuse  for  mistaken  diagnosis  between  these  and 
cataract  and  the  ophthalmoscope  alone  is  very  liable  to  lead  to  error. 

How  nwiy  hundreds  of  patients  are  referred  to  specialists  for  "disease  of 
the  optic  nerve,"  where  the  fundus  is  absolutely  sound  and_  where  a  rational 
d  LnosTs  might  and  should  have  been  made  without  the  mirror!    These  are 
T^Tasthenoma,w\t\i  very  characteristic  symptoms    Painful  fatigue  of 
eves  blurring  of  v  sion  and  difficulty  in  reading  after  a  few  moments  close  ap- 
Xcation  heaviness  of  the  lids  and  frequent  desire  to  close  and  rub  them,  are 
?Kost  constant  burden  of  complaint.  The  suffcnngs  are  always  aggravated 
hv  PCTsistent  close  use  of  the  eyes,  sedentary  habits,  nervous  temperament 
aLmk  aTd  the  multiform  manifestations  of  hysteria.    People  thus  affected 
"sually  still  young  in  years,  but  old  in  complaints.  In  females  it  is  very 
apt  ffbe  an  accompaniment  of  uterine  disturbances,  and  increased  by  canses 
of  debiUty    The  patient  has  been  a  victim  of  these  painful  troubles  and  fwe- 
bodhi-8  perhaps,  fbr  many  years,  and  still  has  perfect  sight  when  briefly  tried. 
£  S  secrds  he  reads  the  finest  print,  and  has  perfect  definition  for  dis- 
tance bu^  then  the  sight  wavers.    How  can  a  serious  esion  of  the  optic  nerve 
01  of  any  other  important  part  of  the  eye,  persist  so  long,  give  so  much  pain 
and  worry  and  ^till  leave' the  sight  perfect?    ^^al  diseases  o   the  optic 
nerve  in  their  entire  course  to  total  blindness,  are  attended  by  littk  or  no 
pa  n    ThisTs  true  of  many  of  the  worst  diseases  of  the  retina  and  the  A^o- 
T  et  us  look  into  some  of  these  cases  by  common  aids,  and  guided  by 
Ltodicl  oVZTer  wit.    Outwardly  the  eyes  look  healthy.    Te^^^^^^^  sepa- 
rntelv  the  sio-ht  of  the  two  eyes  is  equal  and  perfect  for  distance,  itie 
St  i^ads  the  smallest  diamond  type  distinctly  for  a  few  moments.  Then 
the  letters  mix  b  ur,  and  the  eyes  become  painful.    So  he  desists,  and  closes 
Ind  rubs  hk  eyes.    There  is  probably  some  anomaly  of  retraction,  producing 
fettue  of  accommodation.    Convex  glasses,  one  dioptric  (87  inches  focus) 
d  a?  t  le  prtt  and  enable  him  to  read'longer  without  fatigue  and  ghmnK.-- 
i„g    He  cannot  be  myopic,  but  may  be,  probably  is,  hyperop/e;^  J mther 
investigation  must  now  be  made  to  settle  that  question.    But  of  this  you 
mav  be^oe  tain.  The  patient  has  no  disease  of  the  optic  nerve  nor  other  attec- 
don  thaUs  going  to  lead  to  blindness.    Ton  can  set  his  mmd  at  rest  on  that 
Zt    If  d^staift  vision  is  imperfect,  and  near  work  ^-^^f^^^^^:^^, 
ravopic  and  the  necessary  investigation  should  be  made.    It  m  anv  case,  tne 
S  of  the  two  eyes  is  materialfy  difterent,  they  must  be  examined  sepa- 
rLtel  V  and  the  vision  equalized  if  possible.    If  the  vision  is  very  bad  in  one, 
^nd  perfect  or  nearly  so  in  the  other,  then  there  may  have  been  a  congeni- 
M  d  fference,  o  oneVlong  standing,  but  just  now  found  out.    If  borti  eyes 
Ii-e  bad  for  a  1  distances,  then  there  may  be  a  marked  astigmatism  or  other 
t  ouWe  requiring  the  ophthalmoscope  and  means  ot  investigation  not  at 


DIAGNOSIS  OF  OCULAR  AFFECTIONS  WITHOUT  THE  OPHTHALMOSCOPE.  579 


your  command.  Whether  it  is  a  disease  requiring  treatment,  or  an  optical 
defect  demanding  assistance  from  glasses,  can  only  be  settled  by  an  expert 
examination.  These  asthenopic  troubles  that  give  the  surgeon  and  the 
patient  so  much  anxiety,  depending  as  they  do  upon  so  many  different  causes, 
cannot  be  fully  investigated  or  satisfactorily  treated  by  the  general  surgeon. 

Patients  sometimes  apply  for  advice  about  the  alleged  sudden  failure  of 
the  sight  in  one  eye.  It  has  usually  been  discovered  by  the  merest  accident. 
The  patient  insists  that  he  retired  with  two  good  eyes,  and  arose  with  one 
blind.  How  do  you  know  that  the  patient  is  mistaken?  If  he  has  a 
matured  cataract,  or  confirmed  glaucoma,  or  old  alterations  of  the  cornea, 
none  of  these  could  have  developed  in  so  short  a  time.  If  there  is  strabismus 
confined  to  the  defective  eye,  it  cannot  be  of  sudden  origin.  If  the  bad  sight 
dates  from  childhood,  or  has  come  on  very  slowly,  without  pain,  inflammation, 
or  any  unusual  subjective  symptom,  it  often  passes  unnoticed,  till  by  some 
mere  accident  the  patient  is  led  to  try  the  two  eyes  separately.  If  some  confusion 
of  vision,  pain,  or  other  uncommon  worriment,  such  as  flashes  of  light,  glim- 
mering, etc.,  have  prompted  him  to  the  test  of  the  two  eyes,  the  difiiculty  is 
l)robably  recent,^  and  needs  immediate  intelligent  attention.  The  previous 
history  and  habits  of  the  patient  as  to  shooting,  and  with  which  eye  and 
what  success,  may  also  assist  in  clearing  up  the'date  of  the  difiiculty.  Has 
the  eye  ever  been  injured,  and,  if  so,  in  what  way  and  when  ?  Has  he  ever 
used  an  opera  glass  with  satisfaction  ?  Without  binocular  vision  that  instru- 
ment is  of  little  benefit.  If  the  defect  is  very  old,  particularly  if  congenital, 
the  ophthalmoscope,  even  in  expert  hands,  is  often  simply  negative  in  its  find- 
ings. But  when  the  lesion  is  serious  and  of  recent  date,  it  is  often  quite  pos- 
sible to  make  a  fair  diagnosis  without  the  instrument.  Suppose  the  patient  to 
have  had  good  eyes  till  quite  lately.  All  at  once  he  sees  flashes  of  light,  glim- 
mering, trembling  in  the  air  like  heat,  and  confusion  of  sight.  He  tries  sepa- 
rately, and  finds  which  eye  is  at  fault.  These  troubles  continue,  with  varia- 
tions, for  a  few  days.  Then  he  discovers  a  dark  curtain  drawing  in  front  of 
the  eye.  It  passes  across  from  one  side  to  the  other,  cutting  oflT  all  sight 
except  perhaps  in  one  oblique  direction.  With  this  significant  description, 
you  ask  him  to  close  the  eye  gently.  You  place  the  two  index  fingers  on 
the  ball  and  find  its  tension  much  reduced.  The  fatal  diagnosis  is  detachment 
<)f  the  retina.  If  the  patient  has  long  been  very  near-sighted,  this  conclusion 
is  greatly  strengthened. 

Again,  there  may  have  been  great  and  sudden  failure  in  one  eye,  perhaps 
without  any  premonitions,  or  these  may  have  been  very  brief.  The  patient 
IS  advanced  in  years,  has  often  suftered  from  rheumatism,  and  actually  has 
organic  lesion  of  the  heart.  The  arteries  feel  hard  to  the  finger,  indicative 
ot  atheromatous  degeneration.  While  coughing,  lifting,  straining  at  stool, 
m  a  violent  fit  of  anger,  or  even  without  any  special  provocation,  a  large, 
red,  ragged  cloud  comes  before  the  eye.  Here  is  a  case  of  hemorrhage  into 
the  vitreous,  from  bursting  of  an  intra-ocular  vessel,  a  very  serious  aftair  for 
the  eye,  and  still  more  grave  as  a  prophetic  indication  of  a  similar  accident  to 
the  brain.  Spontaneous  rupture,  even  of  a  subconjunctival  vessel  producing 
a  blood-shot  eye,  is  of  no  consequence  in  itself,  except  as  it  takes  place  in 
advanced  years ;  and  then  it  means  brittle  arteries,  and  danger  to  the  brain 
or  other  vital  organ. 

Once  more,  you  are  consulted  by  a  woman  advanced  in  preo;nancy.  More 
or  less  rapid  failure  oi  sight  in  one  or  both  eyes  has  brought  her  to  you. 
lou  find  vision  generally  impaired,  especially  in  the  direct  line,  by  a  central 
cloud  or  scotoma.  Some  pain  and  photopsia  have  been  felt  and  seen,  but 
outwardly  the  eyes  appear  normal.  You  suspect  Brighfs  disease,  and  an 
analysis  of  the  urine  confirms  your  suspicion.    The  patient  has  albuminuric 


580  INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

retinitis,  with  changes  so  peculiar  and  characteristic,  when  seen  with  the 
ophthalmoscope,  tha"  the  diagnosis  of  renal  disease  can  be  made  from  them 
aCe  Still,  we  can  be  reasonably  certain  of  the  true  lesion  without  using 
the  ophthalmoscope.  These  eye  symptoms,  in  a  case  of  pregnancy,  should 
lead  us  to  expect  puerperal  convulsions  betore  or  at  conlinement.  ^ 

Again,  a  patient  with  perhaps  a  syphilitic  or  rheumatic  histoi-j-,  <^°n|P^™/ 
of  double  vision.  This  may  or  may  not  have  followed  headaches  and  other 
evidences  of  brain  disturbance.  It  may  have  come  from  a  current  of  an-, 
or  from  no  appreciable  cause.  He  is  giddy  and  uncertain  in  his  gait  Ihe 
moment  one  eye  is  shut,  the  diplopia  ceases,  and  he  sees  without^ confusion. 
Sr  closing  one  eye  and  walking  across  the  room,  his  head  swims  and  he  staggers. 
Let  him  now  shut  that  eye  and  walk  with  the  other  open.  He  feels  secure 
and  steady.  He  has  paralysis  of  some  one  of  the  six  rotatory  muse  es  &nd  the 
fame  eje  IS  the  one  which  he  cannot  walk  with.  Further  investigation  will 
differentiate  the  implicated  muscle.  r  i  i 

Another  patient,'^a  youth,  has  had  excruciating  attacks  of  headache 
accompanied  by  vomiting.  These  paroxysms  have  lasted  for  months,  ihey 
come  suddenly,  even  when  he  is  eating  his  dinner,  and  quickly  he  vomits 
Hs  food  and  il  relieved.  He  may  eat  again  at  once.  Tins  is  causeless  vonr it. 
ing,  not  preceded  by  protracted  nausea,  but  by  violent  pain  in  the  head.  At 
ength  dimness  of  vision  begins  in  both  eyes.  The  pupils  are  dilated,  and 
hefe  isa  vague  stare  in  the  expression.  This  is  a  case  of  double  optic 
nZntis  from  central  brain  lesion,  probably  a  tumor.  Of  course  the  prognosis 
is  verv  grave,  both  for  sight  and  for  life. 

A  child  is  brought,  with  supposed  cataract  m  one  eye.  Your  attention  is 
attracted  at  once  to  a  peculiar,  yellowish,  copper-colored  reflex  from  the 
pupil.  You  see  that  it  is  too  deep  m  the  eye  tor  cataract  and  that  it  has  not 
the  color  of  an  opaque  lens.  Otherwise  the  eye  looks  well.  There  is  no  pain 
as  yet,  and  the  little  victim  perhaps  still  sees  somewhat  with  it  l?iagnosis 
glioma,  or  rather  sarcoma,  of  the  retina;  and  prognosis:  death  in  a  tew 

""A^Jerson  more  advanced  in  years,  has  complained  at  intervals,  for  a  long 
time,^f  pain,  injection  of  the  eye,  and  fai  ing  sight  At  first  detects  a 
circumscribed  defect  of  vision  in  a  certain  bmited  portion  ot  the  field 
Slowly  the  blind  region  enlarges,  and  the  pain  increases  m  frequency  and 
severity  till,  at  last,  the  blind  eye  is  intensely  painful  all  the  time.  Tension 
is  hicreased  ciliary  injection  is  marked ;  and  large,  tortuous,  and  inosculating 
vessels  are  seen  in  loops  around  the  cornea.  The  pupil  is  excessively  dilated ; 
the  anterior  chamber  verv  shallow;  the  iris  discolored  and  its  tissue  greatly 
atrophied.  This  is  probablv  a  case  of  secondary  glaucoma  coming  trom  a 
sarcoma  or  other  tumlr  of  the  choroid.  A  similar  growth  in  the  ciliary  body 
would  be  seen  distinctly  behind  one  edge  of  the  lens,  pushing  it  and  the  ins 

A  female,  up  in  years  and  probably  unmarried,  consults  you  for  excessive 
nervousness.  ' Her  eyes  are  protruded.  Her  expression  is  anxioiis  She 
gets  scared  and  "  files  all  to  pieces"  at  nothing.  Her  pulse  runs  froni  120  o 
140,  feeble  and  irregular.  There  is  more  or  less  enlargement  ot  the  mjoM 
o-land.  These  peculiar  troubles  vary  in  intensity,  as  they_  are  .influenced 
by  mental  or  bodily  disturbance,  but  her  condition  at  all  times  is  pitiable. 
'Hiis  is  a  case  of  Graves's  or  Sasedow's  disease.  It  sometimes,  but  raiely, 
attacks  men.  Exophthalmus,  as  a  common  symptom  ot  tumors  ot  t  ie 
orbit,  can  hardly  be  confounded  with  exophthalmic  g'-^^t^e  when  we  le- 
mcmber  that  the  former  very  seldom  affects  both  eyes,  and  thatjie  Utter 
always  does,  though  perhaps  in  different  degrees.  Then  the  peculiai  com- 
h  nation  of  the  three  leading  diagnostic  symptoms  of  Basedow's  disease- 


INJURIES  AND  DISEASES  OF  THE  ORBIT. 


581 


the  exoplithalmus,  the  goitre,  and  the  nervous  palpitation  of  the  heart — ■ 
makes  mistakes  impossible. 

Pulsating  exophthahniis  is  rarely  seen  on  both  sides;  is  always  of  traumatic 
origin ;  and  is  distinguished  by  the  striking  pulsation  and  bruit  over  the  region 
of  the  orbit.  Its  pathology  is  found  to  be  rupture  of  the  internal  carotid 
into  the  cavernous  sinus  of  the  brain,  and  nothing  but  ligation  of  the  caro- 
tid can  relieve  it.  Many  years  ago  I  reported  a  case  caused  by  the  passage 
of  a  cart  wheel  over  a  man's  head,  where  both  carotids  had  to  be  tied  before 
the  symptoms  could  be  relieved.  How  often  do  we  diagnose  locomotor  ataxia 
by  the  extreme  and  persistent  contraction  of  the  pupils.  Such  pupils  do  not 
change  in  size  under  varying  degrees  of  light,  but  contract  instantly  when 
the  patient  looks  at  and  reads  fine  print,  or  accommodates  for  any  small, 
near  object.  I  recall  a  case  in  which  the  patient  was  first  treated  for  diplo- 
pia, resulting  from  paralysis  of  the  external  rectus  of  one  eye.  From  this  he 
completely  recovered  in  about  a  year.  He  consulted  me  again  for  slowly 
failing  sight.  This  was  at  least  two  years  after  his  first  recovery.  I  then 
detected  this  peculiar  smallness  of  the  pupils,  and  beginning  gray  atrophy 
of  the  right  optic  nerve.  The  myosis  persists  to  this  day,  notwithstanding 
total  blindness  in  both  eyes  fi^om  optic  atrophy. 

A  knowledge  of  the  semi-decussation  of  the  fibres  of  the  optic  nerves  in  the 
chiasm,  and  of  their  peculiar  distribution  in  the  retinae,  often  enables  us  to 
fix  the  seat  of  a  tumor  at  the  base  of  the  brain.  Double  optic  neuritis  gene- 
rally means  brain  lesion,  but  does  not  locate  it.  Hemiopia^  an  extinction  of 
vision  in  one-half  the  field,  the  dividing  line  being  vertical — especially  wnen 
it  afifects  both  eyes — may  be  a  means  of  determining  the  seat  of  the  lesion. 
For  instance,  darkness  in  the  right  half  of  the  field  in  both  eyes,  means  lesion 
of  the  left  tractus  opticus  at  the  base  of  the  brain,  and  vice  versa.  Blindness 
in  both  outer  halves  of  the  field  (resulting  from  paralysis  of  the  inner  half  of 
each  retina)  points  to  tumor  of  the  pineal  gland  or  the  infundibulum,  involv- 
ing the  posterior  part  of  the  optic  chiasm.  Extinction  of  both  inner  halves 
of  the  field,  a  rare  occurrence,  has  been  rationally  explained,  by  Dr.  Knapp, 
as  indicating  an  atheromatous  degeneration  of  the  coats  of  the  arteries  in  the 
circle  of  Willis.  Other  symptoms  about  the  eyes  help  to  fix  the  seat  of  cere- 
bral troubles,  but  I  cite  these  to  show  how  much  precision  may  be  gained  by 
observing  the  rational  symptoms  without  the  use  of  the  ophthalmoscope. 
Indeed,  in  these  cases,  the  instrument  may  be  of  no  use  whatever,  as  its 
fi.ndings  are  often  negative.    [See  page  679.] 

Injuries  and  Diseases  of  the  Orbit.  ' 

Injuries  of  the  Orbit. — All  serious  life  must  be  w^rought  out  in  the  face 
of  foes.  Scars  and  mars  of  the  face  mean  courage  ;  w^ounds  in  the  rear  tell 
the  sad  tale  of  retreat  and  mortification.  The  eyes  were  planted  in  the 
face,  to  look  ahead  and  insure  progress.  The  motto  of  true  manhood  is 
onward  and  upward.  It  is  not  a  mere  question  of  animal  existence,  and  the 
survival  of  the  fittest.  Fight  we  must,  to  live.  But  true  nobility  prompts 
to  the  divine  art  of  healing,  and  of  helping  the  weak.  For  these,  and  still 
higher  reasons,  w^ounds  of  the  face  and  eyes  are  far  more  frequent  and  import- 
ant than  injuries  of  the  occiput  and  podex.  The  jewel  of  the  face  and  light 
of  the  soul,  is  the  eye.  Its  precious  safety  is  guaranteed  by  firm  and  promi- 
nent bony  protections,  and  the  delicacy  with  which  the  ball  is  pivoted  in  the 
socket.  Its  round  form  and  easy  rotation  save  it  often  from  rupture  and 
injuries  that  would  otherwise  destroy  it.  The  application  of  blunt  force  is 
warded  ofiF  by  the  bones.    Penetrating  weapons,  unless  very  direct,  pass  the 


^82         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

unharmed  globe  and  enter  the  cavity.  Contusions  of  the  face  are  very 
frequent,  but  not  often  serious.  A  black  eye  is  the  result  of  such  a  contusion 
ao-ainst  the  bony  iDrojections.  Except  when  the  violence  is  great,  the  concus- 
sion is  not  injurious  either  to  the  eye  or  to  the  brain.  In  direct  blows  on 
the  eye,  and  in  severe,  indirect  concussion,  both  may  be  damaged.  Severe 
contusions,  in  addition  to  the  bloody  infiltration,  are  liable  to  be  followed  by 
inflammation  and  abscess.  In  predisposed  subjects,  or  in  times  of  epidemics, 
erysipelas  with  its  alarming  consequences  may  result.  Orbital  abscess,  and 
loss  of  the  eye,  or  even  of  life,  is  in  that  case  to  be  apprehended.  Periostitis 
and  protracted  trouble  with  the  bones,  are  a  rare  sequel.  Great  depression, 
vomiting,  and  other  evidences  of  cerebral  disturbance,  add  gravity  to  the 
prognosfs,  and  demand  immediate  attention.  Contusions  of  the  face  and  eyes 
are  to  be  treated  as  they  are  elsewhere,  never  forgetting,  however,  the  proba- 
bility of  erysipelas  and  abscesses  supervening. 

Orbital  abscesses  should  be  detected  and  opened  as  quickly  as  possible. 
As  a  rule,  the  pointing-place  of  an  abscess  is  the  best  place  to  open  it.  But 
pus-collections  in  the  eyelids,  or  orbit,  require  special  care.    The  mcision 
should  be  parallel  to,  and  as  far  as  practicable  from,  the  free  margin  of  the  lid. 
If  the  matter  comes  from  the  orbit,  make  the  opening  close  to  the  edge,  so  that 
the  cicatrix  may  not  evert  the  lid.    When  the  time  and  symptoms  indicate 
a  deep  collection,  an  early  exploratory  puncture  ought  to  be  made,  avoiding 
the  eye  and  other  important  organs.    If  required,  a  free  incision  to  the  bone 
may  be  practised,  and  the  exploration  thence  continued.    If  the  reaction  is 
erysipelatous,  constitutional  supporting  treatment  must  be  pushed  from  the 
start.    Of  course,  w^arm  fomentations,  poultices-  and  other  local  treatment 
have  their  value.    Abscesses  in  the  orbit  are  rare,  except  after  wounds  and 
erysipelas.    But  I  have  seen  them  in  parturition,  in  low  forms  of  fever, 
and  as  an  evidence  of  pyemia.    The  fistulous  tract  is  usually  very  long  in 
healing,  and  then  is  almost  sure  to  end  in  an  indiwn  adhesion  to  the  bone. 
Orbitat  abscess  is  very  apt  to  result  in  total  blindness,  even  when  the  integ- 
rity of  the  globe  is  preserved.    The.  inflammation  directly  invades  and  dis- 
oro;anizes  the  optic  nerve,  and  white  atrophy  of  the  papilla  follows.  The 
dauo-er  to  the  sight  is  particularly  great  in  facial  erysipelas.    In  penetrating 
wounds  of  the  orbit,  even  with  the  presence  of  a  foreign  body,  the  sight 
sometimes  escapes  marvellously.    In  others  the  optic  nerve  may  be  directly 
severed  or  injured,  and  loss  of  vision,  without  any  violent  reaction,  is  present. 
I  have  seen  this  in  several  instances.    Optic  neuritis  and  atrophy,  or  the 
latter  alone,  have  followed. 

The  sym'ptoms  of  orbital  cellulitis  and  suppuration,  are  pain,  swelling, 
protrusion  and  fixation  of  the  eye,  and,  generally,  marked  constitutional 
disturbance.  These  go  on  increasing  in  intensity,  till  fluctuation  and  pointing 
are  detected.  Even  after  free  evacuation  of  the  pus,  the  suftering  from  pres- 
sure within  the  unyielding  orbit  is  apt  to  continue  for  several  days._  Vigi- 
lance and  early  incisions,  in  such  collections,  may  save  sight,  deformity,  and 
Ions:,  severe  suffering.  Recovery  after  these  abscesses  is  always  tedious,  and 
the^ball  retreats  to  its  natural  position  very  gradually.  If  the  bones  are 
deeply  cut  or  fractured  at  the  same  time,  slower  healing  and  suddenly  tatai 
developments  may  be  witnessed.  Clean  cuts  of  the  face  and  eyelids  heal 
promptly  when  properly  adjusted.  Extreme  i)ains  should  be  taken,  by  using 
deep,  firm  sutures,  to  so  adjust  wounds  of  the  lids  that  the  cut  tarsus  may  not 
be  notched  or  distorted.  Healing  by  first  intention  is  of  the  first  importance. 
In  view  of  the  gravity  of  orbital  cellulitis  and  abscess,  treatment  must  be 
prompt  and  energetic.  In  most  cases  sight  will  be  lost,  and  m  the  severest 
forms,  the  cornea  sloughs  and  the  globe  atrophies.    The  starting  point  and 


INJURIES  AND  DISEASES  OF  THE  ORBIT. 


583 


nature  of  the  reaction  must  be  kept  in  view,  in  the  rational  treatment. 
Perfect  quiet,  warm  poultices,  often  changed,  anodynes,  tonics,  etc.,  inwardly, 
are  the  safest  remedies.  When  tlie  time  comes  for  making  incisions,  they 
must  be  resorted  to  boldly,  but  not  blindly.  If  erysipelas  has  extended  to  the 
orbit,  the  same  local  treatment  and  suitable  internal  remedies  must  be  tried. 
If  a  penetrating  wound  is  the  starting  point,  the  track  must  be  dilated  by 
means  of  grooved  director  and  bistoury.  Should  the  presence  of  a  foreign 
body  in  the  cavity  be  detected,  it  should  be  removed  as  quickly  as  possible. 
If  caries  of  the  bony  orbit,  or  periosteal  abscess,  is  at  the  bottom  of  the  pro- 
cess, the  chief  attention  is  to  be  directed  to  that  cause.  The  origin  of  this 
form  of  abscess  is  usually  syphilitic,  and  the  progress  is  very  slow.  The 
history,  and  a  close  observation  of  the  course  of  the  disease,  will  establish 
the  diagnosis  and  direct  the  therapeutics.  Evidences  of  dead  and  detached 
bone  must  be  watched  for  with  a  view  to  its  prompt  removal.  Deformity, 
in  such  a  case,  is  inevitable.    I  introduce  the  following  illustrative  cases  :— 

I  was  consulted  by  an  elderly  lady,  in  very  feeble  health,  for  total  blindness  of  both 
eyes.  She  had  lost  the  sight  some  months  before,  during  an  attack  of  erysipelas  of  the 
face.  There  had  been  great  protrusion  of  the  eyes,  and  a  discharge  of  matter  through 
the  lids,  leaving  retracted  cicatrices.  By  inspection  with  the  ophthalmoscope,  I  found 
the  optic  papilla  in  either  eye  very  v^rhite,  the  vessels  small,  the  margins  ragged,  and  the 
surrounding  retina  hazy,  showing  the  previous  existence  of  neuro-retinitis.  Facial 
erysipelas,  extending  to  the  cellulo-adipose  tissue  in  the  orbits,  had  destroyed  the  sight 
of  both  eyes. 

As  showing  the  danger  to  sight  in  spontaneous  orbital  cellulitis  and  ab- 
scess, I  give  the  points  of  a  case  that  occurred  during  the  war : — 

A  man  of  50  years  sent  for  me  in  January,  1864,  for  severe  sweUing  of  the  right  eye. 
According  to  the  patient's  own  account,  he  had  been  attacked  with  erysipelas  of  the 
face,  in  the  course  of  which  the  inflammatory  exophthalmus  had  made  its  appearance. 
From  careful  examination  into  the  history  of  the  attack,  and  an  inspection  of  the  face, 
I  was  convinced  that  the  man  had  been  seized  with  spontaneous  inflammation  and  sup- 
puration of  the  cellular  tissue  'of  the  orbit,  and  that  the  swelling  of  the  face  and  lids 
was  but  symptomatic  of  the  orbital  abscess.  The  globe  was  protruded  directly  forward 
and  entirely  immovable ;  the  pupil  was  dilated  and  fixed^  and  all  perception  of  light 
had  vanished.  The  slightest  pressure  of  the  eye  backwards  or  against  the  orbit  pro- 
duced excessive  pain.  Fluctuation  was  detected  at  the  upper  and  inner,  as  well  as  at 
the  lower  and  outer  part  of  the  orbit.  Free  incisions  were  made  and  pus  escaped  from 
both  points.  The  patient  recovered  in  a  few  weeks,  but  the  eye  was  completely 
amaurotic.  There  was  abundant  exudation  in  the  optic  papilla  and  surrounding  retina 
and  choroid.    Some  weeks  afterwards,  atrophy  of  the  papilla  appeared. 

A  woipan  of  28  years  was  attacked  two  weeks  after  confinement  by  severe  pain  behind 
the  right  eye,  with  rapid  swelling  and  loss  of  sight.  When  I  saw  her,  a  w'eek  after,  I 
found  the  eye  much  protruded  and  immovable ;  enormous  chemosis  and  swelling  of  the 
eyelids  ;  almost  complete  insensibility  of  the  cornea,  with  slight  liaziness  ;  discoloration 
of  the  iris ;  pupil  moderately  large,  but  filled  with  lymph  ;  no  perception  of  light ; 
severe  pain  on  pressing  the  globe  backwards.  As  the  eye  was  already  lost,  I  made  no 
incisions.  Three  days  after,  under  poulticing,  pus  began  to  discharge  through  the  con- 
junctiva oculi,  with  occasional  shreds  of  necrosed  cellular  tissue.  About  a  w^eek  after 
this,  when  the  swelling  had  very  much  abated  and  the  eye  had  retreated  considerably, 
the  cornea  became  badly  infiltrated,  and  soon  sloughed  away,  leaving  a  shrunken  globe. 

A  stout  laborer  was  struck  by  the  fist  on  the  outer  part  of  the  orbit.  Decided 
exophthalmus  soon  followed.  The  eye  was  limited  in  its  movements,  and  very  painful 
when  pushed  backwards.  A  few  days  after,  fluctuation  was  felt  through  the  upper  and 
lower  eyelids.  I  made  free  incisions,  as  usual,  with  discharge  of  matter.  Excepting 
some  symblepharon  and  slight  impairment  of  sight,  this  patient  got  well. 


584         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

Evidently  here  the  suppuration  was  not  deep  behind  the  eye,  and  the 
vision  was  damaged,  but  not  destroyed.  In  the  case  of  spontaneous  cellulitis, 
occurring  in  the  puerperal  period,  the  cornea  was  insensible  from  the  begin- 
ning, and  was  finally  destroyed  by  sloughing  in  consequence  of  its  ansesthesic 
state.  When  the  protrusion  was  greatest,  the  enormous  chemosis  covered  and 
protected  the  cornea.  As  it  subsided,  the  cornea  was  more  exposed,  and  suc- 
cumbed at  a  period  when  it  w^ould  not,  if  the  normal  sensibility  had  been 
preserved. 

In  the  history  of  surgery,  many  fatal  cases  of  penetration  to  the  brain, 
through  the  orbit,  are  recorded.  I  have  referred  to  one  or  two,  in  my  ana- 
tomical synopsis.  Remarkable  histories  of  large  foreign  bodies,  lodged  in 
the  socket,  have  been  given.  Haynes  Walton  reports  a  case  in  which  an 
iron  hat-peg,  three  and  three-tenth  inches  long,  entered  and  remained  in  the 
orbit  for  many  weeks.  It  was  successfully  extracted,  the  vision  and  move- 
ments of  the  eye  remaining  unimpaired.  I  myself  saw  IS^elaton  remove  the 
ivory  handle  of  an  umbrella  from  the  orbit  of  a  man,  after  it  had  sojourned 
there  three  years.  It  was  nearly  two  inches  in  length,  and  half  an  inch  in 
thickness.  I  had  seen  the  same  patient  before  at  Desmarres's  Clinique. 
Military  surgery  contains  accounts  of  many  wonderful  injuries  of  the  orbit 
and  eye,  by  gunshot  projectiles  and  other  weapons.  A  Union  general,  now 
living  in  Washington  Gity,  had  both  optic  nerves  severed  by  a  ball  that  tra- 
versed from  temple  to  temple,  behind  the  eyes.  I  saw  him  some  months 
after  the  casualty,  and  both  optic  nerves  were  white.  Eising  from  the 
perusal  of  these  histories,  one  feels  that  nothing  possible,  is  impossible  I 
Injuries  and  diseases  of  the  antrum,  frontal  sinuses,  and  ethmoid  cells,  as  far 
as  they  lead  to  troubles  of  the  eye,  can  only  be  mentioned  here.  Bearing  in 
mind  their  anatomical  relations,  the  intelligent  diagnosis  of  these  diseases  is 
not  difficult.  I  have  several  times  seen  fistulous  openings  into  the  frontal 
sinuses  mistaken  for  fistula  lachrymalis.  And  what  surgeon  has  not  wit- 
nessed the  professional  alarm  at  emphysema,  in  wounds  of  the  ethmoid  and 
frontal  sinus  ?  Intelligence  is  always  cool  and  collected.  Ignorance  is  rash 
and  emotional. 

Tumors  of  the  Orbit. — Almost  every  form  of  morbid  growth  found  in 
the  body,  is  represented  in  this  cavity.  In  the  various  neoplasms  that 
originate  here,  or  encroach  upon  this  space  from  without,  there  is  one  most 
characteristic  symptom — exophthalmus.  According  to  the  seat  and  size  of 
the  tumor,  will  be  the  direction  and  degree  of  the  protrusion  of  the  eye.  A 
growth  in  the  funnel-space  behind  the  eye,  especially  if  quite  at  the  apex, 
may  not  cause  noticeable  prominence  for  a  long  time.  Impaired  vision  from 
pressure  on  the  optic  trunk,  and  disturbed  circulation  of  blood  in  the  retina, 
may  be  the  first  evidences  of  such  an  afiection.  At  length  the  exophthalmus, 
usually  in  the  direct  axis  of  the  orbit,  attracts  attention.  But  for  a  long 
time  nothing  can  be  felt  by  the  finger,  the  eye  filling  so  fully  the  space  in 
front.  Then,  when  the  globe  is  almost  out  of  the  socket,  the  finger,  pressed 
behind,  detects  the  cause.  I  have  notes  of  a  number  of  such  cases,  of  which 
the  following  three  are  samples : — 

A  stout  lady,  of  ruddy  complexion  and  perfect  health,  consulted  me  ten  years  ago, 
for  blindness  of  one  eye.  There  was  white  atrophy  of  the  optic  papilla  and  complete 
abolition  of  sight.  She  complained  slightly  of  a  feeling  of  pressure  behind  the  eye. 
This  condition  continued,  and  at  the  end  of  about  two  years  I  noticed  beginning  ex- 
ophthalmus. This  increased  slowly,  and  I  determined  to  operate.  The  protrusion 
was  direct,  the  rotation  almost  perfect,  and  by  partially  luxating  the  eye  with  my 
finger,  I  could  feel  a  very  firm  growth  pushing  the  eye  forwards.    Th«  eye  being  hope- 


1 


INJURIES  AND  DISEASES  OF  THE  ORBIT. 


585 


lessly  blind,  I  did  not  hesitate  to  enucleate  it.  This  preliminary  operation  was  ex- 
tremely easy.  I  then  liad  free  access  to  a  very  hard  mass,  that  completely  filled  the 
socket.  It  was  thoroughly  dissected  out,  and  was  found  to  embrace  the  atrophied  optic 
nerve.  Recovery  was  prompt.  In  about  two  years  a  reproduction  was  detected, 
growing  from  the  apex  of  the  orbit.  Its  progress  was  very  slow  and  not  at  all  painful. 
At  length  a  second  operation,  to  empty  the  orbit,  was  executed.  Recovery,  as  before, 
was  rapid.  Now  she  has,  after  several  years,  a  renewal  of  the  morbid  growth,  filling 
the  cavity,  but  causing  no  special  inconvenience.  She  is,  and  has  always  been,  in 
excellent  general  health.  The  only  known  cause  of  the  development  of  this  tumor  was 
the  sting  of  a  bee  on  the  eyelid. 

The  early  history  of  a  second  case,  I  extract  from  the  published  Transac- 
tions of  the  International  Medical  Congress,  held  in  Philadelphia  in  1876  : — 

R.  W.,  aged  twenty-four,  of  stout  figure,  robust  health,  and  sanguine  temperament, 
was  injured  by  the  horn  of  a  calf  on  Jan.  18,  1876.  The  point  of  the  horn  struck  the 
lower  lid,  glancing  inwards  and  backwards,  and  entering  the  orbit  just  above  the  tendo 
oculi,  causing  an  ugly  contused  wound  and  a  severe  concussion.  Tiie  wound  bled  pro- 
fusely, but  healed  in  the  course  of  a  week  without  surgical  treatment.  There  was  no 
bleeding  from  the  nose  ;  no  ocular  hemorrhage  ;  nor  was  the  patient  rendered  uncon- 
scious by  the  shock.  Sight  was  not  affected,  and  there  was  no  diplopia,  headache, 
giddiness,  or  other  symptom  of  injury  of  the  brain.  There  was  no  protrusion  noticed. 
About  five  weeks  after  the  accident,  while  stooping  and  driving  a  cross-cut  saw,  a  sharp 
pain  was  felt  above  the  right  eye,  running  back  over  the  ear  to  the  temple.  This 
sharp,  peculiar  pain  came  on  at  intervals,  several  times  during  the  day,  but  was  always 
provoked  by  stooping  or  straining,  and  soon  passed  off  when  the  patient  straightened 
himself  up,  and  rested  from  sawing.  There  was  no  giddiness,  throbbing,  or  bruit.  Late 
in  April,  it  was  first  noticed  that  the  sight  of  the  eye  was  misty  at  times,  but  without 
pain  or  other  symptom  of  disease.  For  this  failure  in  sight,  a  physician  was  consulted, 
who  first  detected  an  undue  prominence  of  the  eye.  From  that  period,  about 
May  1,  for  about  three  months,  the  exophthalmus  increased  slowly,  but  varied  very 
perceptibly  between  morning  and  evening,  being  always  greater  in  the  morning. 
After  that  time  it  remained  stationary.  When  I  first  saw  this  patient,  in  August,  there 
was  a  striking  exophthalmus  of  over  one-fourth  of  an  inch,  with  slight  injection  of  the 
sclerotic  conjunctiva,  and  some  serous, 'chemotic  swelling  within  the  external  commis- 
sure. Corresponding  to  this  were  seen  some  large,  deep-seated,  inosculating  vessels  on 
the  sclerotic.  The  pupil  was  larger  than  the  other,  and  somewhat  sluggish.  The 
movements  of  the  globe  were  limited  by  its  prominence,  and  by  the  stretching  of  the 
muscles,  but  there  was  no  paralysis.  There  was  a  divergence  when  fixing  with  the 
other  eye,  and  the  motion  upwards  and  inwards  was  less  excursive,  but  there  was  no 
diplopia,  which  I  attributed  to  the  imperfect  sight.  Strongly  marked  features  of 
swollen  disk,  and  some  neuritis  ;  boundaries  of  the  disk  obscured,  and  veins  very  large 
and  tortuous  to  their  extreme  branches  ;  slight  alteration  of  the  macula  lutea,  blurring 
its  distinctive  features.  Vision  very  defective  in  consequence  of  a  large  central  scotoma, 
which  patient  expressed  as  well  defined,  but  not  complete.  Tension  of  the  globe, 
natural.  No  pulsation  whatever  of  the  globe,  nor  bruit  on  auscultation.  When  the  eye- 
ball was  pressed  directly  backwards,  it  was  arrested  by  a  solid  resistance. 

Diagnosis:  Tumor  of  some  kind  at  apex  of  orbit,  probably  of  aneurismal  character. 
In  the  complete  absence  of  the  three  most  characteristic  symptoms  of  aneurism  pulsa- 
tion, bruit,  and  some  degree  of  elasticity  on  pressure — I  relied,  in  coming  to  this  opinion, 
upon  the  evidently  traumatic  origin  of  the  affection,  upon  its  peculiar  history,  upon  the 
absence  of  inflammatory  symptoms,  and  upon  the  exclusion  of  the  symptoms  of  either 
benignant  or  malignant  tumor  at  the  apex  of  the  orbit.  The  symptoms  followed  so  soon 
after  the  injury,  and  in  the  beginning  were  so  characteristic,  as  to  make  this  opinion  more 
probable  than  any  other.  The  sudden,  sharp,  severe  pain  running  backwards  over  the 
temple,  and  caused  by  stooping  and  straining,  coming  on  about  four  weeks  after  the 
blow,  might  be  explained  by  the  sudden  rupture  of  the  ophthalmic  artery,  directly  as  it 
entered  the  orbit  through  the  optic  foramen. 

This  patient  was  presented  to  the  ophthalmological  section  of  the  congress  for  exami- 
nation ;  but  none  of  those  present  were  willing  to  venture  a  positive  diagnosis. 


586         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


On  April  15,  1877,  the  patient  again  called  on  me  at  my  office.  There  was  then 
ffreat  protrusion  of  the  eyeball,  with  aggravation  of  all  the  other  symptoms,  and  a 

tumor  could  now  be  felt  behind 


Fig.  918. 


Fibro-sarcoma  of  orbit  causing  exophthalmus. 


the  globe.  Enucleation  of  the 
eyeball  was  resorted  to,  as  the 
vision  was  then  lost  from  optic 
atrophy.  The  tumor  was  readily 
removed.  It  was  firm  and  fibrous 
in  character,  and  the  size  of  a 
small  pullet's  egg.  It  was  situated 
between  the  optic  nerve  and  the 
inner  wall  of  the  orbit,  but  was 
not  firmly  connected  with  either. 
The  mistaken  diagnosis  in  this 
case  was  perhaps  excusable.  It 
was  certainly  instructive.  The 
recovery  was  permanent,  and  the 
patient  wears  an  artificial  eye- 
This  indicates  that  the  tumor  was 
a  benignant  growth. 

The  third  illustrative  case 
has  furnished  the  subject  of 
rig.  918  :— 

Mrs.  B.,  62  years  old,  apphed  for 
advice  in  November,  1881.  She 
said  that  the  disease  had  begun 
three  years  before,  and  assigned 
it  to  the  sting  of  a  wasp.  Soon 
after,  her  friends  noticed  a  slight 
prominence  of  the  eye ;  she  felt 
some  discomfort  when  exposed  to 
the  wind  and  bright  light,  and,  at 


times,  aching  pain.  Nine  months  subsequently,  the  exophthalmus  having  increased  and 
the  pain  beino-  constant,  she  consulted  a  physician,  who  discovered  a  swelling  at  the  outer, 
inferior  margin  of  the  orbit.  For  the  next  two  years  all  the  symptoms  grew  worse,  till 
she  was  no  longer  able  to  close  the  lids  without  great  efibrt.  There  was  no  history  of 
injury,  nor  of  any  hereditary  predisposition.  Her  health  had  never  been  robust,  and  yet 
she  had,  in  her  whole  life,  not  suffered  from  any  serious  illness.  At  the  date  above 
given,  the  exophthalmus  was  enormous,  the  displacement  being  inwards  and  upwards  ; 
the  cornea  was  clear  and  the  pupil  active,  and  she  counted  fingers  at  twelve  feet ;  the  oph- 
thalmoscope revealed  partial  atrophy  of  the  disk,  with  marks  of  neuritis  ;  the  margins  of 
the  papilla  were  ill-defined  and  irregular,  and  the  veins  tortuous.  An  elastic  growth, 
fiUino-  the  orbit,  and  projecting  in  a  nodular  form  at  the  lower,  outer  part,  could  be 
distinctly  felt.  The  patient  was  in  constant  dread  that  the  eye  would  "  come  out  of  her 
head,"  and  had  to  push  it  back  often  with  her  hand.  When  ready  to  enucleate,  I  pushed 
the  lids  back  beyond  the  eyeball,  where  they  closed  in  tightly,  so  that  no  speculum 
was  needed.  The  removal  of  the  eye  was  extremely  easy,  and  I  then  passed  my  finger 
back  and  pulled  out  the  tumor.  It  was  moulded  to  the  general  form  of  the  cavity^  but 
was  more  prominent  outwards.  Dr.  Robert  Sattler's  microscopic  examination  revealed 
a  fibro-sarcoma.  There  has  been  no  return,  and  the  patient  wears  an  artificial  eye 
comfortably. 

If  the  tumor  is  seated  backwardly  and  inwardly,  the  eye  will  be  pushed  for- 
wards and  outwards.  The  displacement  is  always  in  the  opposite  direction 
to  the  seat  of  the  growth.  When  far  forwards,  the  eye  is  displaced  laterally, 
and  but  little  increased  in  prominence.  Double  vision  is  a  common  cause  of 
worrimont,  when  the  dislodgment  is  indirect  and  considerable.  If  not 
directly  invaded  by  the  morbid  growth,  the  rotatory  muscles  preserve  their 


INJURIES  AND  DISEASES  OF  THE  ORBIT. 


587 


functions  for  a  very  long  time.  The  limitation  is  first  and  chiefly  noticed 
towards  the  side  of  the  tumor,  and  is  in  proportion  to  its  size.  The  lids 
stretch  with  the  slow  increase  of  the  exophthalmus,  and  still  cover  the  eye^ 
even  in  the  extremest  cases.  If  the  progress  is  rapid,  the  pain,  impaired 
motion,  double  vision,  and  violent  reaction  from  exposure,  show  themselves 
much  earlier.  In  that  event,  ulceration  of  the  cornea  and  loss  of  vision  may 
be  expected  much  sooner. 

Of  the  many  kinds  of  orbital  grow^th,  some  are  fatally  malignant,  others 
less  so,  and  some  harmless,  except  from  the  want  of  room.  Some  are  ex- 
tremely firm, others  less  so;  some  are  cystic  or  mixed, others  bony.  In  some 
instances  the  growth  is  very  slow.  These  are  apt  to  prove  benignant. 
Others,  of  rapid  progress,  are  more  likely  to  be  malignant.  The  difterent 
kinds  of  vascular  tumor  are  generally  traumatic,  and  sudden  in  their  appear- 
ance. Exostoses  are  always  of  very  slow  growth,  especially  those  of  the  ivory 
variety.  When  accessible  to  the  touch,  much  may  be  learned  of  the  tumor's 
consistence  by  that  means.    A  case  in  point,  of  exostosis,  is  the  following:^ — 

Mary  E.  T.,  23  years  old,  of  rugged  constitution  and  in  good  health,  consulted  me 
March  13,  1878.  It  was  difficult  to  procure  a  clear  history  of  her  case,  on  account 
of  the  patient's  stupidity.  For  three  years  the  family  had  noticed  a  divergence  of  the 
left  eye  when  she  fixed  objects  closely,  or  was  embarrassed.  About  one  year  before,  an 
unnatural  prominence  of  the  eye  had  been  observed.  Since  that  time  exophthalmus  and 
divergence  had  slowly  increased,  and  the  siglit  had  disappeared.  No  traumatic  or  consti- 
tutional origin  of  the  affection  could  be  traced  or  even  supposed.  Her  health  liad  been 
uniformly  good.  The  patient  had  a  broad  face,  flat  nose,  and  stolid  expression.  Her 
condition,  when  examined,  was  found  to  be  as  follows :  The  left  eye  was  pressed  upwards 
and  outwards,  and  protruded  to  such  a  degree  that  the  centre  of  the  cornea  was  half 
an  inch  in  advance  of  the  other ;  the  movements  were  limited  downwards  and  inwards, 
but  free  in  other  directions.  With  that  eye  she  had  only  vague  perception  of  light, 
the  sight  of  the  other  being  perfect.  The  prominence  was  so  excessive  that  slight 
pressure  on  the  upper  lid  caused  it  to  close  in  behind  the  ball.  At  the  lower  and  inner 
part  of  the  orbit  a  tumor  was  seen,  dislodging  the  eye — bony  hard  to  the  touch,  some- 
what nodulated,  but  round,  and  extending  deeply  into  the  socket ;  the  pupil  did  not 
respond  to  light,  when  the  other  eye  was  excluded,  but  remained  large  and  fixed. 
With  the  ophthalmoscope  I  discovered  marked  neuro-retinitis  from  stasis  ;  the  entire 
retina  was  hazy,  and  the  vessels  were  tortuous  and  obscured  at  many  points  with  exuda- 
tions ;  the  disk  was  much  engorged,  and  its  margins  were  difficult  to  identify.  It  was 
evident  that  the  eye  was  visually  useless,  and,  the  tumor  being  large,  deeply  seated,  and 
firmly  attached  to  the  os  planum  of  the  ethmoid,  I  thought  it  safest  and  best  to  enucleate 
the  eye  and  then  remove  the  growth;  this  was  done  with  the  patient  under  ether.  After 
enucleation,  1  found  by  the  finger  that  the  tumor  was  firmly  united  to  the  inner  wall  of 
the  orbit,  and  extended  nearly  to  the  apex.  Cutting  through  the  capsule  of  Tenon  and 
the  periosteum,  I  denuded  the  mass  as  extensively  as  possible  ;  then,  with  the  bone- 
nippers,  an  effort  was  made  to  cut  off  a  portion  of  it,  but  it  was  so  hard  that  with  my 
utmost  strength  I  could  only  bring  away  very  little.  I  then  opened  a  strong  pair  of 
bone-forceps  very  widely,  forced  them  over  it  so  as  to  secure  a  firm  hold,  and  by  a  few 
wriggling  movements  detached  it  en  masse  from  its  connections,  and  drew  it  out,  thus 
completing  the  operation  in  a  few  minutes,  and  without  any  shock  from  chiselling  or 
slipping  of  the  forceps.  But  little  bleeding  occurred,  and  the  patient  soon  rallied  from 
the  ether.  Two  days  afterwards  she  returned  to  her  home  in  the  country  ;  the  fol- 
lowing night,  however,  my  assistant  was  called  to  her  to  arrest  a  severe  hemorrhage 
from  the  nostril  of  that  side.  A  section  of  the  tumor  measured  16  mm.  in  its  longest 
diameter;  in  its  transverse  diameter  it  measured  about  10  mm. ;  the  rough  bony  pedicle 
measured  8  mm.  in  one  direction,  and  5  mm.  in  the  other,  showing  that  it  was  continuous 
with  the  OS  planum  by  a  constricted  neck.  The  entire  growth  came  clean  away,  bring- 
ing no  true  bone  with  it.    It  was  as  hard  as  ivory  throughout,  admitting  of  a  nice 

•  Transactions  of  the  Am.  Med.  Association,  vol.  xxx. 


588         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

polish,  and,  when  being  sawed,  emitted  the  peculiar  smell  of  ivory.  Its  general  form 
(supplyino-  the  portion  that  was  chipped  off  by  the  nippers)  was  round,  similar  to  a  wal- 
nut, but  nodulated  and  traversed  by  a  deep  fissure,  which  passed  around  it,  between  the 
pedicle  and  the  convex  portion  that  pressed  against  the  eye.  Its  weight  was  3  drachms, 
and  with  the  portion  that  was  chipped  away  would  have  been,  perhaps,  half  a  drachm 
more  No  vessels  were  to  be  seen  on  its  surface  or  in  its  structure.  The  patient 
returned  about  a  year  after  the  operation  to  procure  an  artificial  eye,  and  there  was  no 
trace  whatever  of  any  reproduction  of  the  tumor. 

These  operations  are  always  difficult  and  tedious,  and  often  only  partially 
successful.  If  possible,  the  eye  should  be  preserved  m  all  operations  in  the 
orbit  But  sometimes  enucleation  is  a  necessity;  and  it  always  greatly 
facilitates  the  removal  of  an  orbital  tumor.  If  sight  is  gone,  the  sacrilice 
does  not  seem  very  great.  Any  mutilation,  when  necessary  to  save  lite,  is 
iustifiable.  Very  great  care  is  needed  to  save  the  eye  from  injury,  with  its 
muscles  and  optic  nerve.  Sometimes  one  or  more  of  the  muscles  must  be  cut, 
and  the  ball  luxated  by  the  finger,  to  secure  access  to  the  tumor.  When 
the  operation  is  completed,  the  divided  muscles  may  be  stitched,  and  de- 
formity thus  prevented.  .  . 

Cysts  originating  in  the  ethmoid  bone,  and  sometimes  m  the  orbit,^  can 
only  be  treated  surgically.  They  are  filled  with  colored,  ropy  fluid,  mixed 
with  firm  flakes.  Free  incision,  syringing  out  the  contents,  and  the  use  ot 
irritatins;  injections  will  generally  succeed  in  effecting  a  cure. 

The  following  case  is  typical  of  this  class  of  tumors : — 

A  stout,  healthy  man  from  the  country  consulted  me  for  a  very  high  degree  of  exoph- 
thalmus  of  the  ri<^ht  eye.   A  small  scar  just  above  the  orbit  was  the  result  of  a  severe  blow 
received  when  a'boy.    Besides  this  no  other  injury  could  be  recalled.    The  protrusion 
was  so  great  that  the  eyehds  could  only  be  closed  by  an  effort.    He  dated  the  commence- 
ment ot^this  symptom  back  only  six  months.    The  luxation  was  forwards,  downwards, 
and  inwards.    A  fluctuating  tumor  was  felt  between  the  ball  and  the  upper  and  outer 
part  of  the  orbit.    I  elevated  the  lid,  and  thrust  a  trocar  through  the  cul  de  sac  of  the 
coniunctiva  in  the  direction  of  the  tumor.    About  an  ounce  and  a  half  of  ropy,  slightly 
reddish  fluid  escaped.    The  ball  sank  back  almost  to  its  natural  position  at  once.    On  , 
his  return  in  two  weeks,  a  re-accumulation  had  taken  place,  but  much  less  in  quantity. 
A  similar  puncture  was  made  with  the  same  result  as  before.    A  few  weeks  later  I  saw 
him  ac-ain.    The  exophthalmus  was  as  marked  as  on  the  first  visit.    I  then  made  a  free 
incisio°n,  over  an  inch  long,  through  the  skin,  parallel  with  the  margin  of  the  orbit,  and 
opened  the  cyst  extensively.    After  the  escape  of  the  contents,  the  sac  was  syringed 
with  water,  when  three  or  four  masses  of  coagula,  each  nearly  as  large  as  the  little 
fino-er,  were  washed  out.    By  examination  with  the  finger  the  cyst  was  found  to  be  very 
lar^e,  extending  to  the  apex  of  the  socket.    As  much  as  possible  of  the  wall  of  the  cyst 
was  removed  with  scissors.  For  several  weeks  the  cavity  was  daily  washed  out  with  water, 
and  the  incision  kept  open  by  a  tent.    Finally,  the  tent  wa-s  left  out,  the  wound  closed,  and 
the  patient  was  well  for  about  a  year.    The  remaining  exophthalmus  was  sbght ;  the 
vision,  at  first  much  impaired,  improved  till  he  could  read  No.  8  of  Jaeger  s  tests.  He 
came  back  a  year  after  with  a  decided  return,  which  had  appeared  withm  two  weeks. 
There  was  no  pain,  redness,  or  soreness  on  pressure.    I  incised  the  cyst  freely  as 
before,  and  about  an  ounce  of  pus,  mixed  with  the  same  glairy,  ropy  flui4  escaped  A 
probe  detected  denuded,  but  smooth,  bone  at  the  apex  of  the  cavity.    The  wound  was 
kept  open  as  before,  the  cavity  washed  out  daily  with  water,  and  injected  with  pure 
tincture  of  iodine.    This  was  done  for  a  week.    The  tent  was  continued  for  ten  days 
afterwards,  and  at  that  time  the  bare  bone  was  covered,  and  the  cavity  much  jeduced  in 
size.    Still,  a  httle  glairy  fluid  escaped  each  day  with  the  pus.    I  then  injected  for  three 
times,  every  second  day,  a  60-grain  solution  of  nitrate  of  silver.    In  a  week  after  that 
treatment  I  found  the  cavity  very  much  smaller,  and  bleeding  readily  wli en  touched 
with  the  probe.    I  then  injected  the  iodine  for  three  successive  days.    The  tent  was 
used  for  several  weeks  till  the  cavity  was  permanently  obUterated,  so  that  nothing  was 
seen  but  an  indrawn  cicatrix. 


INJURIES  OF  THE  EYEBALL. 


589 


!N"othing  but  persevering  and  heroic  treatment  can  destroy  such  cysts.  I 
have  repeatedly  dealt  with  cysts  of  the  ethmoid  bone  in  a  similar  way.  They 
encroach  upon  the  orbit,  interfere  with  the  tear-sac,  push  the  eye  to  one  side, 
and  demand  treatment.  Where  the  shell  of  bone  over  the  cyst  is  thin,  a  pecu- 
liar feeling  and  crepitus  are  detected,  when  it  is  pressed  Avith  the  linger.  In 
one  instance  this  was  very  striking. 

Tumors  of  the  optic  nerve  usually  destroy  vision,  and  the  protrusion  is 
m  the  direct  line.  In  rare  cases,  the  tumor  and  nerve  have  been  removed, 
leaving  the  ej'e,  but,  as  a  rule,  the  useless  eye  is  sacrificed,  for  the  readier 
removal  of  the  tumor. 

Vascular  tumors  of  the  orbit,  always  attended  by  pulsating  exophthalmus, 
present  very  different  appearances,  on  post-mortem  examination.  In  some, 
where  this  symptom  was  intensely  marked,  and  a  shrill  bruit  was  audible 
over  the  eye,  but  little  alteration  was  found  after  death,  and  this  mostly  in  the 
cavity  of  the  cranium.  As  a  rule,  these  symptoms  are  found  to  be  due  to  a 
traumatic  rupture  of  the  carotid  artery  in  the  cavernous  sinus.  I  have  seen 
but  two  cases  of  genuine  aneurism  of  the  ophthalmic  artery.  One  was  pro- 
duced by  a  small  shot  that  penetrated  the  orbit  and  wounded  the  artery.  It 
was  cured  by  compression.  I  published,  many  years  ago,  a  case  of  very  great 
protrusion  of  the  eye,  with  pulsation,  and  a  loud  bruit,  attended  by  optic 
neuritis.  The  papilla  was  greatly  swollen,  the  vessels  were  very  tortuous, 
and  there  were  numerous  hemorrhages  in  the  retina.  A  cart-wheel  had 
passed  over  the  man's  head  a  short  time  before  the  disease  developed.  The 
late  Prof.  H.  E.  Foote,  afc  my  request,  ligated  the  carotid  artery  with  tem- 
porary benefit.  Six  weeks  after,  the  murmur  and  pulsation  having  returned, 
he  tied  the  other  artery,  with  the  result  of  effecting  a  complete  cure.  In 
nearly  all  cases  of  tumor  behind  the  eye,  the  exophthalmus  and  impaired 
sight  are  united  with  great  swelling  of  the  optic  disk  from  venous  stasis. 
In  a  man  seen  recently,  with  great  prominence  of  the  eye  and  but  little 
sight,  the  swollen  papilla  was  remarkable.  It  stood  out  into  the  vitreous 
with  its  round  form  perfectly  defined,  and  the  vessels  passing  up  over  it  as 
if  springing  up  on  an  artificial  mound.  By  deep  pressure  at  the  upper 
and  inner  part,  the  edge  of  the  retro-bulbar  growth  could  be  felt.  Operative 
interference  will  soon  be  imperative.  A  malignant  tumor  of  the  orbit,  in 
a  little  girl,  became  so  large  and  produced  such  pressure,  that  in  the  midst  of 
a  fearful  paroxysm  of  pain  the  whole  superior  maxillary  suddenly  separated 
from  its  fellow  with  an  audible  noise.  The  pain  ceased  instantly,  and  the 
teeth  of  that  side  projected  half  an  inch  beyond  the  line  of  the  others.  The 
detachment  was  from  the  median  raphe.  The  child  died  a  few  weeks 
afterwards  from  invasion  of  the  brain.  The  enormous  size  that  these  fatal 
growths  attain,  is  almost  beyond  belief.  In  such  extremities,  death  is  a  most 
welcome  visitor. 

Injuries  of  the  Eyeball. 

That  the  eye  is  a  delicate  orgoM  is  best  known  to  the  surgeon  acquainted 
with  its  sensitive  structures  and  exquisite  functions.  In  spite  of  the  bony 
safety-box  in  which  it  is  so  nicely  pivoted,  the  fatty  cushion  behind,  and 
tbe  watchful  shutters  in  front,  the  eye  is  often  surprised  and  seriously  injured. 
Always  open  during  the  wakeful  hours,  it  is  constantly  exposed  to  the  vapors 
and  fine  dust  of  the  atmosphere.  Cinders  and  other  particles  driven  by  the 
wind,  often  strike  the  e3^e  and  fix  themselves  upon  it,  causing  great  suffer- 
ing. It  would  be  impossible  to  enumerate  all  the  parts  of  seeds  and  grains, 
scales  of  insects,  and  other  trifles,  for  which  there  is  no  room  in  the  eyes ! 


590 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


Foreign  Bodies  in  the  Eye. — Foreign  particles  that  remain  any  time 
in  the  eye,  nearly  always  fix  themselves  in  one  of  two  positions.  They 
adhere  to  the  eyeball  in  front,  generally  to  the  cornea,  or  sweep  under  and 
fasten  themselves  on  the  inside  of  the  upper  lid.    Rarely,  they  gravitate 
between  the  lower  lid  and  the  ball.    Instinctive  resistance  to  any  sudden 
feeling  of  something  in  the  eye,  prompts  to  spasmodic  closure  of  the  lids  and 
rude  rubbing  with  fingers  or  knuckles.    This  often  fixes  and  imbeds  the 
cinder,  while  promptly  seizing  the  lid  and  holding  the  eye  open,  would  favor 
its  escape  with  the  gush  of  tears.    The  circumstances  under  which  the  trou- 
ble occurs,  will  often  help  to  decide  what  it  might  he ,  but  only  a  thorough 
examination  can  determine  what  it  is.  When  consulted  for  a  supposed  foreign 
body  in  the  eye,  or  when  that  is  a  possibility,  though  not  suspected  by  the 
patient,  a  critical  inspection  of  the  cornea  and  the  eyeball  should  be  made. 
To  do  this,  good  light  and  good  sight  are  indispensable.    Separating  and 
holding  the  lids  gently  apart,  and  directing  the  patient  to  turn  the  eye  as 
desired,  the  surgeon  makes  a  hasty  search  of  the  entire  surface  of  the  cornea. 
If  the  foreign  body  is  very  minute,  of  a  dark  color,  and  lodged  near  the 
centre  of  the  cornea,  it  is  better  seen  obliquely,  as  you  thus  get  a  background 
of  iris  rather  than  of  black  pupil.    Should  it  be  of  light  color,  it  will  require 
very  close  attention  to  see  it.    Oblique  illumination,  using  a  large  collecting 
lens  of  about  three  inches'  focus,  will  materially  aid  the  search.  Common 
day  light,  and  still  better,  a  good  lamp  light,  may  be  thus  focussed  upon 
the  cornea,  and  promenaded  over  its  surface.    While  the  seat  of  the  foreign 
body  may  be  made  clear  by  focal  illumination,  another  similar  lens  may  be 
used  to  magnify  it  and  make  its  detection  certain.    By  these  aids,  it  cannot 
escape  notice,  however  small.    If  nothing  is  found  on  the  cornea  or  ball  by 
a  hasty  but  adequate  inspection,  the  surgeon  should  evert  the  lids  and  scrutinize 
their  conjunctival  surfaces.    The  lower  lid  is  easily  everted  by  drawing  it 
.  down  towards  the  cheek,  directing  the  patient  to  look  up,  but  the  foreign 
body  is  far  more  likely  to  be  found  under  the  upper  lid.    To  evert  it  is  not  so 
easy,  and  requires  professional  tact.    Seize  the  lashes  near  the  middle  of  the 
lid  with  the  thumb  and  index  finger  of  the  left  hand,  and  direct  the  patient 
to  look  steadily  and  far  down.    Then  drawing'  the  lid  slightly  away  from  the 
eye,  and  downw^ards,  you  press  a  small  probe,  the  end  of  a  pencil,  or  even  the 
tip  of  the  finger,  above  the  tarsus,  sliding  the  lid  down  while  the  free  edge  is 
raised  by  the  left  hand,  and  the  eversion  is  accomplished.    Nothing  but  prac- 
tice, with  light  and  intelligent  fingers,  will  make  this  important  manoeuvre 
easy.    There  is  no  one  thing  by  which  a  patient  who  has  been  once  handled 
by  expert  fingers,  will  detect  awkwardness  and  inexperience  as  quickly  as  by 
the  way  the  upper  lid  is  everted.     Finding  the  foreign  body,  probably  on  the 
tarsal  surface,  near  the  free  edge  of  the  lid,  you  can  readily  remove  it,  and 
the  agony  is  over.    Or  failing  still  to  find  it,  you  next  explore,  as  best  you  can, 
the  upper,  concealed  folds  of  conjunctiva.    Keeping  the  lid  everted,  and  the 
eye  turned  far  downwards,  you  place  the  probe  on  the  skin  far  back,#press 
it  downwards,  and  then  hoist  it  forwards,  thus  prying  out  the  folds.  Strings 
of  matter,  granulations,  or  warty  excrescences,  may  be  discovered  surrounding 
a  beard  of  wheat  or  barley,  a  grain  of  wheat,  a  piece  of  straw  or  splinter  of 
wood,  a  husk  of  some  seed,  or  other  intruder.  Thus  it  is  found  and  removed. 
That  done,  little  or  no  other  treatment  is  required.    The  patient  may  have 
suffered  for  months,  and  been  blindly  tortured  with  the  severest  reniedies. 
If  only  one  eye  has  been  affected  with  stubborn  conjunctivitis,  without 
chronic  disease  of  the  tear  sac,  this  thorough  search  for  a  foreign  body  lodged 
in  the  upper  folds  should  not  be  neglected.    It  will  often  lead  to  brilliant 
discoyeries,  and  secure  the  lasting  gratitude  of  the  patient.    I  have  removed 
scales  of  seeds,  wings  of  insectSj'^and  other  foreign  bodies  that  had  been  fast- 


INJURIES  OF  THE  EYEBALL. 


591 


ened  on  the  cornea,  in  plain  view,  for  months,  and  the  irritation  aggravated 
by  severe  local  astringents.  I  once  found  a  dry  stramonium  seed  in  the 
upper  cul-de-sac  of  the  conjunctiva;  it  had  been  in  the  eye  some  thirty-six 
hours  and  the  pupil  was  widely  dilated.  Small  particles  of  steel,  stone, 
powder,  and  other  hard  substances,  driven  not  by  the  wind  but  by  mechani- 
cal forces,  may  not  merely  lodge  on  the  eye  or  under  the  lids,  but  be  more 
or  less  deeply  imbedded.  There  is,  then,  generally,  more  reaction,  pain,  and 
traumatic  inflammation,  both  before  and  after  removal.  If  the  foreign  body 
be  on,  or  imbedded  in,  the  cornea,  photophobia,  spasm  of  the  lids,  and  weeping, 
may  seriously  embarrass  the  examination  and  necessary  treatment. 

The  removal  of  foreign  bodies  from  the  cornea  is  not  always  easy,  especially 
when  they  are  metallic,  and  have  remained  several  days.  Undergoing 
chemical  changes,  the  oxidized  substance  incorporates  itself  with  the  corneal 
tissues,  producing  a  dirty-rust  ring.  This  will  remain  after  the  little  mass 
of  metal  has  been  removed.  By  some  persistence  this  ring  can  be  detached. 
It  is  essentially  foreign.  A  sharp  spud,  or  a  sort  of  gouge  (Fig.  919),  is  better 
for  removing  particles  from  the  cornea  than  a  needle, 
and  less  dangerous  in  inexperienced  hands.    An  ope-  F^g-  919. 

rating  chair  or  lounge  may  be  used  to  seat  the  patient, 
or  to  lay  him  comfortably  down.    Standing  behind  «== 
or  beside  the  patient,  as  may  be  niost  convenient  the      ^^^^    ^^^^^.^^  ^^^.^.^^ 
lids  are  separated  by  the  lett  hand,  and  the  spud  held 

bodies  from  the  cornea. 

in  the  right.    In  holding  the  eyelids  securely  open, 

with  the  thumb  and  index  finger,  care  must  be  taken  not  to  evert  them. 
The  patient  is  urged  to  hold  the  eye  still  in  a  given  direction.  The  first 
touch  of  the  cornea  will  make  him  wince  from  apprehension,  but  he  will 
soon  learn  to  control  the  eye.  A  good  light  and  a  favorable  position  for  seeing 
the  foreign  body  are  indispensable.  Then  supporting 
the  ball,  with  the  lids  well  apart,  the  surgeon  perse-  Fig-  920. 

veres  till  he  has  completely  removed  the  foreign  body,  ^ 
with  its  stain,  if  such  exist,  doing  as  little  damage  -"^^-^^-^X^jf 
to  the  cornea  as  possible.  If  the  particle  be  more  deeply    ^^^^^  ^^^^^^  ^^^^^.^^ 
imbedded,  the  spud  may  not  succeed,  and  a  broad 

eign  bodies  from  the  cornea. 

needle  (Fig.  920)  will  serve  best.   If  the  patient  cannot 

control  his  eye,  a  speculum  (Fig.  921),  fixation  forceps  (Fig.  922),  and  even 
ether,  may  be  used.    In  rare  instances  a  scale  of  metal,  piece  of  cap,  or  glass, 

Fig.  921.  Fig.  922. 


Fixation  forceps. 


Liebreich's  spring-stop  speculum  for 
separating  the  eyelids.  . 


may  be  driven  so  deep  as  to  be  ready  to  fall  into  the  aqueous  chamber.  The 
least  touch  of  the  needle  might  push  in  the  foreign  body,  when  it  would 


592 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


naturally  fall  to  the  bottom  of  the  chamber  and  soon  create  violent  reaction. 
The  difficulties  and  dangers  of  removal  would  be  then  greatly  increased.  In 
every  case  where  such  an  accident  is  imminent,  thorough  aneesthesia  is  neces- 
sary. The  spring  speculum  and  fixation  forceps  must  be  applied  so  as  to  secure 
the  greatest  accuracy  in  the  use  of  instruments.  A  narrow,  very  sharp,  spear 
knite,  bent  on  the  fiat,  must  be  passed  through  the  cornea  a  little  to  one  side  of 
the  offending  body,  and  pushed  carefully  through  the  chamber  till  well  behind 
it.  Then  by  depressing  the  handle,  the  blade,  with  its  fiat  surfax^e,  is  brought 
firmly  against  the  cornea,  and  the  possible  entrance  of  the  foreign  body  into 
the  chamber  is  blocked.  While  one  hand  thus  carefully  holds  the  foreign 
body,  the  other  picks  or  prizes  it  out  with  a  broad  needle.  The  fixation 
forceps,  at  this  stage  at  least,  must  be  held  by  an  assistant.  No  operation 
on  the  eye  demands  greater  coolness  and  skill  than  the  manoeuvre  described. 
Should  the  aqueous  humor  escape  before  the  object  is  attained,  the  surgeon 
must  desist  and  wait  for  its  reaccumulation. 

The  length  of  time  that  a  foreign  body  may  remain  buried  in  the  cornea, 
undiscovered,  is  illustrated  by  a  case  in  which  a  piece  of  wheat-beard  was 
removed  after  two  and  a  half  years: — 

A  farmer,  in  September,  1866,  while  feeding  a  threshing  machine,  felt  something 
strike  the  left  eye.  Severe  inflammation  followed,  and  he  was  kept  in  a  dark  room 
for  two  months.  The  eye  then  grew  gradually  more  comfortable,  so  that  he  could 
work,  but  remained  delicate,  till  in  March,  1869,  when  severe  suffering  again  set  in. 
I  saw  him  on  April  29.  There  was  vivid  ciliary  injection,  and  intense  intolerance  to 
light.  A  dark,  grayish  speck  was  seen  in  the  centre  of  the  cornea.  By  oblique  illumi- 
nation, a  distinct  projection  from  the  corneal  surface  was  detected.  This  was  readily 
removed  by  a  spud,  and  at  the  same  instant  the  aqueous  humor  escaped.  On  exami- 
nation, the  substance  removed  proved  to  be  a  short  piece  of  wheat-beard  which  had 
punctured  the  cornea,  and  which  after  that  long  period  had  worked  to  the  free  surface. 

Accidental  Wounds  of  the  Eyeball.— These  may  be,  (1)  Incised,  when 
infiicted  by  the  blade  of  a  knife,  scissors,  piece  of  glass,  or  any  other  sharp 
substance ;  (2)  Punctured,  as  when  caused  by  a  pin,  needle,  thorn,  or  sharp, 
round  instrument,  such  as  the  tine  of  a  fork  ;  (3)  Mixed  wounds,  of  a  contused 
and  lacerated  character ;  and  (4)  Ruptures  of  the  strong  supportmg  tunic, 
generally  of  the  sclera,  by  blunt  force,  such  as  the  blow  mflicted  by  a  wmd- 
fass,  the  horn  of  a  cow,  the  fist,  a  ball,  or  a  small  stone. 

Incised  wounds,  if  clean,  sharp,  and  not  deep  enough  to  open  the  eyeball, 
are  not  serious,  and  soon  heal  by  simple  rest  with  the  eyes  closed.  Even 
when  passing  through  the  cornea  or  sclera,  and  of  considerable  length,  if  no 
prolapsus  of  the  iris  or  ciliary  body  occurs,  and  if  no  deep-seated  organ,  such 
as  the  lens,  is  injured,  they  soon  recover  with  the  same  treatment.  If,  however, 
the  anterior  chamber  is  opened,  even  by  a  small  wound,  the  sudden  loss  of 
aqueous  is  very  apt  to  wash  the  iris  into  the  open  cut,  producing  prolapsus. 
This  is  easily  recognized  by  the  little,  round,  dark  prominence  at  the  seat  of 
the  cut,  looking  something  like  the  head  of  a  house-fiy.  With  that,  the  pnpil 
will  be  more  or  less  eccentric  and  altered  in  shape.  It  wdl  be  pear-shaped, 
with  the  small  end  at  or  towards  the  wound  in  the  cornea  or  the  sclero-cor- 

neal  junction.  c       ^  4i  -a 

Li  the  vitreous  cavity  is  opened,  prolapsus  of  more  or  less  ot  that  lluia 
will  be  likely  to  show  itself.  Even  here,  if  the  cutting  body  has  not  pene- 
trated very  deeply,  and  if  no  great  loss  of  vitreous  has  taken  place,  with 
intra-ociilar  hemorrhage,  the  wound  may  heal  with  little  injury  to  sight. 

Punctur  e.d  Wounds.— Wovm(\^  by  a  pin,  needle,  thorn,  or  sting  of  a  bee,  it 
deep,  are  extremely  dangerous  to  sight,  and  are  liable  to  be  followed  by  dis- 
astrous inflammation,  even  of  the  uninjured  eye. 


INJURIES  OF  THE  EYEBALL. 


593 


1  once  treated  a  woman  whose  eye  was  put  out  by  a  pin.  She  was  beating  carpet, 
and  the  pin  struck  the  eye  with  such  force  as  to  penetrate  deeply  through  the  cornea' 
iris,  and  lens.  She  suffered  for  many  months,  but  recovered  with  a  blind  eye,  the  good 
eye  never  having  seriously  sympathized  with  it. 

On  December  31,  1881,  a  man  was  struck  in  the  face  by  a  bramble  bush.  He  suf- 
fered repeated  attacks  of  inflammation,  the  sight  growing  more  and  more  cloudy,  till 
July,  1882,  when  I  saw  him.  There  was  a  scar  near  the  upper  edge  of  the  cornea,  and 
a  slight  synechia  anterior.  I  saw  a  piece  of  brier  in  the  iris,  and  removed  it  by 
iridectomy  with  the  portion  of  iris  in  which  it  rested.  The  other  eye  was  hopelessly 
blind  from  previous  disease,  but  the  eye  which  was  operated  on  recovered. 

Thorns  of  black  locust,  honey  locust,  etc.,  often  destroy  the  eye,  especially 
when  a  piece  breaks  off  and  remains. 

Wounds  of  a  contused  and  lacerated  character  are  nearly  always  disastrous 
to  sight,  and  often  lead  to  grave  complications,  involving  the  sight  of  the 
remaining  eye,  and  even  danger  to  life.  Of  course,  the  risks  are  greatly  en- 
ha.nced  bj  the  penetration  and  lodgment  of  the  wounding  body,  or  of  some- 
thing else  that  may  be  carried  in  with  it.  Intra-ocular  hemorrhage  and 
inflammatory  disorganization  from  panophthalmitis,  with  its  violent  and  pro- 
tracted sufferings,  are  almost  sure  to  follow,  in  any  event.  In  all  such  fatal 
accidents  to  sight,  if  the  eye  would  eventually  heal  and  remain  inoffensive, 
it  would  be  a  happy  issue ;  but  prolonged  suffering  and  sympathetic  dano-er 
to  the  fellow-eye  are  always  to  be  apprehended.  ^ 

Ruptures  of  the  eyeball  from  blunt  force  take  place  in  the  sclera,  a  short  dis- 
tance back  of  and  parallel  to  the  base  of  the  cornea.  Simple  rupture  of  the 
cornea  is  extremely  rare.  In  ruptures  of  the  sclera,  the  yieldino-  conjunctiva 
generally  escapes,  while  the  lens  is  often  driven  through  the  rent  and  lodo;ed 
under  the  mucous  membrane.  In  that  case,  a  large,  round  elevation,  formed 
by  the  lens,  whose  color,  perhaps,  may  partly  be  seen  through  the  distended 
and  semi-transparent  conjunctiva,  will  indicate  what  has  happened.  I  have 
repeatedly  incised  the  conjunctiva  and  removed  the  lens  after  this  accident, 
with  preservation  of  even  useful  vision.  Patients  recover  with  very  little 
suffering  in  these  cases,  and  the  rupture  is  not  often  the  cause  of  sympathetic 
loss  of  the  sound  eye. 

Penetrating  Wounds  of  the  Eye.— A  question  of  great  importance,  in  all 
cases  of  eye-wound,  is  whether  or  not  the  offending  body  has  entered  the  eye- 
ball. To  determine  this,  is  by  no  means  easy  in  very  many  cases.  If  the 
wound  is  large  and  deep,  the  immediate,  partial  or  complete  collapse  of  the 
globe,  and  the  escape  of  a  portion  of  its  peculiar  contents,  reveal  at  once  to  the 
most  ignorant,  or  even  careless,  the  nature  of  the  injury.  But  if  the  injurino- 
body  is  small  and  propelled  with  great  force,  it  may  penetrate  deeply  into 
the^  eye  with  a  scarcely  perceptible  wound,  and  almost  without  pain.  The 
patient  himself  feels  sure  that  it  could  not  have  gone  into  his  eye,  for  he  hardly 
felt  it,  and  he  often  misleads  his  physician.  It  is  well  known  to  surgeons  of 
experience  that  a  small  particle  flying  with  great  force,  and  lodging  deeply 
in  the  eye,  hurts  much  less  than  one  moving  slowly  and  lodging  oifthe  eye 
or  under  the  ltd.  besides,  the  pain  is  much  greater  for  hours,  and  even  days 
and  weeks,  afterwards,  in  the  latter  case  than  in  the  former.  It  frequently 
happens  that  a  foreign  body  of  minute  size  penetrates  the  eye,  producino- 
sooner  or  later,  cataract,  or  other  serious  trouble,  and  that  the  patient  cannot 
remember  when,  where,  or  how  the  accident  occurred,  so  little  did  it  attract 
his  attention  at  the  fatal  moment.  This  should  warn  us  always  to  make  a 
most  minute  and  critical  examination  of  the  eye  when  the  circumstances 
prove  such  an  occurrence  possible.    For  instance,  a  slight  stins;  is  felt  in  the 

VOL.  IV.— 38 


594         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

eye  of  a  bystander  when  a  percussiou-cap  is  exploded.    He  rubs  the  eye  for  a 
foment,  iipes  a^yay  a  tear,  and  feels  it  no  more.    On  close  nispection  a  par- 
dck  of  he  cylinder  is  found  to  haye  passed  through  the  cornea  and  lodged 
in  the  anterior  chamber,  the  iris,  or  the  lens-or  eyen  to  haye  cleared  all  of 
"hese  and  -one  deep  into  the  yitreous-causipg,  perhaps,  yeiy^  little  imme- 
dia  e  in  pa^-ment  of  yision.    The  first  step  in  the  diagnosis  is  to  find  he 
wmd  ;  the  second,  to  determine  whether  or  not  it  extends  through  all  the 
coa    of  the  eye;  and  the  third,  to  ascertain  if  the  injuring  body  has  re- 
bounded, has  lodged  in  the  tunics  themselyes,  or  has  cleared  them  and 
ente  -ed  the  -lobe  to  remain.    In  seeking  the  wound  each  part  ot  the  eye 
must  be  hispected  in  systematic  order,  beginning  with  the  one  most  com- 
monly iniured,  the  cornea.    In  this  examination  we  may  be  otten  guided 
wHh  some  certainty,  to  the  seat  of  injury,  by  the  circumstances  under  which 
U  occurred,  and  by  the  existence  of  a  scratch  or  cut  of  one  or  other  eye- 
d     But  a  the  eye^s  nearly  always  open  at  such  times,  if  the  body  is  small 
it  strikes  the  cornea  directly,  without  grazing  or  passin.  through  the  lids, 
in  these  cases  the  diagnosis  is  often  extremely  difficult     The  cornea,  coyered 
by   ts  smooth,  polished  epithelium,  acts  as  a  reflector,  forming  images  of 
objects  in  front  of  it.    If  the  epithelium  at  any  point  be  abraded  or  rough, 
a  corresponding  blur  and  defect  will  be  seen  in  the  sharp  image  of  the  win- 
dow ow^ds  which  it  looks.    The  eye  should  be  examined  at  an  angle  and 
made  to  moye  slowly  so  that  the  little  image  may  trayel  oyer  all  parts  of  its 
Trface  in  succession.    Another  excellent  means  of  detecting  a  yery-  small 
scrateh  or  wound  in  the  cornea  is  by  oblique  illummation.    Darken  the  roorn 
and  lio-ht  your  gas  or  lamp,  seat  your  patient  facing  it,  and  concentrate  the 
Ueht  Spon  the  cornea  by  a  strong  coiwex  lens  of  two  or  three  inches  tocus 
It- an  abrasion  or  wound,  he  it  eyer  so  minute,  exist  you  will  thus  see  it  Of 
couL,  if  the  cut  be  large,  with  hernia  of  the  iris,  it  is  seen  at  once  without 

^'^Discotered  the  seat  of  the  wound,  has  it  penetrated  ?  _  If  the  iris  is  drawn 
into  it  by  the  escape  of  aqueous  humor,  forming  a  hernia,  eyer  so  small,  yes. 
S  L  chamber  has  its  relations  altered-that  is,  if  the  iris  is  "ear  or  in  con- 
tact with  the  cornea,  whether  prolapsed  or  not-yes.  11  there  is  blood  in  the 
chamber,  much  or  little,  without  the  possibihty  of  a  seyere  concussion  of  the 
eye  with  or  without  unnatural  softness  of  the  ball  to  the  touch,  yes  It  a 
small  hole  is  seen  in  the  iris,  corresponding  in  size  to  the  co™ea  yound  and  in 
the  probable  direction  of  the  penetrating  body,  with  or  without  blood  in  the 
chamber,  or  alteration  of  the  depth  of  the  chaniber,  yes.  f  the  foreign  to 
can  be  certainly  seen  in  the  ins,  lens,  or  chamber,  yes.  If,  witli  the  wound 
of  the  cornea,  with  or  without  changes  in  the  chamber  or  the  tens  on  of 
?he  globe,  th;  lens  is  becoming  certainly  milky, 

with  perhaps  a  visible  wound  in  its  capsule  yes.  All  of  these  sjmp- 
loms  failing,  in  a  case  of  manifest  wound  of  the  cornea,  you  dilate  the 
h5  and  Is'e  the  ophthalmoscope.  If  the  funclus  of  th^ye  is  darkened  bj 
blood,  the  circumstances  precluding  rupture  ot  mtra-ocular  yesse  s,  tl  eie  is 
almost  certainly  penetration.  If  the  foreign  body  can  be  positiyely  seen 
w  thin  the  organ-iin  the  chamber,  iris,  lens  yitreous,  or  ratma-the  diagno  s 
s  sure.  Of  course,  impairment  of  sight  and  the  appearance  of  a  foud  n  the 
field  of  yision,  caused  by  extravasated  blood  or  the  foreign  body  or  both 
come  in  as  cor^^boratiye  eyidence  of  penefjtion  The  sight  may  be  destroyed 
at  once  or  yery  soon ;  or  it  may  be  little  aftected,  according  to  the  size,  di.ec- 
l^and  finXesting  place  of  the  ofie.iding  body.  The  ya  ue  of  softness  of 
the  globe  as  an  evi?lence  of  penetration,  is  yery  great,  when  it  certainly  is 
present.    But  the  tension  is  often  not  altered.   If  the  foreign  body  is  small, 


INJURIES  OF  THE  EYEBALL. 


595 


it  may  pass  deeply  into  the  eye  without  any  escape  of  humor,  either  aqueous 
or  vitreous,  and  hence  may  leave  the  tension  normal. 

When  the  patient  is  not  seen  for  some  minutes,  hours,  or  even  days  after 
the  injury,  the  wound  may  be  firmly  closed,  and  the  lost  humors  reproduced, 
so  that  undue  softness  is  no  longer  present.  The  reproduction  of  lost  humors 
is  very  rapid,  as  is  known  to  all  operators  on  the  eye.  In  fact,  if  the  patient 
is  not  seen  for  several  days,  the  eye  may  be  too  hard,  from  internal  inflam- 
mation and  secretion  ;  this  increased  tension  then  becoming  the  indirect  evi- 
dence of  penetration. 

The  ophthalmoscopic  evidence  of  penetration,  when  positive,  that  is, 
when  the  body  itself  is  seen,  or  suffused  blood,  or  a  cloudy  sleeve  of  opacity 
along  its  track  in  the  vitreous,  is  quite  sufficient.  Still,  the  result  of  such 
an  examination  may  be  altogether  negative,  and  yet  the  ofltender  be  in  the 
eye.  Should  it  rest  far  forward  in  the  vitreous — behind  the  iris  or  ciliary 
circle— it  is  detected  with  great  difficulty,  if  at  all.  In  that  case,  there 
being  none  of  the  symptoms  already  emphasized,  we  should  make  a  reserved 
diagnosis  and  wait  for  further  developments ;  should  the  extraneous  body 
be  in  the  eye,  it  is  almost  certain  to  give  rise  to  trouble  sooner  or  later. 
Moreover,  the  supposed  visible  intruder  may  prove  to  be  a  globule  of  blood, 
or  air,  or  both ;  but  that  does  not  invalidate  its  importance  as  an  evidence 
of  penetration.  On  the  question  of  the  actual  presence  of  the  foreign  body 
in  the  eye,  it  may  leave  doubt  which  can  only  be  cleared  up  by  time.  So 
the  cloud  seen  by  the  patient,  after  an  injury,  may  or  may  not  be  caused  by 
the  presence  of  a  foreign  body  in  the  globe,  but  is  strong  presumptive  proof 
of  penetration. 

But  the  eye  may  be  struck  behind  the  cornea,  in  the  sclerotic  region. 

And  as  this  part  of  the  globe  is  covered  by  conjunctiva  and  capsule  of  Tenon  

both  being  thin,  elastic,  and  movable  over  its  surface — the  wound  may  easily 
escape  notice  when  small.  Its  torn  edges,  and  especially  the  ecchymosis,  always, 
perhaps,  present  for  a  short  time  after  the  injury,  will  attract  attention  to 
the  injured  spot.  The  thing,  then,  has  struck  there,  but  has  it  entered  ?  If 
the  spot  is  over  the  sclero-corneal  junction,  or  very  little  back  of  it,  we  may 
still  look  in  the  anterior  chamber  for  signs  of  the  passage  of  the  wounding 
body.  The  iris  may  be  wounded  near  its  ciliary  margin,  or  a  small  knuckle 
of  Its  periphery  may  protrude  through  the  w^ound.  Blood  in  the  aqueous 
chamber  has  here  also  the  same  positive  significance  as  in  wounds  through 
the  cornea.  Should  neither  prolapsus  iridis,  hemorrhage,  nor  any  appreciable 
rent  in  the  iris  be  discovered,  it  is  still  wise  to  make  a  scrutinizing  search 
with  the  ophthalmoscope,  in  this,  as  iit  all  cases  of  suspicious  injuries  of  the 
eyeball.  Physicians  in  general  pass  too  lightly  over  such  accidents,  assuring 
the  patient  at  once,  perhaps,  that  nothing  is  in  the  eye. 

I  would  insist  upon  the  importance  of  small  wounds  of  the  iris,  sometimes 
forming  a  sharp  hole  in  this  curtain,  admitting  light,  and  giving  a  red  reflex 
from  the  bottom  of  the  eye  with  the  ophthalmoscope.  They  prove  not  only 
penetration,  but  the  almost  certain  presence  of  the  foreign  body  in  the  back 
of  the  eye.  A  very  small  hole  or  cut  in  the  iris,  can  only  be  made  by  the 
passage  of  a  very  small  body,  and  one  w^hich  must  clear  the  cornea  before 
striking  the  iris.  Eeboundnig  in  that  case  is  impossible.  Such  an  injury 
could  only  be  caused  by  a  smalf  body,  or  by  a  pin  or  needle,  a  splinter,  or  some 
long,  slender  projectile.  In  the  latter  case,  the  missile  might  rebound.  If, 
however,  it  has  also  cleared  the  iris,  and  is  hence  invisible,  it  may  be  found  in 
the  suspensory  ligament  or  margin  of  the  lens,  or  in  the  vitreous  behind  it. 
I  he  body  being  small  and  the  edge  of  the  lens  barely  grazed,  there  is  not 
likely  to  be  traumatic  cataract — an  infallible  evidence  of  penetration  when  it 
is  detected.    The  ophthalmoscope  may  or  may  not  detect  the  foreign  sub- 


596  INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

Stance  in  the  fundus.  The  same  observations  which  were  made  above  about 
ophthalmoscopic  evidences  of  penetration,  and  their  significance  apply  here. 

If  the  wound  in  the  conjunctiva  and  sclerotic  is  large,  and  iiiade  either  by 
a  laro-e  body  entering  directly,  or  glancing,  there  will  probably  be  loss  ot 
vitreous,  recognized  by  its  characteristic  ropiness,and  flabbiness,  or  collapse, 
of  the  globe.  In  this  event,  the  foreign  body  may  be  lodged  in  the  globe  or  not. 
In  such  destructive  injuries  there  is  almost  certainly  free  hemorrhage  within 
the  eye,  preventing  any  immediate  inspection  ot  the  fundus.  But  a  wound 
of  the  sclerotic  conjunctiva  does  not  necessarily  indicate  penetration,  ihe 
iniurino-  body  may  have  glanced  backwards,  between  the  conjunctiva  and 
scleroti",  piercing  the  latter  perhaps  in  the  region  of  the  equator,  or  sparing 
the  globe  and  plunging  deep  into  the  socket.  Sometimes  a  shot,  or  scale  ot 
metfl,  when  driven  with  great  force,  passes  entirely  through  the  globe  and 
lodo-es  in  the  apex  of  the  orbit.  In  rare  cases  a  rough  scale  may  be  tound 
grasped  by  the  sclerotic,  after  having  traversed  the  vitreous. 

Some  years  ago  a  machinist  called  on  me  witl.  an  injured  eye.    There  was  a  large 
ragged  wound  in  the  sclerotic,  the  ball  being  flabby  and  filled  w.th  blood     1  was  sure 
thaf  a  rough  scale  of  metal  had  entered  deeply  and  had  remained  m  the  ball.  I-nnjed.ate 
enucleation  was  urged,  but  the  patient  would  not  consent.   The  eye  was  hopelessly  lo»t 
andTeat  suffering^as  certain  to  ensue,  with  much  danger  to  the  other  eye,  and  even 
to  life     But  I  could  not  move  him  from  his  conviction  that  there  was  no  foreign  body 
hi  he  eye,  and  that  the  sight  could  be  restored.   Of  course  I  refused  ^  P'-<««"be  ^r  to 
take  any  responsibility  in  the  case,  and  the  patient  left  me.    Two  weeks  afterwards  he 
eturned,  wit'h  fearful'swelling  of  the  eye  and  face,  excruci^ing  P^-. -d  commenc.„g 
rigidity  of  the  muscles  of  the  jaw.    In  this  extreme  condition,  hopeless  as  '  J^^-  ^e 
beVed  for  enucleation.   The  operation  was  very  difficult,  and  when  at  last  the  opt.c 
ne»e  was  embraced  by  the  scissors,  they  would  not  close.    After  much  f  oible-  how- 
ever I  succeeded  in  removing  the  eye.    A  large  metallic  scale  was  found  embraced 
Ty  he  wouTded  sclerotic,  one  end  projecting  backwards  by  the  f'^^^^P^^::^ 
The  tetanus  continued,  as  I  expected,  and  after  the  most  fearful  sufferings  I  ever  wit- 
nessed, the  poor  victim  died,  two  weeks  after  the  operation. 

Another  somewhat  similar  case  was  operated  on  by  my  associate.  Dr.  S.  C.  Ayres,  on 
the  10th  of  April,  1876.  Immediately  after  enucleation,  the  ball  was  opened  aiid 
examined.  To^ou;  surprise,  no  foreign  body  was  found,  but  a  cicatrix  three  lines  in 
™  was  detected  in  the  sclerotic  just  below  the  optic  nerve,  through  which  ,t  had 
nassed  out  of  the  eye  into  the  orbit.  The  socket  was  at  once  examined  by  the  ope- 
t^'s  finger,  and  the  end  of  the  foreign  body  distinctly  felt,  wedged  back  in^  U.e  apex. 
With  a  good  deal  of  trouble,  it  was  seized  and  removed  by  the  forceps.  I  was  five- 
dgl  ths  of  an  inch  in  length,  and  three-eighths  in  breadth,  and  somewhat  like  a  piece 


of  knife-blade. 


I  have  several  times,  enucleated  eyes  wiiere  the  sight  had  been  destroyed 
by  bin  shcrand  where'  none  were  found  in  the  globe,  but  distinct  cica  rices 
ot-  entranced  exit.  Such  shot  or  bullets  may  sojourn  m  t^e  socket  per- 
fects harmless.  In  one  instance,  however,  I  saw  an  aneurism  of  the  oph- 
thalmic artery  developed  some  months  after  such  an  injury.  Occasionally  a 
p^n^^^^^^^^^^  body,  or  a  shot,  spares  the  eyeball,  but  plunges  behind  it  and 
wounds  the  optic  nerve,  causing  instant  loss  ot  sight. 

Sudden  loss  of  sight  following  a  penetratmg  wound  of  the  orbit-the  eye 
ball  itself  having  escaped  injury— may  thus  be  accounted  tor. 

I  once  saw  a  young  man  who  had  fallen  from  a  load  of  hay  on  the  sharp,  slender 
tin!  of  a  steel  fork.  He  jerked  it  out,  with  some  difficulty,  but  never  saw  light  after- 
w  rds  men  I  examined  him  many  years  afterwards,  I  found  the  cicatnx  jn  the 
ivi  W  no  trace  of  iniury  in  the  -lobe.  On  ophthalmoscopic  examination,  I 
fS  liot'hini  bu^t  ireme  X7atrophy  of  the  optic  nLve.  It  is  almost  certain  that 
the  nerve  had  been  wounded,  perhaps  severed,  by  the  fork. 


INJURIES  OF  THE  EYEBALL. 


597 


A  still  more  interesting  case  occurred  in  my  practice,  some  years  ago.  An  old  gentle- 
man received  an  accidental  discharge  of  birdsliot  in  his  face,  with  immediate  total  extinc- 
tion of  sight  in  both  eyes.  Two  days  afterwards  I  saw  him,  and  found  his  condition,  briefly, 
as  follows :  The  right  eye  was  collapsed  and  riddled  by  shot,  and  there  were  numerous 
marks  of  others  that  had  entered  the  face  and  lids  of  the  same  side.  The  left  side  of  the 
face  showed  only  one  mark  of  a  shot  in  the  lower  lid,  opposite  the  edge  of  the  bony  orbit. 
The  pupil  was  largely  dilated  and  fixed,  with  bare  perception  of  light.  Otherwise  the 
eye  was  intact,  and  the  ophthalmoscope  revealed  absolutely  nothing  wrong.  The  disk 
appeared  natural  in  all  respects,  and  moderate  pressure  with  the  finger  on  the  globe 
produced  tlie  usual  visible  pulsations  of  the  arteries  on  its  surface,  showing  that  the 
main  retinal  artery,  as  it  enters  the  trunk  of  the  nerve  a  little  back  of  the  globe,  and 
follows  in  its  axis  to  the  interior  of  the  eye,  had  not  been  injured.  I  diagnosed  injury 
of  the  optic  nerve  some  distance  behind  the  globe,  beyond  the  point  at  which  it  receives 
the  artery.  The  patient  suffered  great  pain  in  the  right  eye,  for  which  I  was  induced  at 
last  to  enucleate  it.  One  shot  was  found  in  the  bottom  of  the  vitreous,  but  the  others 
had  passed  entirely  through,  into  the  orbit.  He  was  altogether  free  from  pain  afterwards. 
The  vision  of  the  left  eye  gradually  returned,  so  that  he  could  see  to  walk  about,  re- 
cognize persons,  and  read  large  print.    The  optic  nerve  showed  moderate  white  atrophy. 

An  enumeration  of  all  the  kinds  of  foreign  body  that  have  been  known  to 
penetrate  the  eye  would  be  an  impossible  task.  The  most  common  are  pieces 
of  metal,  percussion-caps,  fragments  of  stone  or  wood,  and  shot.  Sometimes 
we  are  surprised  to  find  the  foreign  body  very  difiterent  from  what  we  had 
expected  from  the  history  of  the  accident  and  the  nature  of  the  wound  or 
cicatrix. 

For  instance,  a  little  boy,  five  years  old,  was  amusing  himself  by  exploding  caps, 
laying  them  on  the  pavement  and  striking  them  with  a  stone.  A  fragment  struck  the 
inner  segment  of  the  cornea,  and  made  a  w^ound  of  about  one  line  in  length.  For  some 
days  he  did  not  suffer  much  pain,  and  his  physician  thought  the  injury  was  not  serious. 
At  length,  the  inflammation  and  pain  increasing,  he  was  brought  to  me.  Tiie  iris  was 
discolored,  and  pressed  forward  almost  in  contact  with  the  cornea  ;  the  lens  was  opaque  ; 
the  foreign  body  had  evidently  passed  through  the  cornea,  the  iris,  and  into  or  through 
the  lens.  It  was  not  possible  to  detect  it.  I  enucleated  the  eye,  expecting,  of  course, 
to  find  a  piece  of  cap  in  it.  After  severing  the  recti  muscles  I  passed  my  finger  behind 
the  globe  to  luxate  it.  The  pressure  caused  the  corneal  wound  to  open,  and  the  soft 
opaque  lens  escaped  from  the  eye.  I  caught  it,  fortunately,  and  dropped  it  into  the 
basin.  On  finishing  the  operation,  and  opening  the  eye  very  carefully,  I  found  no  piece 
of  cap  ;  the  lens  in  the  basin  was  then  examined,  and  a  small  piece,  not  of  the  cap,  but 
of  stone,  was  found  in  it. 

Another  time,  an  eye  had  been  extinguished  by  the  sudden  discharge  of  a  gun- 
cartridge.  The  evidences  of  penetration,  and  of  the  presence  of  a  foreign  body  deep  in 
the  eye,  were  clear.  I  discovered  in  the  enucleated  eye  a  piece  of  mother-of-pearl! 
On  careful  inquiry,  the  patient  confessed  that  he  had  been  foolish  enough  to  strike  the 
cartridge  with  his  pearl-handled  knife  ;  the  cartridge  exploded,  and  all  that  he  ever  saw 
of  the  knife  was  the  piece  of  pearl  found  in  the  vitreous. 

Another  man,  while  handhng  some  pieces  of  w^ood,  felt  something,  he  did  not  know 
what,  strike  his  left  eye.  It  produced  a  triangular,  incised  wound  of  the  cornea,  injured 
the  lens,  and  caused  cataract.  Sight  was  lost  at  once,  and  for  seven  weeks  he  suffered 
constant  pain.  At  that  time  the  cornea  was  flattened,  opaque  in  the  centre,  and  appa- 
rently drawn  down  by  the  cicatrization  ;  the  ball  w^as  tender  to  the  touch,  over  the  ciliary 
region  ;  the  sclerotic  and  ciliary  zone  were  intensely  injected.  On  removal,  the  vitreous 
was  found  liquid  ;  the  retina  in  position,  but  in  thickened,  opaque  folds.  Corresponding 
to  the  corneal  wound  was  a  cicatricial,  tense  ridge,  or  band,  running  across  the  ciliary 
processes,  and  having  a  firm,  fibrous  feeling  and  resistance.  Within  this  cicatrix  was 
included  an  eyelash,  lying  in  the  direction  of  the  cicatrix,  with  the  bulbous  end  farthest 
from  the  cornea.  No  other  foreign  substance  was  found  ;  the  wounding  body  had  car- 
ried the  cilia  in,  and  had  left  it,  after  rebounding. 


598         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

TliP  r.resence  of  a  foreign  substance  remaining  in  the  ball,  after  penetration, 
increases  the  gravity  of  the  case  more  or  less,  according  to  its  nature,  size, 
J^^^ater  or  lesf  roughness,  and  especially  its  position.  A  small,  smooth  body 
liarbeconie  encjited  'A  the  vitreous,  and  remain  harmless  Indeed,  this 
may  occur  but  rarely,  when  it  is  in  the  iris,  retina,  or  choroid.  In  such  in- 
dices Us  presence  is  nearly  always  resented,  and  it  keeps  up  endless  trouble 
anTnevetleasing  danger  to  the  other  eye.  _  When  fixed  in  or  near  the  cihary 
region-the  most  usua!  place-there  is  certainty  of  txouble  sooner  or  later,  and 
^reat  danc^er  of  sympathetic  ophthalmia.  It  is  in  the  lens,  perhaps,  that 
Straneou'bodies  are  longest  tolerated,  after  producing  cataract  But  even- 
tually they  may  escape  tiom  the  lens  and  produce  violent  and  destructive 


reaction : — 


A  .nan  wliile  opening  a  keg  of  paint,  in  April,  1875,  with  a  hammer  and  chisel,  felt 
some  h,n/s  ■  ke^his  brow,  bringing  a  drop  of  blood  ;  at  the  same  moment  a  stinging 
something  s">k^  "  '       5  |  following  the  accident,  and  he 

i^rted  that  thel  It  ma^:d  periectly  good  until'three  weeks  before  I  saw  him  v^hich 
va  ovei  a  year.  At  that  time  May  22,  1876,  he  could  only  count  fingers  at  3i  feet. 
There  was  crtaract,  but  without  complete  opacity.  Deep  in  the  lens  was  seen  a  shiny, 
sm^ptel^e  "tal.  In  the  anterim-  capsule  was  a  visible  wound,  with  a  tuft  of  lens- 
srstance  protruding  through  it  into  the  aqueous,  and  undergoing  absorption  In  the 
corfea  a  sma  scar  was  foulid  where  the  me.al  had  entered.  The  patient  called  to  con- 
suit  m^  abTut  the  failing  sight.  I  advised  him  to  wait  a  few  weeks,  as  he  was  suffering 
no  D^n  There  were  no  uf gent  symptoms.  1  believed  that  the  absorption  through  the 
rent  in  the  capsule  would  go  on,  and'that  eventually  the  foreign  body  would  eome  for- 
ward  and  be  more  easily  and  certainly  removed  with  the  lens.  Before  long  he  returned, 
Lvtg  suffere'Tn tense  pain  for  the  previous  ten  days.  The  foreign  body  had  c^nie  for- 
war  r  out  of  the  lens,  and  had  fallen  into  the  anterior  chamber.  It  was  very  small,  but 
dis  nct"y  v  s  ble,  lying  in  the  lower  rim  of  the  anterior  chamber.  The  patient  having 
b^en  etherised,  I  made  a  careful  incision  at  the  sclero-corneal  junction  chise  in  front  of 
the  offendin'  ubstance.  The  corresponding  part  of  the  iris  was  then  drawn  out  and 
sntpped  oTbringing  with  it  the  piece  of  metal.   It  was  not  larger  than  half  a  pin  s  head. 

I  had  another  case  under  observation,  where  a  piece  of  metal,  of  much  larger  size 
and  of  errentic  shape,  had  penetrated  the  lens  some  Je-  be  ore,  and  ^  ^  remained 
there-the  whole  opaque  lens-substance  having  become  liqu  d.  The  foreign  body 
moved  freelv  around  in  the  closed  capsule,  according  to  the  position  of  the  head,  always 

r  .in!  to  the  most  dependent  part.    No  doubt  the  fluid  lens-substance  was  grad- 
gravitating  to  the  most  depenaen  p  ^^^^  ^ 

rJeLtsits''  ifAMy  o^^t^Zt,  the  capsule  and  ultimately  fell  into  the  aqueous 
chamber  The  patient  suffered  no  inconvenience  from  it,  except  the  blindness. 

Some  vears  since  a  young  man  was  brought  to  me  suffering  severely  froin  an  eye  that 

formed  l^iSe  was  extensive  suppuration  in  the  vitreous,  extending  from  the  sdero  c 
eyeball,  and  bad  tben  rebounded. 


INJURIES  OF  THE  EYEBALL. 


599 


The  pages  of  our  experience,  written  and  traditional,  are  full  of  marvellous 
accounts  of  foreign  bodies  tolerated  in  the  eyes  for  years.  One  instance,  from 
my  own  case  book,  must  suffice : — 

An  Irish  stone-cutter  had  his  left  eye  put  out  by  a  piece  of  stone.  Shortly  after,  the 
right  eye  was  injured  by  a  knife,  causing  traumatic  cataract.  This  Sir  William  Wilde 
extracted,  giving  the  man  "good  sight" tor  over  twelve  years.  Then  iritis  attacked  it, 
producing  a  false  membrane  in  the  pupil  so  that  he  could  not  work,  and  in  that  condition 
he  came  to  consult  me,  fourteen  years  after  the  loss  of  the  left  eye.  This  eye  was 
atrophied,  and  on  examination,  a  piece  of  stone  was  seen  projecting  from  it,  directly 
between  the  lids.  The  visible  part  was  about  one-quarter  of  an  incli  long,  the  end  in 
the  shrunken  eye  being  larger  than  that  which  was  seen.  So  the  sclera  was  incised 
and  the  piece  removed.  It  was  half  an  inch  long,  and  a  quarter  of  an  inch  wide  at  its 
widest  end.  When  the  right  eye  had  been  operated  on  for  traumatic  cataract,  and  re- 
stored to  useful  sight,  the  left,  containing  the  foreign  body,  was  not  atrophied,  but  pain- 
ful. The  pain  persisted  for  twelve  years,  when  sympathetic  iritis  set  in,  impairing,  but 
not  destroying,  the  sight  of  the  right  eye.  Soon  after  this  the  left  ball  shrank,  passing 
into  the  condition  in  which  it  was  when  I  saw  him.  Fortunately,  the  siglit  of  the  right 
eye  was  such  that  by  fitting  it  with  a  cataract  glass  he  could  see  to  shovel  dirt,  and 
was  satisfied. 

Sympathetic  Ophthalmia. — If  while  one  eye  is  suffering  from  an  injury 
or  an  inflammation,  the  other  is  attacked  by  disease,  not  fairly  attributable  to 
any  other  cause,  we  call  it  sympathetic.  Sympathetic  ophthalmia  embraces 
a  variety  of  lesions  in  different  parts  of  the  eye,  all  recognizing  a  common 
cause.  Although  traumatic  inflammation  of  one  eye  is  the  most  frequent 
cause  of  sympathetic  destruction  of  the  fellow  eye,  still  this  may  arise  from 
other  troubles.  The  presence  of  a  foreign  body  in  the  injured  organ  increases 
the  danger  to  the  other.  The  most  dangerous  region  is  the  ciliary,  embracing 
a  narrow  zone  around  the  cornea.  It  is  very  liberally  supplied  with  nerves 
and  bloodvessels. 

Dr.  Alt  sa3^s  that  seventy-six  per  cent,  of  sympathetic  diseases  are  refer- 
able to  trouble  in  the  ciliary  body  of  the  oflending  eye.  The  iris  is  usually 
involved  at  the  same  time,  a  complication  called  irido-cyclitis.  ^N'ot  unfre- 
quently,  and  in  the  most  dangerous  cases,  the  whole  uveal  tract  and  the 
retina  become  implicated.  But  very  rare  instances  arise  of  fatal  sympathetic 
loss  of  one  eye,  where  the  iris,  ciliary,  and  choroid  in  the  other,  have  not 
been  affected.  A  phthisical  globe,  perfectly  painless  and  free  from  all  out- 
ward manifestations  of  irritation,  has  been  supposed  to  give  rise  to  sympathetic 
disease.  In  the  majority  of  cases,  however,  it  seems  to  be  bony  degeneration 
of  the  choroid  in  such  stumps  that  finally  provokes  pain  and  irritation,  and 
sympathetic  trouble.  Cyclitis,  or  irido-cyclitis,  whether  traumatic  or  spon- 
taneous, seems  to  be  the  immediate  provocation  of  sympathetic  suffering. 
Injuries  in  this  dangerous  region,  especially  when  complicated  with  prolapsus 
of  the  iris  or  of  the  ciliary  body,  always  involve  very  great  danger  to  the  fellow 
eye.  If,  in  addition  to  the  wound  and  its  complications,  a  foreign  body  is 
lodged  in  the  eye,  the  danger  is  heightened.  The  resulting  inflammation  is 
then  much  harder  to  subdue,  and  returns  on  the  slightest  provocation.  Even 
when  the  foreign  body  becomes  encysted  in  the  ciliary  region,  and  remains 
harmless  for  many  years,  it  is  liable  to  be  dislodged  and  to  give  rise  to  serious 
trouble  in  both  the  injured  and  the  well  eye.  Accidental  and  surgical  inju- 
ries of  all  kinds  in  this  region  are  necessarily  serious. 

In  the  past  fifteen  years,  numerous  cases  of  sympathetic  destruction  of  one 
eye,  following  a  Graefe's  extraction  in  the  other,  have  been  reported.  Few 
operators  of  large  experience,  have  been  saved  from  this  sad  disaster.  Worse 
than  this  has  happened  to  me  and  to  others : — 


600         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

A  few  years  since,  I  operated  successfully  on  an  eye  for  cataract.  All  went  so 
well  that,  in  a  week,  yielding  reluctantly  to  the  urgent  wishes  of  the  patient,  I  ex- 
tracted the  other  lens.  Fatal  reaction  followed  ;  the  first  eye  became  involved  in  sym- 
pathetic inflammation  ;  and  the  patient  was  left  hopelessly  bhnd. 

Even  iridectomy  has  been  the  cause  of  loss  of  the  fellow  eye,  but  the  dan- 
ger involved  is  excessively  small. 

I  recall  the  ca»e  of  a  young  lady  who  consulted  me,  many  years  ago,  for  a  large  pro- 
lapsus of  the  iris  at  the  upper  margin  of  the  cornea.  It  had  existed  for  years,  and  was 
the  result  of  a  perforating  ulcer.  Although  quite  large,  it  was  covered  generally  by  the 
uDoer  lid,  and  the  eye  was  useful.  I  clipped  it  off  with  scissors,  and  in  a  tew  days  ugly 
iritis  ensued,  and  persisted  stubbornly.  At  length  it  abated,  and  the  patient  returned 
home  to  the  country.  Some  months  after,  she  came  back  with  complete  disorganiza- 
tion and  blindness  of  both  eyes.  In  such  a  case,  with  a  prolapsus  having  a  large  neck, 
lined  with  membrane  of  Descemet,  connecting  with  the  aqueous  chamber,  and  ot  long 
standing,  I  should  be  very  careful. 

After  one  of  my  earliest  extractions  by  Graefe's  linear  method,  there  remained  a 
moderate  prolapsus  of  the  iris  at  one  angle  of  the  incision.  The  lady  now  over  80,  has 
a  prolapsus  as  large  as  half  a  grain  of  wheat,  coveretl  by  the  upper  hd,  causing  her  no 
inconvenience,  and  with  a  rare  vision  of  1. 

Of  course,  hernia  of  the  iris,  making  traction  upon  the  ciliary  and  other 
structures,  and  keeping  up  persistent  and  dangerous  cyclitis,  may  be  the  result 
of  simple  ulceration  and  perforation  of  the  cornea,  as  well  as  ot  mjury. 

In  the  most  serious  forms  of  irido-cyclitis,  there  is  one  symptom  of  pecu- 
liar sio-nificance.  I  mean  habitual  tenderness  to  pressure  at  some  particular 
point  in  the  ciliary  region.  It  is  nearly  always  above,  and  can  be  detected  by 
pressure  with  the  finger  through  the  lid,  or  with  a  probe.  ^  The  moment  the 
sensitive  p(nnt  is  pressed  upon,  the  patient  involuntarily  shrinks  and  complains 
of  pain.  This  important  and  never-to-be-forgotten  symptom  is  not  always 
present,  but  when  it  is  detected,  great  and  imminent  danger  is  to  be  feared 
It  oftener  exists  when  the  painful  eye  is  blind  and  shi^nken  than  when  it  is 
Blump  If  the  local  tenderness  of  the  stump  is  due  to  bony  deposits,  the  sen- 
sitive and  very  hard  points  are  far  back.  But  they  import  serious  danger 
here  as  well  as  in  the  ciliary  region.  With  this  symptom  of  local  tenderness 
to  pressure,  with  more  or  less  constant  irritation  of  a  blind  eye,  the  surgeon 
should  not  hesitate  to  urge  immediate  enucleation.  ^ 

-  The  following  list,"  says  Dr.  Ludwig  Mauthner,  -  comprises  the  sympa- 
thetic diseases  of  the  eye:  neuralgia  of  the  ciliaiy  nerves ;  iit^^^ 
retina  and  of  the  optic  nerve;  functional  disturbance  of  the  retina;  inflam- 
mation, severally,  of  the  conjunctiva,  cornea,  and  choroid;  inflammation  ot 
the  uveal  tract,  with  or  without  participation  on  the  part  of  the  ciliary  body, 
so  that  there  may  be  both  a  sympathetic  iritis  and  a  sympathetic  choroiditis, 
without  coexisting  cyclitis;  inflammationtof  the  retina,  alone  or  m  conjunc- 
tion with  inflammation  of  the  choroid;  inflammation  of  the  optic  nerve ; 
glaucoma;  disease  of  the  vitreous  and  of  the  lens.'' ^  It  is  questionable 
Whether  some  of  the  cases  reported,  and  from  which  this  list  has  been  made 
up,  were  genuine  cases  of  sympathetic  disease,  or  only  accidental  occurrences 
Mv  limits  will  not  admit  of  discussion  as  to  the  channels  by  which  disease 
may  extend  to  the  fellow  eye,  and  the  mode  of  it.  propagation  The^ge.iei^ 
belief  is  that  the  morbid  process  extends  directly  from  the  injured  to  the 
other  eve,  and  is  not  the  result  of  reflex,  excito-motor  mfluence.  ^  In  addition 
to  the  route  of  the  ciliary  nerves,  the  frequent  presence  of  optic  neuritis  or 
neuro-retinitis  m  enucleated  eyes,  would  indicate  that  the  optic  nerve  and  its 
sheath  were  perhaps  frequent  channels  of  morbid  communication.   I  he  sensory 
branches  of  the  trigeminus,  so  freely  distributed  to  the  ciliary  muscle,  ins, 


INJURIES  OF  THE  EYEBALL. 


and  cornea,  through  the  long  and  short  ciliary  nerves,  would  perhaps  account 
for  the  great  frequency  of  sympathetic  affection  after*  injuries  and  diseases 
of  those  structures,  especially  of  the  ciliary  region  and  the  iris. 

The  fellow  feeling  existing  between  the  eyes  is  vividly  manifested,  in  all 
acute  and  painful  affections  of  one  eye,  by  the  tenderness  to  light,  spasm  of 
the  lids,  weeping,  and  ready  fatigue  of  the  other.  If  this  is  not  identical 
with,  it  is  certainly  very  similar  to,  the  "  sympathetic  irritation''^  which  is  so 
often  the  precursor  of  sympathetic  ophthalmia.  It  is  true  that  the  early  and 
intense  suffering  of  one  eye  with  the  other,  in  the  beginning  of  acute  affec- 
tions, whether  of  traumatic  or  idiopathic  origin,  generally  subsides  in  a  few 
days,  while  the  sympathetic  irritation  that  forebodes  danger  to  the  sound 
eye  generally  does  not  come  on  for  some  weeks  or  months  ;  still,  the  persist- 
ence of  the  suffering  of  the  early  stage  for  weeks  or  longer,  without  abate- 
ment, certainly  indicates  quite  as  much  danger  of  sympathetic  loss  of  the 
sound  eye.  While,  in  either  case,  the  irritation  and  functional  weakness  may 
continue  for  years  without  issuing  in  destructive  inflammation,  it  is  wise  to 
to  act  on  the  assumption  that  such  danger  is  ever  imminent.  While  it  is 
undoubtedly  true  that  neuro-retinitis  may  extend  from  the  injured  to  the 
well  eye,  following  the  optic  nerve  through  the  chiasm — and  that  irido-cy- 
clitis,  through  the  ciliary  nerves,  often  gives  rise  to  inflammation  of  the  same 
parts  in  the  sound  eye — it  is  certain  that  optic-neuritis  in  one  eye  can  only 
excite  the  same  disease  in  the  other,  and  not  cyclitis ;  and  vice  versa. 
Where  the  two  diseases  are  found  together  in  the  offending  eye,  they  may 
Ukewise  be  associated  in  the  other,  sympathetically.  When  the  known 
conditions  of  danger  exist,  there  are  certain  premonitory  symptoms,  which 
sometimes  result  in  sympathetic  ophthalmia  in  a  few  days,  and  at  other 
times  not  for  weeks  or  even  months. 

This  warning  irritation  is  of  immense  practical  importance.  If  it  is 
recognized,  and  the  offending  eye  promptly  removed,  before  actual  sympa- 
thetic inflammation  of  any  kind  has  been  set  up  in  the  fellow  eye,  the 
patient  is  saved  from  blindness.  The  exceptions  to  this  rule  are  extremely 
rare.  In  my  own  large  experience  I  do  not  recall  a  single  one.  What  then 
are  these  alarming  symptoms?  One  of  the  most  common,  is  a  certain  vague 
smokiness  before  the  eye,  with  difliculty  in  focusing  small  objects.  If  the 
patient  strives  to  read  fine  print,  it  is  difiicult,  and  soon  becomes  painful.  The 
pupil  is  usually  sluggish,  rather  dilated,  and  the  patient  often  speaks  of  a  waver- 
ing mist  before  him,  like  the  glimmerings  of  a  heated  atmosphere.  These 
disturbances  are  often  periodical,  and  perhaps  worse  when  the  diseased  eye  is 
suffering  paroxysms  of  pain.  Tested  in  the  usual,  accurate  way,  the  vision 
is  below  the  normal.  Sometimes  flashes  of  light,  changing  colors,  and 
photopsia  of  various  kinds  and  degrees,  torment  the  patient.  Rarel}^  there 
are  extreme  intolerance  to  light  and  Tiarassing  blepharospasm.  These  symp- 
toms of  retinal  irritation  are  occasionally  attended  by  concentric  narrowing 
of  .the  field  of  vision,  as  well  as  by  marked  dimness  of  direct  vision.  With 
these  symptoms,  there  may  be  the  faintest  blush  of  redness  in  the  ciliary 
region,  but  often  there  is  none  at  all.  Much  of  the  indisposition  to  fix  on 
and  focus  small  objects,  is  due  to  the  pain  produced  in  the  injured  eye  by 
efforts  of  accommodation.  Should  these  warnings  come  on  while  the  injured 
or  diseased  eye  is  subject  to  paroxysms  of  more  or  less  severe  pain,  or  if,  in 
the  absence  of  spontaneous  pain,  there  should  be  found  a  tender  spot  over 
the  ciliary  region,  danger  is  impending.  This  tender  point  in  the  useless  eye 
is  characteristic  of  cyclitis,  and  sometimes  a  corresj^onding  one  is  found  in  the 
threatened  organ,  i^early  always  above,  it  may  be  detected  by  pressure 
with  the  finger  or  a  probe  through  the  upper  lid.  The  moment  the  sensitive 
place  is  reached,  the  patient  winces.    In  cases  of  quiescent  atrophy  of  the 


602         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

fflobe  dating  back  many  years,  ossification  of  the  choroid,  or  calcareous 
defeneration  of  the  lens,  may  at  length  give  rise  to  pam  tenderness,  and 
sympathetic  danger.  The  shrunken  stump  then  becomes  hard  and  pamlul 
to  the  touch,  especially  posteriorly. 

I  recently  removed  such  an  eye  from  a  gentleman,  fifty  years  old.  It  had  been  put 
out  by  a  pen-knife  in  boyhood,  and  never  gave  the  least  discomfort  till  within  the  past 
two  years.  It  then  grew  painful  and  tender  to  the  touch,  and  gave  ri^e  not  only  to 
sympathetic  irritation  in  the  sound  eye,  but  at  times  to  excruciating  attacks  of  facial 
neuralgia,  and  to  falling  fits  of  unconsciousness.  All  these  symptoms  disappeared  when 
the  eye  was  enucleated. 

An  eye,  whether  plump  or  shrunken,  that  contains  a  foreign  body,  is 
always  liable  to  become  troublesome  and  dangerous  to  its  fellow  ^ 

How  lone:  after  the  injury  does  it  require  for  sympathetic  ophthalmia  to  be 
set  up  I  have  known  it  to  be  developed  in  three  weeks.  Mauthner  never  saw 
it  occur  sooner  than  four  weeks.  The  interval  may  vary  from  three  weeks, 
which  seems  to  be  the  shortest  time,  to  months,  aiid  even  to  forty  or  htty 
years,  as  in  the  case  above  cited.  The  reported  cases  of  neuro-retmitis  and 
other  forms  of  sympathetic  ophthalmia,  coming  on  m  a  few  days  alter  enu- 
cleation, were  not  caused,  as  alleged,  by  the  enucleation.  The  diseased  pro- 
cess was  on  its  way  around,  before  the  operation,  and  would  probably  have 
broken  out  at  the  same  time,  had  nothing  been  done.  It  is  hard  for  me  to 
believe  that  the  contusion  of  the  optic  and  ciliary  nerves  by  the  scissors,  m 
enucleation,  could  produce  sympathetic  disease.  At  least,  I  have  had  the 
good  fortune  to  be  spared  seeing  such  cases.  That  traction  on,  or  constriction 
Sf,  the  optic  nerve,  after  enucleation,  may  excite  to  sympathetic  irritation, 
was,  however,  demonstrated  by  a  case  of  my  own  :— 

I  had  enucleated  the  painful  eye  some  months  before.  The  patient  returned, 
complaining  of  harassing  photopsia,  ghmmering,  and  tenderness  to  hght,  so  that  he 
could  not  apply  the  sight  of  the  eye.  All  these  symptoms  were  at  once  reheved  by  a 
little  leather  pad,  pressed  firmly  back  into  the  hollow  socket  by  a  bandage,  which  he 
had  worn  for  weeks.  By  an  operation,  in  which  a  piece  of  the  nerve  stump  was  de- 
tached and  removed,  all  trouble  ceased.    Such  cases  have  been  reported  by  others. 

That  similar  disturbances  might  result  from  cicatricial  compression  of  the 
ciliarv  trunks,  I  can  believe.  Under  all  the  circumstances,  where  sympa- 
thetic inflammation  of  the  good  eye  has  been  observed,  and  with  the  premo- 
nitions of  sympathetic  irritation,  eternal  vigilance  is  the  price  ot  sight. 

Bv  far  the  most  frequent  form  of  sympathetic  inflammation,  is  irido-cyclitis, 
cxteiidins:  in  the  worst  cases  to  the  choroid.  Beginning  usual  y  with  the 
symptoms  of  an  ordinary  acute  or  subacute  iritis,  but  resisting  all  treatment, 
and  leading  to  firm  agglutination  of  thg  entire  iris  to  lihe  capsule  of  the  lens, 
it  results  It  last  in  hopeless  disorganization.  Cvclitis,  with  tenderness  to 
pressure,  softening  of  the  globe,  and  slow  but  fatal  extinction  of  vision,  follow 
in  the  train  Sometimes  encourao;ing  remissions  will  be  seen,  but  soon -the 
turn  comes  and  all  is  lost.  In  the  simple  form  of  serous  iritis,  sometimes 
seen,  enucleation  is  not  necessary,  as  the  disease  may  be  controlled  without. 
In  tiie  plastic  and  malignant  variety,  most  often  witnessed,  enucleation  does 
no  g:ood,  and  may  often  do  harm.  ^  .  n  i.^ 

But  in  other  forms  of  sympathetic  manifestation,  especially  those  sho\\ing 
neuro-retinitis,  it  would  seem  as  though  enucleation  exercised  a  favorable 
influence.  Watchful  anticipation  and  prompt  surgical  interference,  betore 
or  as  soon  as  the  ominous  sympathetic  irritation  has  set  m,  is  the  only  sure 
and  safe  treatment.  Whenever  a  hopelessly  bhnd  eye  is,  and  perhaps  has 
long  been,  comfortable,  with  no  local  tenderness  to  pressure,  and  when  the 


INJURIES  OF  THE  EYEBALL. 


603 


other  eye  is  perfect,  with  no  evidences  of  sympathetic  irritation,  it  is  useless 
to  mutilate  the  patient  out  of  foolish  fear  of  danger.  On  the  other  hand, 
even  a  partially  seeing  eye,  after  an  injury,  should  he  sacrificed  without 
hesitation  if  alarming  symptoms  of  danger  to  the  other  eye  have  set  in. 

In  destructive  injuries  of  the  eye,  with  evidences  of  a  concealed  foreign 
body,  or  even  without,  it  is  often  a  wise  precaution,  to  enucleate  as  soon  as 
possible  after  the  fatal  injury,  before  violent  reaction  has  set  in.  In  that 
way  the  patient  is  saved  from  protracted  and  severe  suffering,  as  well  as 
from  danger  to  the  fellow  eye.  But  even  after  severe  panophthalmitis  has 
set  in,  in  case  tenderness  to  light,  cloudiness  of  vision,  glimmering,  and  other 
alarming  symptoms  are  developed,  I  should  resort  to  removal  of  the  offend- 
ing eye.  I  have  done  it  several  times,  with  none  of  the  fatal  consequences 
described  and  feared  by  Von  Graefe  and  so  many  others.  While  I  would 
warn  against  the  extreme  view  that  every  blind  eye,  whether  from  disease  or 
injury,  ought  to  be  enucleated,  and  that  any  trouble  that  comes  to  the  fellow 
eye  is  presumably  sympathetic,  I  w^ould  still  emphasize  the  fact,  that  any 
blind  eye^  at  any  time  may  become  a  source  of  risk.  This  is  particularly  true 
if  an  artificial  eye  is  worn  over  an  old,  atrophied  globe,  especially  one  in  which 
the  cornea  is  preserved.  Even  after  enucleation,  the  wearing  of  an  artificial 
eye  has,  in  rare  cases,  given  rise  to  sympathetic  developments  that  have  sub- 
sided soon  after  discontinuing  its  use.  In  many  hundred  cases  I  have  never 
seen  this  result,  nor  have  I  ever  lost  a  patient  from  the  removal  of  the  eye. 

The  operation  of  enucleation  is  very  simple.  The  instruments  required 
are  a  pair  of  strabismus  scissors  (Fig.  936),  one  or  two  strabismus  hooks 
(Fig.  935),  a  pair  of  toothed  forceps,  a  stop  speculum  (Fig.  921),  and  a 
pair  of  stout,  blunt-pointed  scissors,  curved  sharply  on  the  flat.  An  assis- 
tant must  be  ready  with  a  few  soft,  clean  sponges.  As  to  anaesthetics,  I 
generally  give  them,  but  often  operate  without,  where  the  patient  pre- 
fers it  and  has  good  self-control.  The  operation  is  a  little  more  tedious 
and  painful  than  a  tenotomy,  but  can  be  easily  borne  without  ether.  The 
patient,  whether  under  ether  or  not,  should  lie  on  the  back  and  be  kept 
quiet  if  possible.  The  speculum  introduced,  the  conjunctiva  is  seized  near 
the  cornea,  raised,  and  rapidly  divided  close  around  the  cornea.  After  the 
first  incision  a  strabismus  hook  may  be  passed  rapidly  round  the  cornea 
under  the  conjunctiva,  raising  and  making  it  tense  so  that  the  scissors  may 
divide  it  regularly  and  quickly.  This  done,  the  forceps  pick  up  the  con- 
junctiva above,  while  the  scissors  detach  it  over  the  insertion  of  the  supe- 
rior rectus.  The  hook  is  slid  under  and  the  tendon  severed  close  to  the 
sclera.  The  same  is  then  quickly  done  for  the  three  other  recti  tendons. 
The  speculum  is  now  removed,  and  the  eyeball  sprung  between  the  lids, 
which  are  pushed  back.  If  any  trouble  is  experienced  in  this  manoeuvre,  it 
is  due  to  the  fact  that  a  tendon  may  partially  or  completely  have  escaped 
division,  or  that  the  globe  is  too  large  to  pass  the  commissure.  In  the  latter 
case,  the  stout,  curved  scissors,  closed  and  passed  behind  the  globe,  may  aid 
in  prying  it  forward.  This  done,  the  index  finger  of  the  left  hand  is  passed 
in  behind  the  globe,  sprbiging  it  more  forwards,  and  rendering  the  optic 
nerve  tense.  The  nerve  is  thus  felt  and  held  securely  by  the  index  finger 
which  guides  the  scissors,  introduced  from  the  opposite  side.  They  are 
passed  in,  closed,  till  the  point  is  felt  by  the  finger.  Then  opening  and  push- 
ing them  a  little  further,  the  nerve  is  snipped  off  between  the  finger  and  the 
sclera.  It  is  hardly  possible  in  this  way  to  fail  in  severing  the  nerve  at  once. 
It  yields  with  a  jerk,  and  the  ball,  coming  forwards,  is  seized  by  the  left  hand, 
drawn  out,  and  the  two  oblique  muscles  detached  with  the  scissors,  using 
great  care  not  to  cut  the  lids  in  this  last  act.  The  moment  the  eye  is  removed 
I  plunge  the  left  index  to  the  apex  of  the  orbit,  and  make  rather  firm  pressure 


604         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

for  a  few  minutes,  stopping  the  hemorrhage  at  once.  That  done,  a  folded 
wet  compress  is  placed  over  the  closed  lids,  and  a  bandage  tightly  applied. 
Usually  the  loss  of  blood  is  next  to  nothing,  and  I  have  had  serious  hemor- 
rhao-e  in  but  two  cases.  These  were  both  in  old  people,  and  m  both  the 
bleedino-  was  readily  controlled  by  the  finger  passed  firmly  into  the  orbit. 
1^0  sponge,  cotton,  or  anything  but  the  finger,  should  ever  be  inserted  into 
the  orbit. 

Treatment  of  Wounds  of  the  Eyeball.— An  incised,  or  even  a  lacerated 
wound  of  the  conjunctiva,  alone,  very  soon  heals.    When  it  is  extensive,  the 
edo-es  should  be  well  united  with  stUches.    Even  when  a  considerable  por- 
tion is  carried  away,  it  slides  and  stretches  so  readily  that  the  denuded  sur- 
face is  easily  covered,  as  is  done  after  the  removal  of  a  pterygium,  ihe 
operation  of  syndectomy  (removing  a  large  zone  of  conjunctiva  trom  the  eye- 
ball immediately  around  the  cornea),  sometimes  practised  for  the  reliet  of 
obstinate  pannus  and  other  diseases  of  the  cornea,  shows  how  extensive  a 
surface  may  be  covered  in  this  manner.    The  same  is  true  of  the  extensive 
removal  of  the  reflected  portions  of  the  conjunctiva,  as  a  mode  of  treating 
granular  eyelids,  gravely  proposed  and  executed  by  a  French  ocuhst.    I  can- 
not believe,  however,  that  such  operations  are  justifiable,  knowing  the  many 
disadvantages  which  result  from  the  great  contraction  of  the  conjunctival 
surface  that  must  follow.    The  restraints  in  moving  the  eyes  resulting  from 
the  marked  symblepharon,  and  the  inevitable  dryness  from  impaired  secretion, 
are  not  compensated  for  bv  the  ends  obtained.   All  surgeons  know  the  serious 
and  incurable  lesions  of  the  conjunctiva  and  lids,  resulting  from  destruction 
of  granulations  by  caustics.    These  facts  should  guide  us  m  saving  all  the 
confunctiva  possible  in  wounds  and  burns  of  that  important  membrane.  Very 
serious  after-eftects  may  follow  wounds  and  losses  of  conjunctiva  at  the  inner 
commissure  of  the  lids.    The  cutting  oft^  or  tearing  away  of  a  canaliculus  by 
a  wound,  gives  rise  to  the  most  troublesome  and  often  hopeless  weeping,  so 
that,  if  possible,  this  complication  should  be  recognized  and  overcome  by 
careful  use  of  stitches,  so  that  the  permeability  of  the  canaliculus  may  be 
restored.    Burns  in  this  region,  for  the  same  reason,  are  very  serious,  and 
often  lead  to  epiphora,  entropium,  trichiasis,  and   an  endless  train  ot 
troublesome  consequences.    Indeed,  burns  of  the  eye  and  lids,  especially 
when  extensive  and  deep,  are  most  disastrous.    The  reaction  follows  very 
slowly,  so  that  the  prospects  at  first  look  hopeful ;  but  in  a  few  weeks  severe 
and  persistent  inflammation  sets  in,leading  to  uncontrollable  adhesions  between 
the  lids  and  the  ball,  to  opacities  and  perhaps  perforation  ot  the  cornea,  and 
to  other  lesions.    One  cannot  be  too  guarded  in  the  prognosis  of  such  cases 
Consequences  inevitable  from  the  first,  are  apt  to  be  put  down  to  the  credit 
of  faulty  treatment.    Wounds  of  the  conjunctiva,  when  properly  dressed 
need  no  local  remedies  but  weak  detergents,  astrmgents  or  paintul 

applications  must  be  allowed.  Of  course,  conjunctival  wounds  often  exist  as 
an  important  complication  of  other  deeper  and  more  serious  injuries,  wJiicn 
then  command  the  chief  attention.  If  a  muscle  be  severed,  or  the  sclera  pene- 
trated, or  if  a  deep  wound  of  the  socket  be  present,  these  become  objects  ot 
solicitude.  Should  a  foreign  body  hang  in  the  conjunctiva,  or  be  lodged  under 
it,  diligent  search  must  be  made  in  order  to  its  speedy  removal,  feometimes, 
when  a  small  piece  of  steel  or  other  substance  has  passed  under  the  conjunc- 
tiva, it  can  only  be  removed  by  firm  seizure  with  forceps  and  snipping  away 
a  small  portion  of  the  membrane  with  it.  Should  a  wound  of  the  conjunc- 
tiva exist  with  a  more  or  less  serious  injury  of  the  lid  or  lids,  the  pioper 
and  exact  adjustment  of  the  margins  of  the  wound  is  the  chief  point  to  be 
secured.    The  presence  and  seat  of  a  wound  of  the  lid,  or  its  entire  absence, 


INJURIES  OF  THE  EYEBALL. 


605 


are  often  valuable  aids  in  the  diagnosis  and  treatment  of  injuries  of  the  eye, 
of  whatever  kind. 

The  treatment  of  injuries  of  the  cornea  depends  much  upon  the  complica- 
tions. If  perforation  have  not  occurred,  and  the  wound  be  not  contused,  simple 
cleansing,  followed  by  quiet,  closure  of  the  lids,  and  cold  applications,  or  a 
comfortable  bandage  for  a  few  hours  or  days,  is  all  that  is  required.  If  the 
chamber  has  been  opened,  the  sudden  spirting  of  aqueous  will  nearly  always 
produce  hernia  of  the  iris.  This  should  be  reduced,  if  possible,  but  it  can 
only  be  done  during  the  first  few  hours.  Plastic  exudation  soon  takes  place, 
and  so  glues  the  protruding  iris  in  the  wound  that  it  cannot  be  returned.  If 
the  prolapsus  is  small  and  quite  recent,  involving  only  a  small  portion,  if  any, 
of  the  pupillary  margin,  the  prompt  and  energetic  use  of  eserine  may  reduce 
it  completely.  Rarely  is  it  safe  or  advisable  to  try  to  return  it  by  a  spatula  or 
other  instrument.  If  the  herniated  iris  cannot  be  relieved,  the  next  best  thing 
is  to  remove  as  much  of  it  from  the  wound  as  possible.  This  requires  much 
delicacy  and  coolness  on  the  part  of  the  surgeon.  If  the  patient  has  great 
self-control,  ansesthesia  is  not  required,  but  otherwise  it  must  be  complete. 
If  the  prolapsus  is  at  all  prominent,  it  can  be  clipped  oif  with  scissors  pressed 
Avell  against  the  cornea.  If  ever  so  little  of  tlie  pigmented  iris  is  snipped 
away,  the  aqueous  trickles  or  spirts  out,  and  the  prominence  at  once  disap- 
pears. Should  this  plan  not  succeed,  the  imprisoned  iris  must  be  seized  with 
small  iris  forceps,  drawn  gently  and  carefully  out,  aVid  snipped  close  to  the 
corneal  surface  with  the  scissors.  Great  caution  is  here  required  in  prevent- 
ing any  sudden  rotation  of  the  eye,  wnich  is  almost  certain  to  occur  if  the 
patient  be  not  unconscious.  The  iris  is  most  acutely  painful  when  seized,  and, 
if  the  patient  roll  the  eye  suddenly,  the  w^hole  or  a  large  part  of  this  membrane 
may  be  dragged  loose  from  its  insertion.  Von  Graefe  relates  a  case  in  w^hich 
the  entire  iris  was  removed  from  the  eye  by  such  an  accident,  and  I  have  seen 
such  an  occurrence  in  other  hands.  When  the  eye  is  perfectly  still,  and  the  iris 
is  drawn  tense,  and  snipped  quickly  and  close,  no  such  accident  can  take  place. 
It  is  of  vast  importance  for  the  future  of  the  eye,  to  remove  every  trace  of  iris 
from  the  wound.  Otherwise,  staphylomatous  protrusion  of  the  cornea,  glauco- 
matous hardness,  and  slow  but  hopeless  loss  of  vision  may  be  the  result.  If 
with  the  corneal  perforation  and  hernia  of  the  iris,  there  be,  at  the  same  time, 
injury  of  the  lens  capsule  and  cataract,  the  danger  of  violent  reaction  is  greatly 
increased.  The  rapid  swelling  of  the  traumatic  cataract  leads  to  pressure  upon 
the  iris,  increased  intra-ocular  tension,  pain,  and  perhaps  panophthalmitis. 
The  first  thing  to  be  done  is  to  free  the  corneal  wound  from  iris,  as  above 
directed,  and  then  to  dilate  the  pupil  and  keep  it  dilated  by  instillations  of 
atropia,  four  grains  to  the  ounce  of  water,  dropped  in  several  times  a  day. 
The  dilatation  draws'  the  pupil  away  from  the  irritating  lens  substance,  and 
Helps  to  control  iritis  and  the  tendency  to  closure  of  the  pupil.  If  the  lens 
swell  so  rapidly  that  large  masses  protrude  through  the  rent  in  the  capsule,  it 
may  be  best  to  remove  it  by  a  linear  incision  in  the  cornea,  or  by  opening, 
and  perhaps  enlarging,  the  oiiginal  corneal  wound.  But  if  the  patient  is 
young,  the  absorbents  active,  and  the  pain  and  increase  of  tension  not  great, 
this  may  not  be  necessary.  In  that  case,  or  after  removal  of  all  the  soft  lens 
substance  that  can  be  readily  let  out,  the  patient  should  be  put  quietly  to 
be  J,  and  ice-cold  compresses,  renewed  often  and  kept  up  day  and  night, 
should  be  used  till  the  reaction  is  controlled.  It  is  next  to  certain,  however, 
that  at  best  the  eye  will  recover  with  secondary  cataract,  adhesions  of  the 
iris,  and  little  or  no  useful  sight.  But  the  patient  is  saved  from  protracted 
sutfoi'ing,  hopeless  loss  of  sight,  and  the  danger,  immediate  and  remote,  of 
sympathetic  ophthalmia  in  the  other  eye.  By  prompt  and  skilful  treatment, 
an  eye  may  be  saved  and  made  useful  at  a  later  period  by  an  iridectomy.  Of 


606         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

course,  if  with  all  the  lesions  already  described,  a  foreign  body  be  lodged  in 
the  lens,  it  must  be  removed  with  as  much  of  the  lens  as  possible.  If  an 
iridectomy  can  aid  in  its  removal,  this  should  be  employed,  and  will,  perhaps, 
help  to  save  the  eye.  Should  the  foreign  body  have  traversed  the  lens  and 
lodged  deep  in  the  eye,  it  cannot  be  removed,  and  the  sight  will  be  lost,  with 
great  danger  of  sympathetic  trouble  in  the  fellow.  In  such  a  case,  immediate 
enucleation  may  be  advisable. 

If  a  limited  contusion  of  the  cornea,  without  perforation  or  rupture  of  the 
globe,  has  occurred,  the  immediate  reaction  may  be  slight,  but  very  destruc- 
tive consequences  are  likely  to  follow.^ 

Wounds  of  the  cornea  proper  are  not  as  dangerous  to  sight,  even  with  the 
serious  complications  mentioned,  as  injuries  of  the  same  kind  at  the  sclero-corneal 
junction.    If  the  aqueous  and  vitreous  chambers  have  both  been  opened,  there 
will  not  only  be  loss  of  vitreous  and  perhaps  intra-ocular  hemorrhage,  but 
prolapsus  of  the  iris  and  of  the  ciliary  circle.    A  careful  removal,  if  possible, 
of  any  foreign  body  from  the  wound  and  the  eye,  must  be  followed  by  snip- 
ping the  iris  from  the  corneal  wound,  and  clipping  off  the  protruding  vitre- 
ous, so  as  to  secure  the  very  best  coaptation.    It  is  seldom  advisable  to  use  a 
stitch  except  for  the  conjunctiva.    If  extensive  wounds  of  this  critical  region 
be  complicated  by  intra-ocular  hemorrhage,  and  the  presence  of  a  foreign  body 
that  cannot  be  reached,  immediate  enucleation  is  the  shortest  and  safest  way 
out  of  difficulty.    Lately,  a  few  successful  cases  have  been  reported  of  removal 
of  pieces  of  steel  from  the  eye  by  aid  of  a  magnet.    In  the^  great  majority 
of  instances  this  plan  fails,  but  it  is  sometimes  worth  a  trial.-  In  wounds 
of  the  sclera,  not  involving  the  ciliary  region,  a  stitch  or  two,  embracmg  the 
ocular  conjunctiva  and  the  superficial  tissues  of  the  sclera,  may  be  resorted  to 
with  advantage.    In  extensive  rupture  of  the  sclera,  parallel  to  the  corneal 
margin,  with  perhaps  complete  loss  of  the  lens  and  escape  of  vitreous,  little 
can  be  done  but  to  cleanse  the  wound  and  apply  a  bandage  for  a  few^  days  or 
weeks.    Such  ruptures  are  not  apt  to  be  followed  by  violent  reaction  or  sym- 
pathetic danger,  and  sometimes  get  well  with  useful  vision.    If  the  lens  has 
escaped  and  lodged  under  the  conjunctiva,  this  membrane  must  be  incised 
and  the  lens  removed.    In  case  of  concussion  of  the  eye,  without  rupture  or 
wound,  the  lens  may  be  luxated,  and  may  become,  as  it  nearly  always  does,  a 
serious  source  of  irritation  and  danger.    If  it  has  been  knocked  through  the 
pupil  into  the  anterior  chamber,  it  must  be  carefully  extracted.    If  displaced 
to  one  side,  behind  the  iris,  it  is  very  liable  to  give  rise  to  irritation  and 
secondary  glaucoma,  with  pain  and  total  blindness.    In  that  case,  if  it  can- 
not be  safely  extracted,  the  eye  should  be  enucleated  in  order  to  save  suffering 
and  place  the  other  eye  in  a  condition  of  safety.    An  operation  for  the  removal 
of  such  a  lens  involves  grave  difficulties  and  risks.    Still,  it  can  sometimes  be 
successfully  done,  and  the  eye  saved.    Should  a  small  foreign  body,  driven 
with  force,  penetrate  deep  into  and  remain  in  the  eye,  with  only  partial  im- 
pairment of  sight, -what  is  the  wisest  course  to  pursue  ?  -  If  it  cannot  be  re- 
moved by  the^magnet,  it  may  be  safe  and  wise  to  keep  the  patient  quietly 
under  observation  for  some  weeks  or  months,  to  see  if  it  will  be  tolerated. 
It  may  become  encysted  in  the  vitreous,  retina,  or  choroid,  and  may  remain 
harmless.    But  such  eyes  are  always  a  source  of  solicitude  to  the  experienced 
surgeon,  and  may  suddenly  develop  trouble,  at  any  time.    If  fixed  in  the 
ciliary  region,  the  foreign  body  will  almost  certainly  give  rise  to  inflammation 
and  sympathetic  danger.    When  forbearance  ceases  to  be  safe  for  the  patient, 
enucleation  must  be  resorted  to.  ... 
Of  all  foreign  bodies  lodged  in  the  eye,  a  shot  is  more  likely  to  remain 


'  See  hypopium  keratitis,  page  620. 


INJURIES  OF  THE  EYEBALL. 


607 


harmless  than  anything  else.  I  recall  three  cases  in  which  both  eyes  were 
destroyed  by  shot.  One  patient  had  extensive  intra-ocnlar  hemorrhages,  fol- 
lowed by  cataract,  but  never  suffered  any  severe  pain,  and  the  eyes  were  pre- 
served with  a  plump,  health}^  appearance.  The  second  patient  I  saw  but 
once,  and  never  heard  of  afterwards,  while  the  case  of  the  third  presented 
eome  interesting  features  : — 

A  boy,  12  years  old,  received  a  discharge  of  bird  shot  in  the  face,  and  was  instantly 
blinded.  The  accident  occurred  September  29,  1881,  and  I  saw  him  one  week  after- 
wards. A  shot  had  penetrated  the  right  eye  through  the  ciliary  region,  near  the  inner 
margin  of  the  cornea.  In  the  left,  another  had  entered  through  the  cornea,  near  its  edge, 
and  had  traversed  the  iris  and  lens,  producing  traumatic  cataract.  The  lens  was  finally 
absorbed,  leaving  a  clear  pupil,  with  some  vision,  and  perception  of  colors.  The  eye  is 
normal  in  size,  tension,  and  appearance.  In  the  right,  chronic  cyclitis  and  atrophy  of 
the  globe  followed.    But  this  eye,  even,  is  now  quite  comfortable. 

If  a  shot  has  entered  the  eye  anywhere  in  front  of  the  equator,  the  round 
discolored  point  of  penetration  can  always  be  detected.  (Plate  XXVII., 
Fig.  6.) 

Concussion  of  the  eye  often  leads  to  serious  and  permanent  injury  to  sight. 
In  niany  cases,  rupture  of  the  lens  capsule  is  detected,  and  of  course  trau- 
matic cataract  follows.  In  others,  no  rent  in  the  capsule  can  be  discovered, 
but  cataract  ensues,  probably  from  loosening  of  the  lens  from  its  intra-capsular 
connections. 

In  other  instances,  no  gross  lesions  can  be  discovered  to  account  for  the 
damaged  sight.  There  must  be  some  molecular  disturbances  in  the  rods  and 
cones,  but  they  are  not  appreciable  by  the  ophthalmoscope.  Sometimes 
hemorrhages  into  the  vitreous  are  found,  and  not  infrequently  genuine 
ruptures  of  the  choroid.  These  are  usually  crescentic  in  shape,  with  concavity 
towards  the  optic  disk.  (Plate  XXVIII.,  Pigs.  1  and  3.)  These  lesions 
are  always  connected  with  serious  damage  to  vision,  from  necessary  injury 
to  the  percipient  elements  of  the  retina.  The  rule  is  that  suppurative 
inflammation  follows  the  penetration  of  a  foreign  body,  whether  the  latter 
lodge  in  the  eye  or  not.  In  rare  exceptions  little  inflammation  ensues,  and 
in  some  none  at  all.  Why  this  great  diflerence,  in  apparently  the  same  cir- 
cumstances ?  It  has  usually  been  attributed  to  diflerence  of  individual  tole- 
ration, due  to  temperament  and  idiosyncrasy. 

In  the  recent  researches  of  Lebert  and  others,  the  germ  theory  seems 
to  aflford  an  explanation.  By  experiments  with  animals,  and  observations 
drawn  from  large  numbers  of  published  cases  in  men,  he  has  come  to  the 
following  conclusions :  (1)  The  simple  presence  of  a  pure  and  chemically 
indifferent  foreign  body  in  the  eye,  excites  no  inflammation.  (2)  Aseptic  foreign 
bodies,  of  metals  which  oxidize,  do  not  give  rise  to  suppurative  inflammation, 
but  cause  trouble,  especially  when  large  and  in  the  vitreous,  giving  rise  to 
detachment  of  the  retina,  etc.,  from  chemical  reactions.  (3)  Suppurative 
hiflanimation  always  follows,  if  the  wound  is  infected  by  germs  of  lower 
organisms  that  rapidly  multiply  in  the  wound  and  around  the  foreio:n  body. 
Suppurative  inflammation  can  come  from  chemical  irritation,  but  if  no 
germs  are  _  present,  usually  does  not.  (4)  The  suppurative  inflammation, 
after  injuries,  from  the  growth  of  microbes,  is  caused  by  the  chemical  sub- 
stances eliminated  by  their  growth,  as  is  the  inflammation  complicating 
cysticercus  cellulosse  in  the  eye.  The  chemically  indifferent  foreign  bodies, 
are  particles  of  stone,  glass,  splinters  of  wood,  eyelashes,  gold  wire,^and  lead^ 
when  free  from  germs. 

^  In  a  brief  note  just  published,  Lebert  adds  the  follow^ing :  (1)  Aseptic 
pieces  of  copper,  unlike  those  of  iron  and  steel,  when  lodged  in  the  anterior 


608         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

chamber,  excite  suppurative  inflammation  only  when  in  contact  with  the  iris, 
but  not  when  sticking  in  the  lens,  and  projecting  into  the  anterior  chamber. 
('^)  If  the  piece  of  copper  is  suspended  in  the  vitreous  humor,  suppurative 
inflammation  does  not  follow.  When  resting  in  the  tunics  of  the  eye,  in  the 
ciliary  reo-ion,  suppuration  ensues,  but  is  limited  to  the  immediate  neighbor- 
hood of  the  foreio-n  body.  (3)  Lead  wire  does  not  excite  suppuration,  either 
in  the  vitreous  or  in  the  anterior  chamber.  But  small  masses  of  lead  sus- 
Dended  in  the  vitreous,  give  rise  to  the  same  form  of  detachment  ot  the 
retina  as  iron  or  copper.  (4)  Metallic  mercury,  introduced  aseptically,  devel- 
ops both  in  the  vitreous  and  anterior  chamber,  severe  suppurative^  intiam- 
mation ;  but  this  diff'ers  from  the  inflammation  produced  by  rapid  germ 
development,  by  not  extending  to  the  neighboring  parts  of  the  eye.  ihese 
results  refer,  of  course,  to  experiments  on  the  eyes  ot  animals. 


Diseases  of  the  Conjunctiva. 


The  known  frequency  of  these  aftections  is  in  part  explained  by  the  con- 
stant contact  of  the  air,  and  of  all  it  contains,  with  the  conjunctiva, 
only  floating  particles,  but  poisonous  vapors  thus  i;each  its  sensitive  sur- 
face and  2:ive  rise  to  irritation  and  inflammation.  The  easy  access  of  con- 
tagious secretions,  also,  gives  a  rational  explanation  of  the  origin  ot  many 
of'these  maladies,  while  the  influence  of  atmospheric  changes  in  exciting  dis- 
eases of  this  portion  of  the  mucous  membrane,  is  likewise  well  established. 

Conjunctivitis.— By  far  the  greater  number  of  morbid  processes  involving 
the  conjunctiva  are  of  an  inflammatory  character  and  we  naturally  begm, 
therefore,  with  the  symptoms  of  coi^junctivitis,  and  first,  the  objectrve  symptoms. 
These  are:  (1)  Increased  injection,  ranging  from  the  slightest  blush  to  the 
most  vivid  redness.    (2)  Swelling,  due  to  inflammatory  hyperemia  and  in- 
filtration of  the  tissues,  but  more  especially  of  the  subconjunctival  structures. 
Hicrh  deo-rees  of  this  swellino-,  when  involving  the  ocular  conjunctiva,  are 
calfed  chemosis.    Chemosis  may  be  serous,  of  a  watery  appearance,  yielding 
readily  to  slight  pressure,  and  indicating  less  severity  ot  inflammation  ;  or 
phlegmonous,%mev,  more  opaque,  tenderer  to  pressure,  and  evidencing  more 
violent  inflammation.    (3)  Perverted  and  increased  secretion.    This  change 
varies  from  a  slight  excess  of  transparent  mucus,  through  the  muco-purulent 
form,  to  the  mos^t  marked  and  profuse  purulent  discharge     The  mild  torm. 
of  coniunctivitis  are  usually  transient,  and  attended  by  little^  danger.  Ihe 
phleo-monous  and  purulent  varieties  are  apt  to  be  disastrous  m  their  conse- 
queifces.    They  are,  however,  but  degrees  of  the  same  process. 

The  subjective  evidences  of  conjunctivitis  are,  a  sense  of  dryness,  itching, 
burnino-,  and  a  feeling  of  sand  in  the  eyes.  Severe  pam  is  not  present  except 
in  violent  forms  of  the  disease,  and  then  arouses  fears  of  trouble  m  the  cornea 
or  the  iris.  Cloudiness  of  vision,  and  rainbow-colors  around  objects,  are  due 
to  flakes  of  mucus  on  the  cornea,  and  disappear  by  ^yashlng  the  eyes  Con- 
stant deficiency  of  sight  generally  results  from  morbid  changes  m  the  epi- 
thelium or  other  structures  of  the  cornea.  ,  ,  ^ 
The  diagnosis  of  conjunctivitis  is  very  easy,  but  the  ready  recognition  of 
serious  complications  is  not  so  simple.    Therein  are  manifested  the  skill  and 

success  of  the  expert.  ;o 

Proanosis.— The  tendency  of  conjunctivitis,  as  of  most  other  diseases,  is  to 
recovery.  Under  favorable  circumstances  it  is  apt  to  get  well  spontaneously. 
Affo-ravated  by  injudicious  treatment  or  bad  surroundings,  or  both,  it  be- 
comes tedious  and  dangerous  to  sight.    When  recovery  is  spontaneous,  or 


DISEASES  OF  THE  CONJUNCTIVA. 


609 


hastened  by  mild  treatment,  the  conjunctiva  is  restored  to  its  physiological 
condition,  even  in  the  most  alarming,  purulent  form  of  the  malady.  As  far, 
then,  as  the  integrity  of  the  membrane  itself  is  concerned,  the  pi'ognosis  is 
always  favorable.  It  is  only  in  chronic  cases,  complicated  by  granular  lids, 
that  serious  lesions  of  the  conjunctiva  itself  are  produced.  The  dangers  of 
conjunctivitis  are,  immediately,  to  the  cornea  and  iris,  and,  remotely,  that  of 
the  formation  of  granulations  and  of  their  endless  duration  and  conse- 
quences. The  things  to  be  most  feared  in  every  case  of  severe  or  protracted 
conjunctivitis,  are  implication  of  the  cornea  and  more  or  less  serious  damage 
to  its  transparency. 

Varieties  of  Conjunctivitis. — The  marked  characteristics  of  some  forms  of 
conjunctivitis  have  led  to  their  separation  and  special  designation,  under  the 
names  of  simple^  catarrhal^  purulent,  and  phlyctenular  conjunctivitis.  The  first 
is  mild,  of  short  duration,  attended  by  little  secretion,  and  causing  but  slight 
inconvenience.  The  second  is  more  serious,  lasting  longer,  giving  rise  to 
more  annoyance,  and  being  attended  by  greater  secretion  of  mucus.  The  third 
is  the  most  acute,  painful,  and  dangerous  to  the  integrity  of  the  eye,  its  diag- 
nostic symptom,  indicated  by  the  name,  being  a  profuse  discharge  of  pus.  A 
form  of  purulent  conjunctivitis  rarely  seen  in  this  country,  but  very  destruc- 
tive to  sight,  is  called  diphtheritic.  In  it  there  is  at  first  no  purulent  dis- 
charge, but  a  plastic  infiltration  of  all  the  tissues,  strangulation  of  the  blood- 
vessels, and  usually  destruction  of  one  or  both  cornese.  Croupy  conjunctivitis, 
where  the  deposit  is  superficial,  and  can  be  peeled  off,  is  much  less  serious. 
The  phlyctenular  variety  is  limited  to  definite  parts  of  the  conjunctiva,  and, 
as  the  name  implies,  is  known  by  the  formation  of  little  elevations  or  phlycte- 
nulse,  the  favorite  seat  of  which  is  the  ocular  conjunctiva,  near  the  cornea. 
They  vary  in  number  from  one  or  two  to  many  more,  in  bad  cases  surround- 
ing the  entire  cornea.  Each  is  a  focus  for  well-defined  local  injection,  the 
rest  of  the  membrane  often  being  quite  free  from  redness.  In  the  mild  cases 
there  is  little  secretion  and  no  intolerance  of  light.  When  the  isolated  phlyc- 
tenul?e  are  more  numerous,  the  patches  of  inflammation  become  confluent, 
the  secretion  of  mucus  is  more  free,  and  the  symptoms  are  those  of  acute, 
catarrhal  conjunctivitis.^  The  diagnostic  lesion  is  the  well-marked  phlyc- 
tenula.  This  peculiar  inflammation  occurs  nearly  always  in  children  with 
the  scrofulous  diathesis.  The  same  little  patients  often  sufier  at  intervals 
with  blepharitis  ciliaris,  scabby  eruptions  in  and  around  the  nose,  on  the 
skin  of  the  lids,  behind  the  ears,  and  on  the  scalp,  with  enlarged  lymphatic 
glands,  hypertrophied  tonsils,  and  other  strumous  manifestations.  The  dis- 
ease seldom  occurs  in  adults,  except  in  such  as  have  had  it,  at  times,  from 
childhood.  ^  When  the  phlyctenulse  are  seated  on  the  cornea,  they  give  rise 
to  more  serious  and  protracted  suftering,  and  often  leave  the  eye  damaged  in 
sight  from  corneal  opacities.  The  disease  is  then  called  phlyctenular  kera- 
titis, but  it  difters  in  nothmg,  save  in  the  seat  of  the  lesion,  from  phlycte- 
nular conjunctivitis.  The  chief  disease  of  the  eyes  in  infancy  is  purulent 
conjunctivitis;  that  of  childhood,  phlyctenular  conjunctivitis.  The  healthiest 
mfaut  may  have  the  one,  but  only  the  scrofulous  child  the  other. 

Etiology  of  Conjunctivitis.— IX  would  seem  that  all  the  varieties  just  described 
may  recognize  the  same  causes,  the  very  diflferent  symptoms  depending  on 
the  peculiar  constitution  of  the  patient,  his  immediate  surroundings,  or  a 
diflference  in  the  directness  and  intensity  of  the  cause.  For  instance,  a 
catarrhal  conjunctivitis,  due  to  atmospheric  causes,  may  be  a2:gravated  by 
bad  ventilation,  filthy  habits,  and  constant  reckless  exposure,  into  the  puru- 
lent form,  with  its  destructive  tendencies.  On  the  other  hand,  the  simple,  the 
catarrhal,  and  the  purulent  varieties,  may  often  be  traced  to  the  same  conta- 
gion. Atmospheric  vicissitudes  acting  on  a  strumous  child,  will  probably 
VOL.  IV.— 39 


610         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDA8ES. 

o-ive  rise  to  phlyctenular  conjunctivitis,  while  in  the  adult  and  non-scrofulous, 
the  catar  hi^^  vlriety  will  follow;  or  if  the  cause  act  with  sufiicient  mten- 
s  tr  a-gravated  hy  bad  health  and  surroundings,  purulent  conjunctivitis 
may  lesflt,  with  all  its  characteristics.    While  these  are  established  facts, 
doubtless  by  far  the  most  frequent  cause  of  purulent  conjunctivitis  ,s  conta- 
Son     To  the  eyes  of  the  infant  it  comes  from  the  genital  organs  of  the 
Ser  during  parturition.    In  the  adult,  it  is  the  resul  of  selt-inoculation 
with  gonorrheal  matter.    The  contagion  may  get  into  both  eyes  at,  or  about, 
rtie  same  time.    But  frequently  the  second  eye  contracts  the  disease  from  the 
secretroiis  of  the  first.    Without  careful  supervision  this  is  almost  certain  to 
occur  when  only  one  eye  is  at  first  involved.    To  prevent  inoculation  of  the 
second  eye  from^  the  first  attacked,  is  much  more  diificult  m  infants  than  in 
adults.    Because  an  infant  is  attacked  by  severe  P'^rulent^conjunctivitrs  s(«„ 
afte  birth,  we  are  not  justified  in  assuming,  necessari  y,  that  the  mother  has 
gonorrhaTa    Simple  lei.corrhcea,  the  lochia,  and  even  the  liquor  amnii,  getting 
fnto The  ey^s,  may  give  rise  to  purulent  conjunctivitis.  Certain  atmospheric  or 
o  hei  rondit  ons  sometimes  predispose  to  the  more  ready  and  rapid  spread 
of  d  e  contagion  of  this  disease,  causing  it  to  assume  an  epidemic  form  At 
such  times,  it  is  not  always  easy  to  trace  the  contagion  where  it  actually  has 
?aken  place  and  sometimes  inflammatory  conjunctival  diseases  arise  without 
contagion,  and,  when  reaching  a  certain  suppurativa  degree,  are  commumcated 
to  others   In  badly  ventilated  asylums,  school-houses  barracks,  and  tenement 
houses  where  large  numbers  of  persons  are  crowded  together  especially  at 
nkhflbe  conjunctiva  becomes  so'^irritable,  and  takes  on  violent  disease  from 
sSSt  ciuBCS,  that  the  destructive  spread  of  conjunctivitis  can  only  be 
preve  ited  by  breaking  up  the  dens  of  infection,  and  isolating  the  diseased 
persons    Isolation,  cleanliness,  fresh  air,  and  healthy  food  must  be  secured, 
if  the  disease  is  to  be  cured  or  prevented  from  spreading. 

OphthdmTa  neonatorum,  the  scourge  of  the  lying-in  room  m  all  ages,  s 
now  80  well  understood  by  educated  physicians,  that  its  occurrence  can  he 
nearly  always  prevented  by  timely  precautions.    I  have  insisted  for  many 
years  in  W  lectures,  on  the  importance  of  promptly  washing  off  the  face 
Lid  eyelids  and  washing  out  the  eyes  of  every  new-born  babe  with  clean 
tepid  water,  before  bathing  its  body.    The  additional  precaution  of  drop- 
dX  a  solut  on  of  nitrate  of  silver  into  the  eyes,  twice  a  da,y,for  the  first  day 
^  tio  after  Wrth,  will  certainly  save  the  child  from  purulent  conjunctivitis, 
and  frorn  pos  ible  blindness  of  one  or  both  eyes.    A  two-per-cent.  solution 
i  qui  eTtrong  enough,  and  causes,  even  when  freely  dropped  into  the  eyes 
no  seriofsTr  ftation.^  A  weak  solution  of  carbolic  acid,  or  a  stronger  one  of 
boraJic  acid  will  answer  the  same  purpose,  but  the  niti^te  is  found  to  be  the 
Zest  preventive.    The  adoption  of  these  wise  precautions  in  most  hospitals 
and  ly   g-in  establishments,  has  recently  settied  beyond  cavil  th^e  Preventab^^^^^ 
Hv  (/ thfs  dangerous  afiection.    The  same  remedies,  at  once  applied  in  adults 
w?ici  known  contact  has  taken  place  by  accident  or  care  essness,  will  remove 
i  destroyTh^^         and  save  the  eye  from  a  frightful  attack  of  purulent 

°°TaS2  0/  Conjunctiviiis.--Rememhevmg  the  tendency  to  spontaneous 
and  slfe  recovery  in  mild  cases,  and  the  great  danger  of  inflammation  of  the 
i^fand  dam'age  to  sight  in  Bcvere  attacks  our  therapeu^^ 
rational.  In  times  past,  when  every  inflammation  of  the  eyes  was  sore 
eyes^"--and  when  nitrate  of  silver,  in  substance  or  strong  solution,  was  he 
invariable  remedy-the  doctor  with  his  lapis  in/-.r,Mte  was  dreaded  as  the 
fierv  fiend,  ready  to  burn  out  the  eyes !  and  he  seldom  failed !_ 

7n  slight  fornix  ot  catarrhal  conjuMs,  a  few  days  of  rest  ™  ^  well-ven^^^^ 
lated  but  sufflcientiy  warmed  room,  some  restriction  of  diet,  gentle  laxatives, 


DISEASES  OF  THE  CONJUNCTIVA. 


611 


and  occasional  bathing  of  the  closed  eyes  with  fresh,  cool  water,  even  without 
any  topical  treatment  with  astringents,  will  lead  to  a  cure.  If  there  is  much 
secretion,  and  gluing  of  the  eyelids  during  sleep,  a  little  pure  vaseline,  fresh 
butter,  or  lard,  rubbed  on  the  lids  at  bedtime,  will  add  much  to  the 
patient's  comfort.  In  addition,  a  solution  of  five  grains  to  the  ounce,  of 
boracic  acid  or  biborate  of  sodium,  dropped  freely  into  the  eyes,  night  and 
morning,  will  expedite  the  cure.  A  very  weak  solution  of  other  astrin- 
gents, such  as  sulphate  of  zinc  or  copper,  or  nitrate  of  silver,  one-half  grain  to 
the  ounce,  used  in  the  same  way,  will  hasten  recovery.  If,  in  spite  of  this 
mild  and  proper  treatment,  the  disease  persists  beyond  a  few  days,  with 
sponginess  of  the  conjunctiva,  and  more  free  secretion  of  mucus,  the  carefully 
everted  conjunctiva  may  be  quickly  and  lightly  brushed  with  a  solution  of 
five  grains  to  the  ounce,  of  nitrate  of  silver,  immediately  washed  off  thor- 
oughly with  cool  water.  The  crystal  or  solution  of  sulphate  of  copper  may 
be  used  in  the  same  way.  This  brushing  should  not  be  applied  more  trhan 
once  a  day,  and  with  great  discrimination,'^keeping  up  the  milder  applications 
in  the  intervals.  As  the  symptoms  subside,  the  remedies  should  be  applied 
more  lightly  and  less  frequently,  till  the  patient  is  quite  weW.  Of  course, 
reading  or  close  use  of  the  eyes,  or  exposure  to  wind,  dust,  smoke,  and  such 
irritants,  must  be  forbidden.  There  is  a  form  of  hypersemia  of  the  conjunc- 
tiva, but  generally  wdth  little  or  no  secretion,  which  persists  in  a  chronic  way, 
and  which  is  not  improved,  but  aggravated,  by  astringents,  strong  or  weak^ 
and  which  is  often  treated  by  inexperienced  persons  as  granular  lids.  It  is 
the  congestion  due  to  necessary  strain  of  the  accommodation  in  hyperopic 
and  astigmatic  patients.  Correct  this  strain  by  the  use  of  appropriate  glasses, 
and  the  conjunctival  redness  disappears  spontaneously.  This  probable  com- 
plication, in  the  treatment  of  all  chronic,  persistent  cases  of  conjunctivitis  or 
of  blepharitis,  should  never  be  forgotten. 

The  local  treatment  of  phlyctenular  or  strumous  conjunctivitis,  is  the  same 
as  that  already  described,  wdth  the  addition  of  certain  mercurial  applications 
known  to  have  a  happy  effect  in  dissipating  the  phlyctenulse.  A  little  pure 
and  finely  powdered  calomel  may  be  dusted  upon  the  eye  once  a  day,  bring- 
ing it  in  contact  with  each  phlyctenula  if  possible.  A  dry  camefs  hair 
brush  may  be  dipped  into  the  powder,  and  a  little  quickly  sent  into  the  eye 
by  tapping  the  brush  with  the  finger.  The  surgeon  will  soon  learn  the 
knack  of  doing  this  before  the  patient  can  wink.  The  same  thing  may  be 
accomplished  by  using  a  salve  once  a  day.  One  grain  of  calomel  with  a 
drachm  of  vaseline  or  lard,  well  rubbed  together,  causes  very  little  irritation, 
when  a  small  piece  from  the  end  of  a  probe  is  put  in  the  eye  by  everting  the 
lower  lid.  The  dust  or  the  salve  should  be  used  once  a  day,  and  continued 
for  some  days  after  the  phlyctenulse  have  vanished,  to  prevent  the  formation 
of  others.  Relapse  is  the  tendency  in  this  disease,  and  can  only  be  perma- 
nently overcome  by  the  use  of  constitutional,  antistrumous  remedies.  Quinine 
in  tonic  doses,  iodide  of  iron,  the  hypophosphites,  cod-liver  oil,  good  nutri- 
tious food  at  regular  meals,  great  attention  to  the  skin,  and  daily  out-door 
exercise  in  the  pure  air,  kept  up  faithfully  for  months,  and  even  years,  will 
not  only  help  to  cure  the  disease,  but  will  fortify  the  little  patient  against 
many  others  of  the  same  fatal  class. 

Treatment  of  Purulent  Conjunctivitis  in  Infa.nts.~Eo  disease  yields  more 
readily  to  prompt  and  judicious  treatment  than  ophthalmia  neonatorum,  and 
none  is  more  dangerous  to  sight  when  neglected  or  badly  treated.  Constant 
cleanhness,  day  and  night,  must  be  observed  throughout.  The  irritating  pus 
must  not  be  allowed  to  stand  in  the  eyes,  but  must  be  frequently  renioved 
with  great  gentleness,  so  as  not  to  scratch  or  abrade  the  corneal  epithelium. 
JNo  syringing  is  safe  for  the  eye  or  the  operator,  and  the  eyes  should  not 


612         INJUEIES  AKD  DISEASES  OF  THE  EYES  AND  THEIE  APPENDAGES. 

often  be  wet  or  washed  with  water.    Absorbent  cotton  furnishes  by  far  the 
best  means  of  moppin-  and  cleansing  the  eyes.  The  ids  should  be  gently  but 
well  Separated  once  an  hour,  or  oftener  if  the  secretion  be  excessive,  and  the 
mfie  That  escapes  should  be  rubbed  off  with  the  cotton       thrown  into  the 
tire    This  can  be  so  lightly  done  as  not  to  waken  the  infant,  and  the  tieat- 
„  e;t  must  be  rigidly\ept  up  as  long  as  the  purulent  discharge  persists. 
Two  oTthree  timis  a  day,  the  eyes  should  be  we  1  washed  with  tepid  water 
T.lnts  are  extremely  sensitive  to  cold  water.    At  each  cleansing,  or  at  least 
o  t  an  hour,  aTw  dr^^  of  a  solution  of  boracic  acid,  Ave  grains  to  one 
ounce  should  be  dropped  into  the  eyes,  and  the  lids  drawn  open  so  that  it 
Zy  reach  the  whole^  suppurating  surface.    It  causes  little  or  no  irritation 
al  as  an  astringent,  and  perhaps  destroys  the  mic^cocci  and  their  germs 
An  equally  safe  tnd  still  niore  efficient  remedy  is  the  nitrate  of  silver,  half  a 
frain  to  one  ounce,  used  with  the  same  thoroughness  and  frequency.  A 
fXtion  of  alum,  one  grain  to  one  ounce,  may  be  applied  in  the  same  way. 
Oncl  a  day,  after'the  sfppuration  is  frankly  established,  I  evert  the  hds  fully 
and  careful  y,  and  pencil  them  with  a  solution  of  nitrate  of  silver,  from  five 
to  ten  grains  to  one  ounce,  taking  great  care  to  prevent  its  running  over  the 
cornea    When  the  lids  are  evertSd  and  held  securely,  their  natuml  spas- 
.  modic' closure  will  fully  evert  the  retro-bulbar  folds,  and  wi    pro  ect  the 
Trnea  from  the  contact  of  the  fluid.  Waiting  a  second  or  two  till  the  brushed 
surface  becomes  whitish,  tepid  water  must  be  freely  used  to  wash  off  the  ex- 
ce  s  of  fluid  before  returning  the  lids.   In  this  way  no  harm  can  come  to  the 
cornea  and  the  suppuration  can  be  very  promptly  and  rapidly  controlled 
rXays  expect  the  child  to  be  brought  back  the  nex   day  after  the  fir 
brushing,  very  much  better.    Once  a  day  is  usually  often  enough  for  this 
trertmef  t  keeping  up  the  cleansing  and  use  of  weak  washes  m  the  intervals. 
But  everwithrimple  cleansing  and  the  daily  brushings,  without  any  other 
medicat"oJ  these  cLes  get  raptdly  well  in  from  one  to  three  weeks.  I  cannot 
"call  a  single  case  in  which  ulceration  and  serious  damage  to  the  cornea  h*ve 
ever  been  witnessed,  under  this  course  of  treatment,  when  the  cornea  has  been 
intact  at  the  beginning.  Whatever  theory  may  be  adopted  as  to  the  patho- 
02V  of  this  afeftion,  all  who  have  tested  the  nitrate-of-silver  treatment  fairly 
Se  as  to  itfefflcacy.    Purulent  conjunctivitis  is  a  self-limited  disease,  but 
fIrsistTmuch  longer^under  cleansing  'and  milder  treatment  than  under  that 
which  I  have  adiised.    As  danger  to  the  cornea  exists  during  the  whole 
iiative  peri<.d,  the  more  quickly  it  is  cut  short,  the  sooner  is  the  danger 
over  As Ihe  swelling  and  suppuration  subside,  the  intervals  between  the 
plnciUings  may  be  prolonged.    Firmness,  but  delicacy,  of  manipulation  in 
^yer t  nglie  lids  and  in  sifely  applying  the  remedy,  c'^"  ^"^y  l'^^,^'!";:!!* 
exDcrience    The  child  should  be  laid  backwards  across  the  nurse  s  lap,  with 
S  head  held  firmly  between  the  surgeon's  knees,  face  upward,  the  water, 
medicine,  and  all  the  needed  implements  being  at  hand.    No  instrument  is 

''^Z:^rn':jT^M  Con^uneHviti.  in  Adults.-U  will  be  admitted  I 
think  hat  with  the  same  management,  or  mismanagement,  a  larger  number 
of  addts  than  of  infants  will  be  blinded  by  this  disease.  The  older  and 
more  decrepft  the  subject,  the  greater  the  danger  to  the  cornea  and  to  sight 
w"th  g  own  persons,  I  insist  that  they  shall  be  put  to  bed  and  kept  there 
till  well  In  the  very  onset  of  the  disease,  I  begin  the  constant  use  of  ced 
coUre  ;es  These  must  be  changed,  day  and  night,  every  ten  or  fifteen 
mi^  tes  and  continue.l  till  the  pain,  soreness,  swelling,  and  violence  of  the 
sc  se  are  under  thorough  control.  Then  they  may  be  intei^itted  for  a  few 
disease  aio  uu  s  Constant  and  careful  removal  of  the 

mXr  Lm  tht  eyei^^^  is  of  the  greatest  importance.    As  soon 


DISEASES  OF  THE  CONJUNCTIVA. 


613 


as  the  suppuration  is  fairly  established,  a  weak  solution  of  boracic  acid,  or  of 
nitrate  of  silver,  the  same  as  in  infants,  should  be  freely  dropped  into  the 
eyes  every  hour  or  oftener.  If  there  is  great  phlegmonous  swelling  of  the 
lids,  chemosis,  and  dangerous  pressure  around  the  cornea,  the  external  com- 
missure of  the  lids  may  be  freely  divided,  and  light  scarifications  of  the  con- 
junctiva resorted  to.  Leeches  to  the  temple  or  side  of  the  nose  may  be 
ordered,  but  their  effect  is  too  slow  to  be  greatly  relied  upon.  The  free 
incision  of  the  commissure  takes  the  blood  more  quickly,  and  directly  relieves 
the  pressure  of  the  lids  on  the  chemosed  eyeball.  A  free  purgative  in  the  be- 
ginning, some  restriction  of  diet,  and  opiates  to  relieve  pain  and  promote  sleep, 
are  usually  required.  In  the  course  of  a  few  days,  when  the  swollen  lids  and 
eyes  are  not  so  very  tender  to  pressure,  and  the  lids  can  be  fully  everted  with- 
out much  suffering,  especially  if  the  suppuration  be  profuse,  the  lids  should 
be  turned  and  pencilled  once  a  day,  as  in  infants.  But  while  in  the  latter  this 
may  safely  be  done  from  the  start,  in  adults  we  must  wait  a  few  days  for  the 
above  changes  to  take  place ;  then  this  more  heroic  local  treatment  is  safer, 
rapidly  controlling  the  disease,  and  abridging  the  period  of  danger. 

Conjunctivitis  GtRanulosa;  Granular  Lids;  Trachoma. — Any  one  of  the 
forms  of  conjunctivitis  which  have  been  described  above,  becoming  chronic, 
is  liable  to  lead  to  anatomical  lesions  of  the  conjunctiva,  which,  in  general 
terms,  are  called  granulations.  In  isolated  cases,'  but  chiefly  in  epidemics  of 
conjunctivitis,  these  exuberant  products  are  rapidly  developed  with  very 
acute  manifestations.  The  acute  stage  subsiding  after  a  few  weeks,  the  case 
runs  on  in  a  subacute  and  persistent  form,  and  the  granulations  become  the 
chief  cause  of  danger,  as  well  as  the  endless  aim  of  treatment.  An  attempt 
has  been  made  by  Saemisch  and  others  to  establish  an  anatomical  classifica- 
tion— conjunctivitis  foUictdosa  and  conjunctivitis  granulosa — the  former  disap- 
pearing completely  under  mild,  careful  treatment,  leaving  no  cicatricial  lesion 
behind,  and  the  latter  always  followed  by  more  or  less  alteration  in  the  ana- 
tomical texture  of  the  conjunctiva.  While  it  is  true  of  rare  forms  of  so- 
called  follicular  conjunctivitis,  that  they  recover  with  perfect  "restitutio  in 
integrum,''  the  two  varieties  are  nearly  always  mixed,  and  the  prognosis, 
therefore,  is  usually  not  so  favorable.  The  distinction  is  further  based  upon 
differences  in  the  distribution  of  the  inflammatory  infiltrations,  the  follicular 
being  grouped  in  closed  capsules  under  the  epithelium,  or  else  the  lymphoid 
elements  forming  in  groups  without  a  limiting  membrane.  In  the  other,  the 
true  granulation,  the  elementary  products  are  more  diffused,  and  pervade  the 
deeper  textures.  Microscopical  anatomy  may  finally,  with  further  investi- 
gation, become  a  basis  of  classification  and  an  aid  in  treatment,  but  practi- 
cally I  agree  with  Goldzieher  that  "conjunctivitis  granulosa"  may  be  held  to 
include  all  varieties,  as  they  require  the  same  treatment.  In  view  of  the  fact 
that  they  are  all  contagious,  very  tedious  in  duration,  and  prone  to  frequent 
acute  relapses,  that  they  usually  lead  to  permanent  cicatricial  changes  in  the 
conjunctiva  and  lids,  and  that  they  seem  to  yield  best  to  the  same'course  of 
treatment,  I  shall  consider  them  all  together. 

^  Granular  eyelids  are  the  uniform  result  of  conjunctivitis  of  some  kind, 
either  acute  or  chronic.  Hence  their  etiology  is  that  of  conjunctivitis.  There 
does  not  seem  to  be  any  specific  granular  virus,  conveyed  by  contagious  secre- 
tions, producing  always  the  same  condition,  and  spreading  in  no  other  way. 
Atmospheric  changes,  and  anything  that  gives  rise  to  colds,  may  be  followed 
by  conjunctivitis  and  granulations.  Morbid  secretions,  either  from  diseased 
eyes  or  from  the  urethra,  are  the  most  frequent  means  of  propagation,  their 
greater  or  less  purulence  giving  them  more  or  less  virulence. 

Granular  eyelids  are  the  scourge  of  some  countries,  while  in  others  they 


614         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

are  scarcely  known.  The  disease  has  made  serious  ravages  in  Belgium,  Italy, 
and  other  countries  of  Europe,  since  its  general  introduction  by  the  return  of 
the  French  army  from  Egypt.  Still,  it  has  prevailed  more  or  less  extensively 
in  most  countries,  before  and  since  that  event.  It  is  much  more  likely  to 
spread  among:  the  poor,  and  those  whose  habits  are  not  cleanly,  especially  if 
they  work  hard  and  indulge  in  all  sorts  of  irregularities  and  dissipations. 
The  crowding  together  of  large  numbers  of  people  in  badly  ventilated  quarters, 
favors  the  a:rave  character  and  spread  of  this  dread  disease.  It  prevails  very 
lara:ely  among  the  farmers  and  laboring  classes  of  all  the  Western  States  and 
territories,  and,  when  it  enters  a  family,  is  very  apt  to  attack  all  its  members 
and  persist  indefinitely. 

The  diagnosis  is  usually  very  easy,  although  many  cases  ot  simple  hyper- 
gemia  of  the  conjunctiva,  or  chronic  cases  of  conjunctivitis,  are  treated  severely 
and  during  long  months  for  supposed  granulations.    The  rough,  rugous,  and 
often  "  cockscomb"  appearance  of  the  everted  lids,  and  of  the  retro-bulbar 
folds,  is  recognized  at  once.   In  more  recent  and  milder  cases,  where  the  in- 
flammatory deposits  are  not  so  large,  the  surface  is  less  rough  and  character- 
istic, but  still  a  very  little  experience  will  prevent  its  being  mistaken.  In 
the  reflected  folds,  the  deposits  are  often  more  sharply  isolated,  roundish,  and 
somewhat  elevated,  in  rows  with  the  folds,  semi-transparent,  like  frogs'  eggs, 
and  but  slightly  vascular.    With  more  violent  inflammation,  swelling,  and 
redness,  their  individual  peculiarities  cannot  be  recognized.  Granulations 
are  confined  mainly  to  the  tarsal  and  reflected  parts  of  the  conjunctiva,  but 
sometimes  extend  to  the  sclerotic  portion,  and  even  to  the  cornea.    In  sonae 
instances  the  hypertrophied  structures  ,and  infiltrations,  although  seemingly 
enormous,  are  superficial,  and  disappear  with  little  or  no  trace  of  cicatricial 
lesion.    In  others,  apparently  not  as  bad,  the  new  deposits  are  deep  and  de- 
structive to  the  conjunctiva  and  tarsus,  and  are  followed  by  serious  lesions, 
distortions  of  the  lids,  and  such  impaired  functions  as  to  make  the  eyes 
almost  useless  and  a  life-long  trouble.    Deep  or  untimely  cauterizations  in- 
crease the  danger  of  serious  organic  lesions,  and  their  disastrous  efl^ects  upon 
vision.    There  is  always,  preceding  and  accompanying  granulations,  inflam- 
mation with  its  symptoms,  perverted  and  increased  secretion,  and  more  or 
less  suffering  and  functional  disturbance  of  vision.    The  droopy  and  sleepy 
appearance  of  the  eyelids  in  these  cases  is  pathognomonic,  and  yet  the  diag- 
nosis must  be  made  sure  by  direct  objective  inspection  of  the  entire  conjunc- 
tiva.   To  this  end  it  is  necessary  to  evert  the  lids.    If  the  patient  does  not 
,   shrink  back  from  the  sur2:eon,  and  will  look  firmly  to  the  floor,  it  will  be 
easy  to  turn  the  upper  lid^'in  the  way  already  described  (page  590).    I  he 
lower  conjunctival  folds  are  readily  exposed  by  drawing  the  lower  lid  down 
while  the  patient  turns  the  eye  upwards.   Inspection  of  the  cornea  is  secured 
by  sliding  the  lids  apart  while  the  patient  turns  the  eye  down,  avoiding 


eversion.  .  . 

Treatment  of  Granular  Conjunctivitis.— In  a  long  and  large  experience  with 
this  disease,  I  find  the  main  difl[iculty  to  be  in  keeping  the  inflammatory  ele- 
ment under  safe  control.  The  proneness  to  acute  relapses,  each  setting  the 
patient  back  and  retarding  recovery,  must  never  be  lost  sight  of  J3y  wise 
circumspection  these  may  be  prevented  or  cut  short,  so  that  at  last  they  will 
cease  to  occur,  and  the  patient  will  get  well.  Just  here  lies  the  difhculty  ot 
treating  these  pa,tients  at  long  range.  They  need  to  be  seen  daily,  and  kept 
under  the  closest  supervision,  for  weeks,  and  months,  and  even  years,  it, 
after  proper  treatment  for  a  few  days  or  weeks,  they  feel  better,  they  insist 
upon  going  home,  promising  to  "  carry  out  the  same  treatment.  it  no 
better,  or  worse,  they  despair  and  change  doctors.  So  they  go  the  rounds, 
and  come  back,  if  at  all,  always  worse.    If  frankly  told  at  the  start  that  the 


DISEASES  OF  THE  CONJUNCTIVA. 


615 


treatment  will  be  very  long,  and  will  require  great  watchfulness  on  both 
sides,  they  go  to  a  more  ignorant  or  less  scrupulous  surgeon,  or  to  a  brazen 
quack,  who  promises  a  certain  and  speedy  cure.  Such  patients  often  try 
every  silly  thing  they  hear  of,  and  express  surprise,  at  last,  that  they  do  not 
get  well  1  Peripatetic  patients,  with  granular  sore  eyes,  do  not  furnish  good 
cases  for  a  novice  who  wants  to  make  a  reputation.  Great  skill  and  eternal 
vigilance  can  alone  guide  to  safe  recovery.  Ugly  and  fatal  complications 
beset  the  long  and  crooked  road  that  leads  to  relief,  and  few  there  be  that 
walk  wisely  and  patiently  therein.  The  discriminating  use  of  a  few  well- 
known  remedies  is  the  secret  of  successful  treatment.  The  management  of 
these  cases  must  be  very  largely  hygienic,  as  well  as  therapeutic.  Cleanli- 
ness, great  attention  to  the  skin,  diet,  and  clothing,  exercise  in  the  open  air, 
rest  of  the  eyes  from  close  work,  regular  habits,  temperance,  and  avoidance  of 
all  known  causes  of  irritation,  are  conditions  that  must  be  enforced,  other- 
wise no  treatment  can  avail.  Whatever  conduces  to  the  best  health,  is 
necessary  to  speedy  recovery  from  any  disease.  If  the  farmer  continues  his 
laborious  life,  the  student  his  studies,  the  good  liver  his  fast  ways,  the  in- 
temperate his  wild  career,  no  science  can  save  the  eyes.  The  thorough 
obedience  and  cooperation  of  the  patient  must  be  secured.  Except  with  free 
livers,  restriction  of  diet  and  severe  antiphlogistic  treatment  are  not  required, 
and  are  often  injurious.  Healthy,  nutritious  food  at  regular  meals,  orderly 
exercise  in  the  open  air,  and  a  general  course  of  tonics,  are  usually  indicated. 

The  local  treatment  of  granular  lids  is  guided  by  two  indications.  The 
first,  that  of  sul)duing  the  inflammatory  reaction  and  keeping  it  within  safe 
bounds.  The  second,  that  of  producing  temporary  local  stimulation,  and  thus 
promoting  the  slow  and  safe  absorption  of  the  morbid  deposits.  Their 
destruction  by  cauterization  is  not  to  be  thought  of.  In  the  first  stages  of 
acute  trachoma,  and  during  the  inflammatory  relapses  that  are  so  trouble- 
some and  characteristic,  local  anodynes  and  soothing  remedies  alone  are  per- 
missible. There  is  a  natural  tendency,  under  favorable  surroundings,  for 
the  inflammation  to  subside  after  a  few  days  or  weeks.  It  should  be 
allayed  by  mild  treatment ;  not  aggravated,  prolonged,  and  rendered  more 
dangerous  to  sight  by  violent  applications.  If  tenderness  to  light,  weeping, 
spasmodic  closure  of  the  lids,  pain,  and  marked  ciliary  injection  are  present, 
the  solution  of  atropia,  four  grains  to  the  ounce,  dropped  in  the  eyes,  from 
three  to  six  times  in  twenty-four  hours,  is  nearly  always  beneficial.  The 
atropia  instillation  should  be  continued  till  these  symptoms  are  overcome, 
abating  its  frequency  as  they  subside.  Cold-water  bathing  of  the  closed  lids, 
at  frequent  intervals,  in  robust  people,  and  during  the  acute  stage,  is  grateful 
and  useful. 

The  regular  use  of  cold  compresses,  for  a  few  hours  at  a  time,  helps  to  sub- 
due the  excessive  local  temperature.  In  the  chronic  stages,  however,  the  acute 
relapses  are  often  better  controlled  by  warm  fomentations  that  hasten  the 
suppurative  tendency,  permitting  astringents  to  be  safely  used.  Moderate 
purgation  once  or  twice  a  Aveek,  and  opiates  at  night  to  ease  pain  and  promote 
sleep,  are  valuable  aids.  Either  from  the  start,  or,  better,  after  a  few  days, 
when  the  intolerance  of  light  and  weeping  have  given  way  to  more  or  less 
mucous  or  muco-purulent  secretion,  a  solution  of  boracic  acid,  five  grains  to 
the  ounce,  or  of  biborate  of  sodium  of  the  same  strength,  may  be  dropped 
freely  into  the  eyes  three  times  a  day.  These  solutions  are  somewhat  astrin- 
gent and  scarcely  at  all  iri'itating.  To  prevent  painful  adhesion  of  the  lids 
at  night,  their  edges  may  be  greased  with  vaseline,  fresh  butter,  or  lard. 

If  keratitis  sets  in,  as  it  is  always  prone  to  do,  with  abrasions  of  the  epi- 
thelium, patches  of  infiltration,  abscesses,  and  ulceration,  the  atropine  should 
be  applied  oftener,  and  the  other  treatment  kept  up  more  rigidly.    With  this 


616         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


complication,  and  sometimes  without  it,  acute  iritis  is  apt  to  occur,  with  its 
characteristic  circumorbital  pains.  In  that  event,  the  mydriatics  are  all  the 
more  important.  It  is  in  view  of  this  complication,  which  seems  to  be 
favored  by  the  local  use  of  eserine,  that  I  am  cautious  about  the  use  of  the 
latter  for  the  purpose  of  preventing  the  destruction  of  the  cornea.  The 
boracic  acid,  cold,  compression  with  a  bandage,  opiates,  quinia,  and  careful 
paracentesis,  are  the  remedies  in  which  I  have  most  confidence.  Still,  I 
sometimes  use  a  drop  of  the  eserine  solution  directly  to  the  ulcerated  cornea, 
once  in  six  or  eight  hours,  keeping  up  the  predominating  influence  of  the 
atropine  all  the  time. 

This  gentle  and  rational  course,  continued  for  a  few  days  or  weeks,  is 
likely  to  subdue  the  inflammatory  troubles,  so  that  very  careful  local  stimu- 
lation may  be  tried.    The  tolerance  of  light,  absence  of  tears,  and  presence 
of  more  or  less  mucous  or  purulent  secretion,  with  fading  away  of  the  sclerotic 
injection  around  the  cornea,  especially  above ^  are  favorable  symptoms.    In  pro- 
portion to  the  amount  of  pus  contained  in  the  discharges,  and  the  succulence 
of  the  conjunctiva,  will  be  the  preferability  of  nitrate  of  silver  over  other  astrin- 
gents or  caustics.    We  begin  with  a  five-grain  solution,  brushed  .quickly  and 
lightly  over  the  thoroughly  everted  lids  with  a  camel's  hair  pencil,  and 
quickly  washed  off  with  water,  so  that  none  of  it  touches  the  cornea.  In 
twenty-four  hours,  if  the  reaction  has  been  brief  and  the  eyes  seem  better,  the 
application  may  be  repeated  in  the  same  manner.    Little  by  little  we  feel 
our  way,  and  determine  the  tolerance  of  the  eyes.    While  a  solution  of  this 
streuirth  does  well,  its  use  may  be  continued.    When  it  ceases  to  produce 
sufiicTent  reaction,  the  proportion  of  the  nitrate  should  be  increased  to  ten 
grains.   Stronger  solutions  than  this  are  seldom  required,  and  are  not  safe. 
Alternating  the  local  remedies  is  nearly  always  found  beneficial.    Use  one 
a  few  days  or  weeks,  as  long  as  it  does  good ;  then  resort  to  another ;  and 
finally  you  may  return  to  the  first  substance  used,  with  advantage.  The 
sulphate  of  copper  in  solution,  or  in  smooth  crystal,  is  a  valuable  remedy,  and 
for  long-continued  use  is  preferable  to  the  nitrate  of  silver,  which  is  likely 
to  discolor  the  conjunctiva.    A  five,  ten,  or  even  twenty-grain  solution  may 
be  brushed  on  once  a  day,  and  then  be  well  washed  ofl',  but  most  surgeons 
use  the  crystal,  passed  quickly  over  once  or  twice,  and  then  freely  washed 
away.    When  the  retro-bulbar  folds  are  thickened,  the  crystal  can  be  passed 
back  under  the  upper  edge  ol  the  everted  tarsus,  so  as  to  reach  them.  In 
many  chronic  cases,  it  is  found  that  the  nuetral  acetate  of  lead  in  saturated 
solution,  and  well  washed  away,  acts  very  favorably  and  produces  little  re- 
action.   It  should  never  be  used  as  a  wash,  dropped  into  the  eyes,  in  such 
cases,  tor  fear  of  precipitation  in  the  cornea.    Tannin,  crystals  of  alum,  and 
many  other  astringents  have  at  different  times  been  recommended,  but  if  no 
one  of  the  three  remedies  above  described  acts  well,  scarcely  any  other  will. 
Of  course  the  conditions  that  admit  of  safe  local  stimulation  to  encourage 
absorption,  make  the  further  use  of  atropine  unnecessary.    As  it  keeps  the 
pupil  dilated  and  paralyzes  accommodation,  thus  causing  great  confusion  of 
vision,  and  often  alarm,  it  should  only  be  used  when  decidedly  indicated.  In 
rare  cases  it  produces  atropinization  and  will  not  be  tolerated  at  all.  In 
these,  hyoscy amine  or  duboisia  must  be  substituted.    Should  an  acute  relapse 
occur  during  this  course  of  judicious  local  treatment,  as  it  is  apt  to  do,  drop 
the  local  irritants  and  return  for  a  time  to  the  soothing  measures,  and  so 
with  one  or  the  other  persevere  to  the  end,  which  is  nearly  always  far  in  the 
misty  future. 

In  intractable  cases  of  granular  lids,  with,  jpannus  covering  and  protecting 
the  cornea,  inoculation  of  gonorrhoea!  pus,  first  suggested  by  Friedrich  Jaeger 
of  Vienna,  in  1812,  has  often  been  successfully  practised.    Brilliant  results, 


DISEASES  OF  THE  CONJUNCTIVA. 


G17 


in  the  most  hopeless  cases,  have  been  published  from  time  to  time,  and  ad- 
verse criticism  has  always  come  from  those  who  have  never  tried  the  remedy. 
In  1855,  Warlomont  published  a  paper  in  high  praise  of  this  heroic  treat- 
ment, in  extreme  cases,  especially  where  the  coriieae  of  both  eyes  were  covered 
by  pannus.  In  1857  I  myself  published  a  paper  on  the  subject,  with  the 
history  of  a  very  successful  case.  As  the  patient  could  see  a  little  with 
one  eye,  I  inoculated  only  the  bad  one,  sealing  up  the  other  and  keeping  it 
free.  After  the  subsidence  of  the  violent  reaction,  I  left  the  other  eye  open 
purposely,  although  only  the  upper  half  of  the  cornea  was  vascularized.  On 
the  third  day  this  eye  was  attacked,  but  less  severely,  and  the  disease  passed 
its  climax  spontaneously  on  the  fourth  day.  From  this  time  the  lids  of  both 
eyes  were  everted,  and  brushed  with  a  twenty-grain  solution  of  nitrate  of 
silver,  once  a  day  for  eight  days,  when  all  suppuration  had  ceased.  The 
granulations,  which  were  enormous,  completely  disappeared  ;  the  sight  of  both 
eyes  was  so  far  restored  as  to  enable  the  patient  to  read ;  and  the  last  news  I  had 
from  him,  twelve  months  afterwards,  he  was  following  a  threshing  machine. 
He  left  the  hospital  seven  weeks  after  the  inoculation  of  the  first  eye,  and 
three  weeks  after  that  of  the  second.  I  treated  a  number  of  cases  by  this 
means,  and  most  of  them  with  prompt  success.  They  were  all  what  might 
be  called  almost  hopeless.  Afterwards,  I  tried  it  as  a  last  resource  in  the  case 
of  a  little  boy.  Both  of  the  eyes  were  lost  by  ulceration  of  the  cornea.  In  this 
case  I  hardly  had  any  hope  of  success,  but  the  granulations  were  cured,  and 
the  patient  was  soon  comfortable.  In  a  second  paper  (October,  1857),  I  said : 
"  The  more  advanced  the  pannus,  by  which  I  mean  the  more  completely  the 
cornea  is  covered  with  vessels  and  exudation,  the  less  danger  is  there  in  the 
treatment.  If  the  vasculo-membranous  layer  covers  the  entire  cornea,  and  is 
so  thick  that  the  pupil  can  scarcely  be  seen,  if  at  all,  then  there  is  very  little 
risk  in  the  procedure,  and  you  are  almost  sure  to  restore  the  patient's  sight, 
provided  that  the  true  substance  of  the  cornea  is  not  the  seat  of  an  incurable 
leucoma."  If  the  pannus  is  only  partial,  some  parts  of  the  cornea  remaining 
clear,  or  if  though  general  it  is  so  thin  that  clear  spaces  are  left  between  the 
vessels,  through  which  the  pupil  is  distinctly  visible,  then  there  is  more 
danger  to  be  apprehended  from  the  application  of  the  pus.  The  thick,  patho- 
logical coating  formed  by  the  pannus  protects  the  tissue  of  the  cornea  from 
the  violence  ot  the  inflammation  produced  by  the  matter,  and  wherever  such 
a  protection  does  not  exist,  softening  and  sloughing,  or  ulceration,  are  liable 
to  occur. 

But  my  impression  is,  from  what  I  have  observed,  that  undue  importance 
has  been  attached  to  the  contra-indication  afforded  by  the  partial  transparency 
of  the  cornea,  for  in  one  of  the  eyes  which  I  treated  thus,  there  were  several 
portions  of  the  organ  that  were  merely  slightly  hazy,  and  traversed  only  here 
and  there  by  minute  vessels.  At  several  points  the  pupil  could  be  distinctly 
seen,  and  yet  I  allowed  the  inflammation  to  go  on  uninfluenced  by  treatment, 
and  the  cornea  did  not  sufter  the  slightest  injury.  The  great  danger  from 
gonorrhoeal  conjunctivitis,  when  it  attacks  a  previously  healthy  eye,  is 
sloughing  of  the  cornea  from  the  violence  of  the  inflammatory  reaction,  and 
more  especially,  perhaps,  from  the  strangulation  caused  by  the  pressure  of 
the  chemosis.  ^s'ow,  where  there  is  a  panniform  condition  of  the  organ, 
aside  from  the  mere  protection  aflforded  by  the  new  formation,  it  is  much 
less  likely  to  slough,  because  it  is  nourished  by  the  new  vessels,  and  the  circu- 
lation in  it  is  not  so  easily  cut  off  by  the  swelling.  For  the  same  reason,  we 
seldom  see  sloughing  of  the  cornea  to  a  large  extent  after  it  has  become 
vascularized  in  acute  keratitis.  In  a  case  of  granular  lids,  then,  with  even 
a  moderate  number  of  vessels  scattered  over  the  cornea,  though  the  pupil  is 
visible  through  nearly  every  part  of  it,  I  think  that  there  is  no  very  great 


618         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES, 


liability  to  ulceration,  especially  if  the  case  be  carefully  watched  and  the 
inflammation  promptly  cut  short  on  the  first  unfavorable  symptom,  as  it 
almost  certainly  may  be  by  the  energetic  application  of  nitrate  of  silver. 

It  is  a  rare  thing  for  a  well-hiformed  ophthalmologist  to  lose  an  eye  affected 
with  o;onorrhoeal  ophthalmia,  if  he  sees  it  and  treats  it  from  the  very  com- 
mencement. AVhy,  then,  should  he  not  be  able  to  control  the  disease  w^hen 
artificially  produced  in  an  eye  protected  by  a  previous  development  of  vessels  ? 
But  experience  alone  can  settle  this  question. 

As  to  the  indications  for  a  resort  to  this  treatment,  they  are  few  and  sim- 
ple. The  first  reason  for  inoculating  a  patient  is  that  you  have  tried  every- 
thing else,  and  have  failed  to  cure  him.  After  a  fair  experiment  with  the  other 
agents  recommended,  if  you  fail  to  effect  a  cure,  then  you  are  certainly  justi- 
fiable in  essaying  a  measure  that  has  rendered  such  signal  services  under 
similar  circtimstances.  I  say,  after  a  fair  trial,  because  I  do  not  believe  in 
waiting  till  the  eyes  are  destroyed,  or  the  corner  so  far  disorganized  that  a 
cure  is  next  to  impossible.  The  sooner  the  remedy  is  applied,  all  things  be- 
ino-  favorable,  the  more  likely  we  are  to  have  a  satisfactory  issue.  Patients 
may  be  cured  in  six  weeks  by  inoculation,  who  w^ould  suffer  for  years,  and 
perhaps  never  recover,  under  the  ordinary  treatment. 

The  same  treatment,  for  the  same  reasons,  has  been  more  recently  advocated 
by  M.  Ch.  Abadie.  His  ability  to  control  the  violence  of  the  reactign  by 
brushing  the  everted  lids  twice  a  day  with  a  ten-grain  solution  of  nitrate  of 
silver,  prompts  him  to  advise  a  more  frequent  resort  to  this  therapeutic  agent. 

As  'an  illustration  of  the  thoroughness  and  promptness  of  this  mode  of 
treatment,  as  well  as  of  its  only  danger,  ulceration  of  the  cornea,  I  give  the 
following  brief  history  :— 

A  very  strumous  lad,  17  years  of  age,  came  for  treatment  April  15,  1882.  He  was  the 
victim  of  an  acute  attack  of  trachoma,  of  four  weeks'  duration.  There  was  enormous 
thickening  of  the  eyehds,  lips,  and  nose.  The  granulations  showed  an  exuberance 
such  as  I'^had  seldom  if  ever  seen.  The  right  cornea  was  clear  and  intact,  but  the 
left  showed  some  symptoms  of  superficial  keratitis.  He  was  treated  for  seven  weeks, 
in  the  usual  careful  way,  with  some  improvement.  Early  in  June,  he  was  taken 
with  a  violent  purulent  relapse  which  we  could  not  certainly  trace  to  inoculation. 
Taken  at  once  to  the  Cincinnati  Hospital,  he  was  subjected  to  the  most  rigid  treatment 
by  Dr.  wS.  C.  Ayres.  For  two  weeks,  iced  compresses  were  applied  day  and  night. 
The  lids  were  everted  and  brushed  freely  with  a  five-grain  solution  of  nitrate  of  silver, 
twice  a  day,  and  were  well  washed  off  with  water  after  each  apphcation.  Both  cornea? 
ulcerated  in  the  centre,  the  ulceration  on  the  left  side  ending  in  hmited  perforation 
with  synechia  anterior.  On  June  26,  he  went  home  much  improved.  In  the  begin- 
nino-  of  September,  he  returned  perfectly  well.  There  were  no  traces  of  granulations, 
and'' but  very  small  central  opacities  of  the  cornciae.  On  the  11th  of  December,  he 
wrote  that  his  eyes  had  slowly  improved  in  sight,  that  he  had  had  no  back-set,  and 
that  he  could  read  half  an  hour  without  fatigue ;  and  he  asked  if  he  could  safely  go 
to  school.    This  patient's  general  health  was,  and  had  ever  been,  wretched. 

Quite  recently,  DeWecker  has  recommended  the  application  of  a  w^atery 
solution  of  the  seeds  of  the  jequirity,  as  a  safer  substitute  for  hioculation. 
It  is  said  to  produce  a  milder  form  of  suppuration  from  the  conjunctiva,  and 
to  be  equally  eflacient  in  its  curative  action.  This  remedy  has  long  been  in 
common  use  in  Brazil  in  the  treatment  of  "sore  eyes." 

In  rare  cases,  after  the  lids  have  finally  healed  and  have  become  as  smooth 
as  they  ever  can  be,  and  when  all  distortions— trichiasis,  phimosis,  etc. — 
have  been  relieved  by  appropriate  surgical  measures,  a  chronic,  vascular, 
relapsing  keratitis  may  persist  and  require  treatment.  In  these  cases  I 
have  often  succeeded  well  with  finely  powdered  sulphate  of  copper.  The 
upper  lid  is  everted,  once  or  twice  a  week,  and  a  little  of  the  powder  applied 


DISEASES  OF  THE  CORi^EA. 


619 


by  means  of  a  moistened  probe,  and  let  down  immediately  on  the  cornea.  A 
drop  of  the  perchloride  of  iron  may  be  used  in  the  same  way,^  allowing  it  to 
run  over  the  cornea.  The  reaction  following  its  api)lication  is  intense  for  a 
few  hours,  but  the  benefit  is  often  very  prompt  and  great.  In  the  same 
cases  a  solution  of  eserine  may  be  used  once  a  day.  It  seems  at  times^  to 
bring  about  a  marked  improvement  in  the  pannus.  Another  remedy,  which 
is  very  soothing  and  safe  for  the  patient  in  home  use,  is  a  salve  of  vaseline 
and  boracic  acid,  fifteen  grains  to  one-half  ounce,  to  be  put  in  the  eyes  twice 
a  day.  Mercurial  salves  of  different  kinds,  used  in  the  eyes  for  granulations 
and  pannus,  are  of  no  value  in  most  cases,  and  positively  injurious  in  many. 

With  one  other  practical  remark,  I  end  what  I  have  to  say  upon  this 
important  subject.  In  the  advanced  stages  of  granulations,  when  the  morbid 
deposits  are  undergoing  slow  absorption,  and  cicatrization  is  setting  in,  we 
often  find,  wdien  the  upper  lid  is  well  everted,  that  the  acino-tubular  glands, 
along  the  back  edge  of  the  tarsus,  are  engorged  by  a  sort  of  gelatinous  sub- 
stance which  keeps  up  the  irritation  of  the  cornea  and  delays  the  cure.  For 
many  years  I  have  been  in  the  habit  of  pressing  this  rudely  out  with  the 
two  thumb  nails,  one  slid  behind  and  the  other  in  front,  and  moved  along 
the  whole  length  of  the  tarsus.  This  being  w^ell  done  two  or  three  times,  at 
intervals  of  a  day  or  two,  very  much  expedites  the  usual  local  treatment. 
This  procedure  is  painful,  but  it  must  be  adopted  firmly  and  without  hesi- 
tation. 

Diseases  of  the  Cornea. 

Keratitis. — Inflammation  of  the  cornea,  in  some  form,  is  the  starting 
point  of  most  of  its  serious  lesions.  The  clinical  symptoms  by  which  this 
process  is  diagnosed,  are  of  easy  recognition.  Loss  of  the  natural  trans- 
parency is  the  first  certain  symptom.  The  degree  of  opacity  may  vary  from 
the  slightest  haziness  to  the  densest  leucoma.  With  this  physical  change,  is 
uniformly  seen  an  alteration  in  the  polish  of  the  reflecting  surface,  giving  it  the 
appearance  of  ground  glass,  and  causing  images  reflected  from  it  to  be  blurred 
and  indistinct.  This  depends  on  abrasions  and  irregularities  of  the  corneal 
epithelium.  With  these  objective  alterations,  there  is  associated  the  most 
characteristic  subjective  symptom,  photophobia.  The  intolerance  of  light,  in 
acute  keratitis,  is  generally  intense,  particularly  in  scrofulous  children.  It  is, 
however,  by  no  means  in  proportion  to  the  physical  damage  to  the  cornea  and 
the  degree  of  impairment  of  vision.  The  dread  of  light  is  often  much  more 
distressing  than  actual,  severe  pain.  The  latter  may  and  often  does  occur, 
especially  when  there  is  infiltration  and  pressure  on  the  nerve  filaments  of 
the  cornea,  or  actual  ulceration.  In  the  latter  case  it  is  sharp  and  severe, 
like  the  thrust  of  a  needle,  but  usually  confined  to  the  eyeball.  With  the 
photophobia  is  always  very  troublesome  epiphora^  and  spasmodic  closure  of 
the  lids.  Of  course  the  w^eeping  is  increased  by  exposure  to  light.  When 
the  eye  is  inspected,  a  more  or  less  complete  red  zone  of  sclerotic  injection 
will  be  seen  around  the  cornea,  fading  out  as  it  is  followed  toward  the  equator, 
which  it  does  not  reach.  This  group  of  symptoms  is  so  characteristic  that  a 
mistake  is  scarcely  possible.  Blurring  of  vision,  necessarily  present,  is  not 
easily  estimated, because  the  patient  can  open  the  eye  but  for  a  brief  moment, 
and  it  instantly  fills  with  tears.  As  the  cornea  performs  a  double  function 
in  the  economy  of  vision,  its  lesions  are  all  the  more  serious.  With  the 
sclera  it  constitutes  the  strong  form-maintaining  tunic,  and,  at  the  same  time, 
it  acts  as  a  refracting  medium.  Faulty  changes  of  curvature,  giving  rise  to  ill- 
defined  images,  and  cloudiness  leading  to  irregular  and  imperfect  illumination, 
combine  to  make  sight  imperfect.    Both  changes  are  usual  results  of  inflam- 


620         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

mation.  Irreo-ular  bulging  of  the  cornea  in  chronic  keratitis,  and  softening 
and  yieldino-  of  limited,  infiltrated  or  ulcerated  portions  in  the  acute  forms  of 
the  disease^  are  by  no  means  uncommon.  Keratitis  may  be  primary  or 
secondary.  The  first  class  embraces  all  forms  beginning  m  and  spendmg  their 
main  force  upon  the  cornea.  The  second  includes  all  cases  m  which  the  cor- 
nea becomes  involved,  as  a  complication,  in  the  course  of  some  other  disease 
of  the  eye.  Primary  keratitis  may  result  from  purely  local  causes,  or  may 
l)e  due  to  a  dyscrasia,  such  as  scrofula  or  syphilis. 

The  etiology  of  this  affection  is  often  difficult  of  discovery,  and  sometimes 
only  conjectural.    Even  when  traceable  to  a  constitutional  affection,  it  is  not 
easy  to  explain  why  it  occurs  in  some  cases  and  not  in  others,  or  in  one  eye 
and  not  in  both.    There  are  local  determining  causes  that  are,  as  yet,  inscru- 
table    Even  in  traumatic  keratitis,  including  that  from  chemical  action, 
the  seriousness  of  the  reaction  varies  very  greatly  in  different  cases,  without 
our  beino-  able  in  all  instances  to  ascertain  the  reason.    Excepting  traumatic 
cases,  and  those  in  strumous  and  syphilitic  subjects,  primary  keratitis  is  of 
rare  occurrence.    The  most  frequent  exciting  causes  of  keratitis  are  atmos- 
pheric changes  and  impurities.     Secondary  keratitis  is  of  very  frequent 
occurrence,  in  the  course  of  acute  conjunctivitis.    In  purulent  conjunctivitis, 
keratitis,  with  its  consequences,  is  the  great  and  only  danger.    In  the  simple 
form  of  inflammation  of  the  conjunctiva,  the  invasion  of  the  cornea  begins 
at  the  maro-in.    At  first  there  is  perhaps  simple  abrasion  of  the  epithelium, 
and  superficial  ulceration  close  to  and  parallel  with  the  margin,  assuming  a 
crescentic  shape.    This  may  go  deeper  and  lead  to  marginal  perforation,  but 
generally  the  part  undergoes  vascularization,  and  then  gets  well.    In  puru- 
lent coniunctivitis  the  cornea  is  apt  to  be  invaded  in  its  centre,  where  its  nutri- 
tion is  most  precarious.    The  attack  may  begin  in  the  form  of  a  hmited 
abscess,  followed  by  open  ulceration,  or  by  direct  ulcerative  invasion.  In 
either  case  it  is  likely  to  lead  to  perforation,  and  to  very  serious  damage  to 


vision. 


There  is  a  form  of  inflammation  of  the  cornea,  peculiarly  destructive  in  its 
tendency  frequently  of  traumatic  but  often  of  spontaneous  origin,  that  is 
usually  called  hypojnmn  keratitis.    It  might  perhaps  be  better  designated  as 
infectious.    It  is  nearly  always  seen  in  adults ;  often  m  stone  masons,  trom 
contusions  by  fine  pieces  of  stone  ;  or  in  harvesters,  from  injuries  by  wheat 
beards.    In  these  cases  the  injury  seems  slight  and  insignificant  at  first,  and 
the  severe  reaction  does  not  set  in  for  two  or  three  days.    Those  laboring 
under  suppurative  inflammation  of  the  tear  sac,  are  peculiarly  liable  to  this 
trouble  from  slight  wounds  or  abrasions  of  the  cornea,  or  without  any  injury 
The  same  source  of  local  infection  makes  the  extraction  of  cataract,  in  such 
persons,  almost  certainly  destructive  to  the  eye.    This  disease  is  charac- 
terized by  rapid  and  limited  infiltration,  abscess,  and  ulceration,  which  is  apt 
to  spread  both  laterally  and  in  depth,  and  which  may  lead  to  speedy  perfo- 
ration.   A  large  portion  or  even  the  entire  cornea  may  be  thus  destroyed 
in  a  few  days.    Very  soon  after  the  appearance  of  abscess  and  ulceration,  an 
accumulation  of  pus  is  seen  in  the  bottom  of  the  anterior  chamber,  which 
increases,  and  may  fill  the  entire  chamber  in  a  tew  days.    The  sufterin^^ 
usually  intense  until  perforation  occurs,  when  it  is  apt  to  abate     In  raie 
cases  there  is  little  pain  or  none  at  all.    This  disease  always  leads  to  perma- 
nent cicatricial  opacity  of  the  cornea  and  serious  injury  to  sight,  and  in  many 
cases  to  hoi)eless  loss  of  vision.   Its  etiology,  diagnostic  symptoms,  and  treat- 
ment, are  all  somewhat  peculiar.  ......      -n  i  i 

Another  variety,  traceable  often  to  hereditary  syphilis,  is  called  parenchy- 
matous keraUtis.  It  is  seen  nearly  always  in  young  persons  of  dwarted 
S^pearance,  and  with  the  peculiar  defect  in  the  front  teeth  described  by 


DISEASES  OF  THE  CORNEA. 


621 


Hutchinson.^  Frequently  there  will  be  found  nodes  upon  the  shins,  and  other 
symptoms  of  tertiary  syphilis.  This  disease  is  extremely  persistent,  leading 
to  great  cloudiness  and  vascularity  of  the  cornea,  and  is  often  complicated 
by  iritis  and  closure  of  the  pupil.  It  nearly  always  attacks  both  eyes  in 
succession.  During  its  progress,  or  soon  after  its  subsidence,  a  destructive  in- 
flammation of  the^cavity  of  the  tympanum  and  labyrinth  is  liable  to  follow, 
terminating  usually  in  total  deafness. 

Still  another  form  of  keratitis  deserves  special  description.    I  mean  the  so- 
called  phlyctenular  keratitis,  sometimes  named  strumous,  because  it  nearly 
always  attacks  scrofulous,  delicate,  and  precocious  children.    The  pustule  or 
pimple  that  gives  it  its  peculiar  name  may  be  single  or  multiple,  and 
situated  anywhere  on  the  cornea.    It  is  usually  small,  and  out  of  all  propor- 
tion to  the  intense  photophobia  and  sufJering  which  attend  it.    The  victims 
of  this  troublesome  disease  are  likely  to  be  afflicted  by  blepharitis  ciliaris, 
phlyctenular  conjunctivitis,  otorrhoea,  cutaneous  eruptions  about  the  face  and 
scalp,  enlargement  of  the  lymphatic  glands,  and  other  scrofulous  troubles. 
The  seat  of  the  phlyctenula  makes  all  the  difference  possible  in  the  symptoms. 
When  on  the  conjunctiva  of  the  sclerotic,-  it  causes  little  suffering  and  soon 
gets  well ;  but  wlien  seated  on  the  cornea  proper,  extreme  intolerance  to  light, 
spasm  of  the  lids,  and  months  of  the  most  distressing  suffering  are  likely  to 
follow.    The  corneal  phlyctenula  sometimes  ends  in  a  small  ulceration,  and 
very  rarely  in  perforation  of  the  cornea  vv^ith  its  consequences.    The  cornea  is 
apt  to  become  vascular,  the  little  tuft  of  vessels  running  from  the  margin  to 
the  seat  of  the  phlyctenula,  and  leaving  after  recovery  often  a  corresponding 
band  of  opacity.    In  other  cases  there  remains  only  a  small  speck  of  opacity, 
indicating  the  seat  of  the  phlyctenula.    The  little  sufferer  is  always  worse  hi 
the  morning,  and  better  towards  evening.    Left  to  its  instincts,  the  child  will 
hide  away  in  the  darkest  corner  it  can  tind,  for  weeks  and  for  months ;  bury- 
ino-  its  face  in  the  pillow,  and  holding  its  pale,  bony  fingers  spasmodically 
on'' the  eyes,  fighting  against  the  light  with  a  deadly  struggle.    In  warm 
weather  the  face  will  be  soaked  with  sweat,  the  skin  chafed  and  covered 
with  eczematous  patches,  the  eyelids  fissured  at  the  outer  angles,  and  bleed- 
ino-  when  pulled  open,  with  scabs  in  and  around  the  nose  and  behind  the 
ears.    This  picture  is  graphic  and  pitiable,  because  true  to-nature.  Photo- 
phobia, always  a  characteristic  symptom  of  acute  keratitis,  is  here  most 
intense  and  persistent. 

Variola  is  often  followed  by  a  severe  and  very  troublesome  form  of  kera- 
titis. It  comes  on  gradually,  during  desquamation,  and  results  in  great  and 
permanent  damage  to  sight.  This  form  does  not  as  often  result  in  ulceration, 
perforation,  and  staphyloma  of  the  cornea,  as  in  dense  opacity.  It  is  always 
very  obstinate,  and  requires  an  invigorating  constitutional  treatment.  When 
ulceration  of  the  cornea,  under  any  circumstances,  extends  in  depth,  there  is 
always  serious  danger  of  perforation.  Mere  perforation  and  loss  of  the  aqueous 
Immor,  in  itself,  is  not  a  dangerous  termination.  It  is  often  to  be  desired 
and  aided,  rather  than  dreaded,  as  it  is  generally  the  turning  point  towards 
recovery.  But  if  great  care  be  not  taken  to  avoid  sudden  perforation  under 
pressure  of  the  surgeon's  fingers,  or  spasmodic  contraction  of  the  eyelids,  a 
liernia  of  the  iris  will  take  place,  with  great  increase  in  the  immediate  and 
remote  danger  to  vision.  As  the  cornea  retains  its  natural  curvature  and 
position  after  loss  of  the  aqueous,  the  lens  is  ^  pushed  forwards,  carrying 
the  iris  before  it,  till  its  convex  surface  rests  against  the  cornea  and  the  an- 
terior chamber  is  obliterated.  If  the  perforation  be  large,  sudden,  and  violent, 
not  only  extensive  prolapsus  of  the  iris  may  take  place,  but  the  capsule  may 

1  See  Vol.  II.,  page  459,  Figs.  .3.39-344. 


622 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


burst,  and  the  lens  be  extruded  from  the  eye,  followed  by  vitreous.  This,  of 
course,  is  destructive  to  vision.  A  hernia  of  the  iris,  however  recent  and 
limited,  cannot  often  be  reduced,  even  by  the  most  prompt  and  skilful  man- 
agement. If  not  reduced,  permanent  distortion  of  the  pupil,  more  or  less 
damage  to  sight,  and  indelible  opacity  of  the  cornea  with  synechia  anterior ; 
danger  of  partial  staphyloma  of  the  cornea,  of  chronic  glaucoma,  and  of 
hydrophthalmic  enlaro;ement  of  the  eye ;  repeated  relapses  of  iritis  and  cho- 
roiditis ;  and  finally  danger  to  the  other  eye  from  sympathetic  ophthalmia, 
will  follow.  Hence  the  vast  importance  of  preventing  prolapsus  and  saving 
the  eye  with  the  least  possible  damage  to  the  sight.  If  the  perforation  is 
limited  and  central,  the  iris  is  much  less  likely  to  prolapse  than  when  the 
ulcer  is  seated  at  or  near  the  periphery. 

There  is  likewise  a  form  of  keratitis  called  neuro-paralytic,  due  to  paralysis 
of  the  sensory  branches  of  the  fifth  pair  of  nerves.  In  this  case  the  cornea 
becomes  insensible  to  the  touch,  and  does  not  feel  the  presence  of  foreign 
particles.  Its  surface  becomes  dry  from  long  and  unconscious  exposure  to 
the  air ;  inflammation,  sloughing,  and  ulceration  take  place ;  and  the  eye  is 
rapidly  destroyed.  This  disease  is  not  as  much,  if  at  all,  due  to  the  trophic 
influence  of  the  corneal  nerves  as  to  the  cornea's  unfelt  exposure.  In^  cases 
where  the  corneal  sensibility  is  not  entirely  destroyed,  the  pain  in  this  dis- 
ease may  be  intense : — 

On  April  9,  1878, 1  was  consulted  by  a  lady,  54  years  old,  laboring  under  this  disease 
of  the  cornea.  When  19  years  old  she  had  had  a  "  wen  "  removed  from  the  left  brow. 
It  seems  that  the  surgeon  in  stitching  the  skin  injured  the  supra-orbital  nerve,  or  one  of 
its  important  branches.  She  felt  it  "  all  over  her"  at  the  instant.  Total  loss  of  feel- 
ing followed  in  the  left  forehead  and  eye.  This  lasted  perhaps  ten  years,  when  partial 
sensibility  returned  and  thus  remained.  There  is  now  a  linear  cicatrix  beginning  3  cm. 
from  the  median  line,  and  1  cm.  above  the  brow,  and  running  parallel  with  it.  At  the 
time  of  her  visit  she  was  suffering  with  severe  pain  in  and  around  the  eye,  and  a  very 
distressing  feeling  of  numbness."  Tension  Httle,  if  at  all,  altered.  She  declared  that 
the  sight  was  abolished,  but  could  not  bear  the  use  of  the  ophthalmoscope.  There  was 
a  small  ulcer  a  little  outwards  from  the  centre  of  the  cornea,  with  some  filamentous 
adhesions  of  the  margins  of  the  pupil  to  the  lens  capsule.  The  whole  left  side  of  the 
face  and  eye  showed  partial  ansesthesia.  I  treated  her  with  occasional  use  of  atropia, 
compress  and  bandage,  and  repeated  paracenteses  of  the  cornea,  making  thirty  in  all, 
at  intervals  of  one  or  two  days.  She  recovered  at  last,  with  fair  vision,  and  has  con- 
tinued well ;  but  the  imperfect  feeling  remains  as  before  the  attack  of  keratitis.  A 
small  crescentic  opacity  of  the  cornea,  opposite  the  outer  edge  of  the  pupil,  is  all  that 
remains  visible  now. 

The  destructive  inflammation  of  the  cornea  that  comes  on  in  low  cases  of 
typhoid  fever,  with  comatose  symptoms,  and  in  meningitis  and  other  exhaust- 
ino-  diseases  which  are  nearing  their  fatal  termination,  is  due  to  the  same  cause, 
and  may  be  often  prevented  by  keeping  the  eyes  closed  and  moist.  The  same 
precautions  should  be  taken  to  protect  the  eyes  in  their  extreme  protrusion 
in  Basedow's  disease,  where  sloughing  of  the  cornea  is  the  sad  result  in  so 
many  cases.  Here  it  is  due  simply  to  inability  to  close  the  lids  and'  protect 
the  eye. 

I  have  already  described  the  corneal  troubles  which  are  due  to  conjuncti- 
vitis and  to  granular  lids,  and  the  lesions  which  so  often  follow. 

Treatment  of  Keratitis.— Yirst,  let  us  consider  those  secondary  forms  that 
come  on  in  the  course  of  acute  attacks  of  conjunctivitis.  In  severe  cases  of 
catarrhal  conjunctivitis,  with  photophobia,  weeping,  ciliary  injection,  and 
more  or  less  severe  pain,  this  is  the  complication  to  be  dreaded  and  guarded 
against.  Sulphate  of  atropia,  four  grains  to  the  ounce,  should  be  freely 
dropped  into  the  eye  from  three  to  six  times  a  day.    In  robust  subjects,  cold 


DISEASES  OF  THE  CORNEA. 


623 


compresses,  often  changed,  and  persevered  in  during  the  acute  stage,  are 
nearly  always  beneficial.  Moderate  purgation  in  the  beginning,  and  full 
doses  of  anodynes  at  night,  will  aid  greatly  in  controlling  the  disease,  ^^"o 
astringent  or  irritating  applications  to  the  eyes  should  be  allowed,  as  long  as 
the  intolerance  of  light,  weeping,  and  ciliary  injection,  are  at  all  pronounced. 
They  always  do  harm,  and  greatly  increase  the  danger  to  the  integrity  of  the 
cornea.  If  the  patient  is  feeble  and  anaemic,  good  nutritious  diet  and  tonics 
are  the  safest  constitutional  remedies.  In  such  persons  warm  applications 
are  better  borne,  and  dry  absorbent  cotton  and -the  bandage,  with  occasional 
cleansing  of  the  eyes,  will  be  most  grateful  and  satisfactory.  When  the 
local,  anodyne,  and  other  cooling  and  soothing  treatment  has  been  continued 
some  days  or  weeks,  till  the  dread  of  light,  weeping,  spasm  of  the  lids,  and 
all  injection  of  the  sclera,  especially  above  the  cornea,  have  passed  away,  then 
a  change  to  prudent  stimulation  may  be  thought  of.  The  patient  now  opens 
the  eye  in  the  light.  It  weeps  little  if  any,  and  there  is  a  more  abundant  se- 
cretion of  mucus  or  muco-pus.  Biborate  of  sodium  five  grains  to  the  ounce, 
alum  two  grains,  sulphate  of  zinc  or  sulphate  of  copper  one-half  grain,  dropped 
into  the  eyes  freely  twice  a  day,  will  be  well  borne  and  will  do  good.  A  solu- 
tion of  boracic  acid  ten  grains  to  the  ounce,  being  unirritating,  may  be  used 
earlier,  or  even  from  the  start. 

Should  a  relapse  of  keratitis  occur,  the  employment  of  these  astringents  must 
be  suspended,  and  the  use  of  atropine,  and  other  soothing  remedies,  must  be 
recommenced.  Should  purulent  infiltration  and  ulceration  ensue,  the  atro- 
pine and  boracic  acid  must  be  used  more  frequently.  If  ulceration  take  place, 
near  the  margin  of  the  cornea^  with  threatened  perforation,  it  is  wise  to  omit 
the  mydriatic  in  favor  of  eserine,  to  contract  the  pupil,  make  the  iris  rigid, 
and  prevent  extensive  prolapsus.  On  the  contrary,  where  the  seat  of  threat- 
ened perforation  is  central,  the  pupil  should  be  kept  fully  dilated,  as  the  best 
safeguard  against  prolapsus.  In  case  the  ulcerative  process  is  attended  by 
great  pain,  with  or  without  hypopium,  a  careful  paracentesis  of  the  cornea 
shoukl  be  tried,  in  preference  through  the  thinned  bottom  of  the  ulcer,  and 
the  aqueous  humor  carefully,  but  completely,  evacuated.  For  fancied,  theoret- 
ical reasons,  some  would  advise  eserine  exclusively,  in  all  cases  of  ulceration 
and  infiltration  of  the  cornea  ;  but  it  is  objectionable,  because  it  greatly 
increases  the  danger  of  iritis  and  its  consequences,  always  present  in  such 
emergencies.  If  there  is  increased  intra-ocular  tension,  hypopium,  and  great 
suffering,  nothing  is  so  prompt  and  sure  as  the  free  use  of  atropine  and  para- 
centesis. If  the  edges  of  the  ulcer  are  infiltrated  and  undermined,  showing 
rapid  lateral  spreading,  these  same  expedients  may  be  followed  by  cauteri- 
sation of  the  sloughing  edges  with  carbolic  acid.  A  small  probe  or  hard- 
wood toothpick,  dipped  in  the  acid,  should  be  rapidly  swept  around  under 
the  necrotic  tissues,  rendering  them  white,  acting  as  a  prompt  antiseptic, 
and  arresting  the  destructive  process..  For  many  years  I  have  been  using  the 
acid  in  this  way,  with  increasing  satisfaction.  If  anything  can  save  an  eye 
from  total  destruction  in  hypopium  or  infectious  keratitis,  it  is  the  use  of 
this  remedy,  repeated  once  or  twice  a  day,  following  Saemisch's  free  corneal 
incision,  which  is  made,  in  such  cases,  w^ith  a  Graefe's  cataract  knife.  The 
patient  being  under  ether,  and  the  eye  fixed,  the  knife  is  passed  through  the 
cornea,  near  one  edge  of  the  ulcer,  carefully  pushing  the  point  behind  the 
ulcerated  spot  and  making  the  counter-puncture,  the  edge  presenting  for- 
wards, on  the  other  side.  Then  by  pushing  the  knife  slowly  and  gently 
forward,  the  width  of  the  ulcerated  portion  is  split.  The  aqueous  escapes 
with  the  shreds  of  lymph  from  the  chamber,  and  complete  relief  of  tension 
follows.  ^  If  tough  shreds  hang  in  the  incision,  they  may  be  drawn  out  wdth 
small  iris  forceps.    Once  a  day  afterwards,  the  lips  of  the  cut  are  opened 


624         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

carefully  with  a  probe  or  the  probe-eud  of  a  Weber's  stricture  knife  and  any 
ZheriL  aqueous  is  allowed  to  escape.  The  eye  should  then  be  bandaged 
I'th  c"rf olized  or  borated  cotton,  and  opened  f-f  t^^^J^. j^f '^S^" 
tion,  for  the  carbolic  application  if  needed,  and  tor  the  tapping  of  the  chamber. 
Carbolic  acid  used  in  the  same  way,  before  or  after  simple  paracentesrs  re- 
peated cleansing,  continued  use  of  cold  water,  atropine  and  boracic  acid  solu- 
Ss  with  freelncisionof  the  outer  commissure  to  relieve  pressure  upon  the 
ball,  combined  with  the  proper  treatment  of  the  purulent  conjunctivitis,  are 
the  best  means  of  saving  the  cornea  in  that  dreadful  disease. 

In  the  management  of  phlyctenular  keratitis,  attacking  as  it  always  does 
delicate,  scrofulous  children,  great  importance  attaches  to  the  h/f  em«  ^^'Yai^ 
tions  of  the  patient.    The  child  must  have  good  nutritious  food  at  regular 

intervals,  and  no  cramming  with  trash  t-etY-'^.r      1.1  ,^.bbed^  "ft  must 
bathed  once  a  day  with  tepid  water,  and  the  skm  thoroughly  rubbed,  it  must 
be  dragged  fron/its  burrow  in  the  dark,  and  carried  forcibly  out  in  the  tresh 
ai>  fof  In  hour  or  two  twice  a  day.    It  must  not  be  allowed  to  bury  its  face 
and  heat  up  its  eyes,  and  the  room  is  to  be  only  moderately  darkened  and  is 
to  be  kept^well  4nrilated.    It  will  add  greatly  to  the  child's  comfort  and 
relieve  its  photophobia,  to  bathe  its  face  thoroughly  sevei-al  times  a  day  with 
very  cold  water.'  Immersing  the  face  in  a  basin  o  iced  water  several  times 
in  succession,  has  a  wonderful  influence  in  controlling  the  spasm  of  the  hd^ 
and  enabling  the  child  to  open  its  eyes  in  the  light.    .Any  e-e— 
patches  of  the  lids  and  nose,  and  fissures  at  the  outer  commissure  of  the  hds 
ZsPbe  cleansed  with  soap  and  water,  dried  thoroughly,  and  h^ely  brushed 
with  a  twenty-grain  solution  of  nitrate  of  silver  once  a  day  till  cured,  in- 
wardly, quinia,  two  grains  three  times  a  day,  for  a  child  five  years  old,  has  a 
marked  effect  in  controlling  the  photophobia.    It  may  be  kept  up  several 
we  ks,  if  necessary,  and  folfowed  by  a  long  course  of         "^oses  of  iron,^^ 
syrup  of  the  iodide  being  one  of  the  best  preparations    Locally,  atropine  may 
be  fiely  used  from  the  start,  and  kept  up  lor  several  weeks,  or  Ull  the  chiW 
opens  its  eyes  freely  in  the  light.    Combined  with  it,  or  separately,  a  solution 
of  boracic  Lid  is  beneficial.  ^Bo  astringents  of       kind  must  be  used  in  the 
acute  stages.    In  a  child  from  five  to  ten  years  old,  a  so  ution  ot  two  giams 
Tf  sulphate  atropia  in  an  ounce  of  water,  must  be  ^-¥^3^-^  he  eye 
three  or  four  times  a  day,  taking  great  pains  to  forcibly  ope"  ^h^  'ds 
fi-»t  it  in  thoroughly.    Care  must  be  taken  in  the  struggle  to  do  this,  not  to 
i;*;  o  let  the  lash  run  into  the  mouth.    The  best  way  is  to  ay  the  child 
backwards,  across  the  nurse's  lap,  and  to  take  its  head  between  the  urgeon^^ 
knees,  face  upwards.    Then  pull  the  lids  well  open,  and  ^PP^y  ^^e  wash  fieely 
When  the  photophobia  is  relieved,  a  weaker  solution  may     ™ed  and  l^^^^^ 
often,  till  it  is  finally  omitted.    The  greater  the  intolerance  of  li|ht  the  mo  e 
urgent  the  use  of  atropia,  and  the  less  danger  of  any  poisonous  f  ects  Whe.e 
the  phlyctenular  process  persists,  and  perhaps  keeps  PH^1>'°? 
fonn  of- a  band,  more  towards  the  centre  of  the  cornea  in  ^K*^     f ~ 
ment,  I  again  resort  to  the  local  use  of  carbolic  acid     The  .oftending  Pat^^^ 
band  in  the  cornea,  is  usually  seen  covered  with  a  dirty-grayish,  necrotic  ™^ 
Holding  the  child's  head  firmly  between  the  knees,  as  before,  and  fepaiat  ng 
the  lids^well.even  using  an  elevator  so  as  to  expose  tlie  cornea  fully 
may  be  used  to  freely  scrape  oft' this  sloughing  epithelial  t^«™e  ^nd  even  t<>  boie 
out  the  phlyctenula.    Then  with  the  same  spud,  or  a  small  P''?^^  ^^e  acid  is 
applied,  limiting  this  carefully  to  the  necrotic  portion,  turning  'tj™'  !^^^^^ 
then  washing  it^'witb  a  few  drops  of  cold  water.   This  is  done  «  ^e  a  daj ,  con 
tinning  the  local  use  of  the  atropine    It  is  wonderful  hovv  qu'f  li  *;'e  « 
treme  symptoms  in  such  cases,  may  be  thus  overcome.    The  necrotic  t^sue 
with  too  little  life  to  live  and  too  nmch  to  die,  in  the  troublesome  keratitis 


DISEASES  OF  THE  CORNEA. 


625 


following  smallpox,  may  be  treated  in  the  same  way,  Avitli  warm  fomentations 
in  addition,  atropine,  and  tonics,  with  good  diet.  In  phlyctenular  keratitis, 
after  the  intolerance  of  light  is  overcome  and  all  the  acute  symptoms  have 
abated,  the  atropine  should  be  omitted,  and  gentle,  local  stimulation  employed. 
By  general  consent,  the  local  use  of  pure,  finely  powdered  calomel,  dusted  on 
the  cornea  once  a  day,  is  the  best  means  of  clearing  oft'  tlie  remaining  oi)aci- 
ties.  If  the  child  is  not  timid,  the  powder  may  be  driven  suddenly  on  to 
the  cornea  by  tapping  the  brush.  In  case  it  is  refractory,  its  head  may  be  held 
between  the  knees,  as  in  using  the  eye-water.  If  this  treatment  acts  well,  it 
should  be  continued  for  weeks  and  months,  till  all  corneal  traces  have  cleared 
away.  Weak  astringents,  excepting  the  acetate  of  lead,  may  be  used  for  the 
same  purpose,  dropped  into  the  eye  once  a  day.  Of  course  the  iron  and 
other  tonics,  cod-liver  oil,  malt,  etc.,  with  good  diet,  should  be  continued  for 
months  after  the  child  is  seemingly  well.  Otlierwise  the  disease  will  recur. 
For  convenient  local  use,  the  calomel  may  be  applied  in  the  form  of  a  salve 
with  vaseline,  one  grain  to  each  drachm. 

Syphilitic  jmrenehyincdo its  keratitis  must  be  treated  constitutionally  as  well 
as  locally.  The  dwarfed  figure,  old  and  leathery  face,  characteristic  teeth,  per- 
haps nodes  on  the  shins,  and  rheumatism  af  the  knee-joints,  can  hardly  be 
mistaken.  And  yet  the  worst  forms  of  scrofula  are  so  allied  to  syphilis  that 
their  difterential  diagnosis  is  by  no  means  easy.  It  seems  indeed  that  the  two 
diatheses  are  often  combined,  and  when  syphilis  and  scrofula  are  married  the 
offspring  cannot  be  happy  !  A  patient  resort  to  tonics,  good  food,  and  care- 
ful hygiene,  is  necessary  in  all  such  cases.  If  the  symptoms  are  such  as  to 
make  it  certain,  or  even  probable,  that  tertiary  syphilis  is  the  fundamental 
malady,  the  careful  use  of  mercurial  inunctions  and  free  administration  of 
iodide  of  potassium  must  be  added,  and  long  and  carefully  persisted  in,  if  a 
cure  is  expected.  As  iritis  is  often  associated  with  this  disease  of  the 
cornea,  the  free  use  of  atropia,  three  or  four  times  a  day,  is  indispensable. 
Local  stimulants  in  any  form  only  aggravate  the  disease  and  intensify 
the  danger.  Warm  fomentations,  or  poultices  often  renewed,  and  kept 
up  for  six  or  eight  hours  a  da}',  are  of  great  value.  It  is  often  a  source  of 
surprise,  to  see  how  well  such  cases  generally  recover  sight,  even  under  the 
most  hopeless  appearances.  But  the  treatment  will  be  long  in  every  case, 
with  occasional  relapses.  Rarely,  undue  hardness  of  the  globe,  pain,,  increased 
failure  of  vision,  and  other  evidences  of  secondary  glaucoma,  will  show  them- 
selves. In  that  case,  notwithstanding  the  presence  of  iritis,  the  atropia  must 
be  omitted.  Warm  applications,  long  continued,  and  eserine  two  or  three 
times  a  day,  must  now  be  the  main  reliance. 

Should  the  excessive  intra-ocular  tension  not  yield  in  a  few  days  to  the 
eserine,  an  iridectomy  must  be  tried.  In  the  case  of  a  girl  fourteen  years 
old,  with  this  form  of  keratitis  in  both  eyes,  glaucomatous  hardness  was  de- 
tected in  one  eye,  and  iridectomy  proposed  for  the  next  day.  In  the  mean 
time,  a  solution  of  two  grains  of  eserine  in  an  ounce  of  water  was  instilled 
every  six  hours.  When  the  time  came,  the  hardness  was  reduced  and  no 
operation  was  necessary.  In  some  very  malignant  cases  of  this  affection,  the 
corneal  infiltration  leads  to  a  sort  of  sclerosis  and  tendinous  opacity  of  the 
entire  cornea.  In  an  instance  of  this  sort,  recently,  in  a  little  girl  of  eight 
years,  with  increased  tension  and  pupillary  membranes  in  both  eyes,  I  prac- 
tised a  double  iridectomy,  as  a  last  resort.  Some  months  after,  the  eyes 
began  to  improve  slowly,  and  the  girl  now  has  useful  and  improving  vision. 

Following  ulcerative  destruction  of  the  cornea,  two  changes  may  occur: 
ene,  flattening,  with,  more  or  less  diminution  of  the  globe  in  "size ;  the  other 
protrusion  with  enlargement,  csiWed  staphyloma.  If  most  of  the  cornea  has 
been  destroyed,  w^ith  sudden  perforation,  and  loss  of  the  lens  and  part  of  the 

VOL.  IV.— 40 


626 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


vitreous,  the  former  is  likely  to  be  the  result.    Where  the  lens  is  not  ex- 
truded, the  cicatricial  tissue,  composed  of  the  blended  remains  of  the  cornea 
and  iris,  is  likely  to  yield  slowly  to  the  pressure  from  within,  and  show  an 
unsightly  prominence.    The  deformity  and  inconvenience  of  a  corneal  staphy- 
loma vary  much  in  different  cases.    If  neither  be  very  great,  the  patient  may 
be  let  alone,  and  watched.    If  the  deformity  be  unsightly,  and  especially  if 
the  protrusion  be  constantly  inflamed  and  painful,  surgical  interference  is 
demanded.     Should  the  whole  globe  be  enlarged  and  seriously  altered,  the 
eye  being  a  constant  source  of  pain  and  danger,  enucleation  will  be  safest. 
But  if  the  changes  are  confined  to  the  corneal  region,  the  back  portion  of  the 
globe  being  natural  in  appearance  and  size,  the  staphylomatous  portion  may 
he  removed.    Thus  the  eye  will  be  reduced  in  size,  and  the  patient  enabled  to 
wear  an  artificial  eye.    I  prefer  a  reduced  stump  like  this,  to  the  small  mova- 
ble button  only,  that  remains  after  enucleation.    But  in  either  case,  an  eye 
can  be  worn  with  comfort  and  great  benefit  to  the  personal  appearance.  The 
easiest  and  best  operation  in  such  a  case,  is  simple  ablation.    The  patient 
lies  on  his  back,  and  does  not  often  require  ether.    The  lids  are  separated  by 
the  fingers  of  an  assistant,  or  by  the  stop-speculum,  the  eye  is  fixed  by  stout 
forceps,  and  the  desired  portion  removed  by  a  Beer's  cataract  knife.  The 
tumor  being  transfixed  from  temple  towards  nose,  with  the  edge  of  the  knife 
held  upward,  rapid  movements  are  made  to  finish  a  regular  flap  above.  Then, 
seizing  this  flap  quickly  with  toothed  forceps,  the  knife  is  turned,  and  the 
removal  finished  below.    Of  course  the  lens  escapes,  and  a  gush  of  vitre- 
ous follows,  before  the  knife  is  reversed.    But  the  section  must  be  completed 
quickly,  the  lids  instantly  closed,  and  a  cold  compress  applied  by  a  rather  firm 
bandao-e.    Otherwise  hemorrhage  may  take  place  from  the  bottom  of  the  eye, 
pushing  out  the  remains  of  the  vitreous,  and  may  be  followed  by  suppurative 
elimination  and  extreme  atrophy  of  the  stamp.    Several  ingenious  methods 
have  been  practised,  in  which  the  conjunctiva  is  stitched  to  close  up  the 
opened  cavity.    But  this  causes  delay,  and  does  not  leave  as  regular  a  stump 
for  the  glass  eye  as  a  well  executed,  simple  ablation.    The  closed  lids,  with 
pressure  kept  up  for  a  few  days,  secures  a  good  result.    In  old  persons,  with 
appearances  that  indicate  danger  of  hemorrhage,  enucleation  is  safer,  and 
the  result  more  prompt.    (Plate  XXYII.,  Fig.  5,  represents  a  well-marked 
case  of  .the  form  of  staphyloma  known  as  buphthalmus.) 

A  word  as  to  fvothesis.  The  patient  nearly  always  wants  a  larger  eye  than 
he  ouo-ht  to  wear.  After  enucleation  of  a  much  and  long  enlarged  eye,  there 
is  an  immense  cavity,  and  the  wearer  thinks  that  this  ought  to  be  filled  out 
even  with  the  other  eye.  It  cannot  be,  without  glassy  staring,  and  immobil- 
ity and  discomfort.  The  artificial  eye  should  always  be  smaller  than  the  other, 
allowing  easy  closure  of  the  lids  over  it.  It  is  seldom  that  the  same  eye  can 
be  worn  more  than  twelve  or  eighteen  months  with  comfort  and  safety.  It 
corroded  on  its  surface  or  edges,  irritation,  slow  adhesions  of  the  lids  to  the 
stump,  and  contraction  of  the  space  will  follow,  till  no  eye  at  all  can  be  borne. 
An  atrophied  eye,  with  the  clear  cornea  preserved,  will  very  seldom  tolerate 
an  artificial  substitute,  and  wearing  it  may  give  rise  to  sympathetic  oph- 
thalmia. Dense  leucoraa  of  the  cornea,  in  an  eye  of  natural  size  and  tree  trom 
irritation  or  increased  tension,  may  be  greatly  improved  in  appearance  by 
taftooivq.  This  is  done  with  pure  India  ink,  and  generally  requires  to  be 
repeated  two  or  three  times,  to  secure  sufficient  staining  The  patient  lies  on 
his  back,  with  his  eyelids  well  propped  open,  and  the  fluid,  brushed  on  the  part 
to  be  stained,  is  pricked  in  very  thoroughly  with  the  tattooing  needles.  Ihe 
ink  is  applied  repeatedly,  and  the  needles  used,  till  the  coloring  is  satis- 
factory   V hen  done,  the  cornea  is  left  exposed  for  some  minutes  till  it  dries. 


DISEASES  OF  THE  IRIS. 


627 


Little  irritation  follows,  and  the  cosmetic  process  may  be  repeated,  at  intervals, 
till  the  end  is  gained.  If  not  a  source  of  pain  and  danger  to  the  other  eye, 
:and  presentable  in  looks — or  if  it  can  be  made  so — I  much  prefer  to  preserve 
the  natural  eye.  Artificial  eyes  are  an  endless  source  of  trouble  and  expense, 
and  few  persons  are  so  prudent  as  to  be  able  to  wear  them  at  all,  for  many  years. 

Diseases  of  the  Iris. 

Malformations  of  the  Iris. — Among  malformations  of  this  part  may  be 
especially  mentioned  the  affection  known  as  coloboina  iridis^  or  congenital  fis- 
sure of  the  iris,  and  that  known  as  multiple  pupil,  of  which  a  remakable 
example,  involving  both  eyes,  is  illustrated  in  Plate  XXYII.,  Figs.  3  and  4. 

Iritis. — Remembering  the  delicacy  and  wonderful  activity  of  the  iris,  we 
are  not  surprised  to  find  it  the  seat  of  frequent  inflammation.  Iritis  may  run 
an  acute  course,  or  may  appear  in  a  slow  and  insidious  form. 

Symptoms. — These,  in  most  cases,  are  so  sharp-cut  and  characteristic,  that 
a  false  diagnosis  is  inexcusable.  And  yet  how  often  is  this  disease  pronounced 
"  sore  eyes,"  and  treated  with  nitrate  of  silver,  till  hopeless  closure  of  the 
pupil  takes  place  !  While  iritis  yields  to  timely  and  intelligent  treatment, 
with  great  certainty,  nothing  can  be  more  fatal  than  such  a  mistake  of 
diagnosis.  Severe  and  somewhat  paroxysmal  pains  in  the  eye  and  face,  too, 
are  attributed  to  simple  neuralgia,  with  serious  delay  in  the  recognition  of 
the  true  malady.  Hence  the  vital  importance  of  a  speedy  and  correct 
diagnosis.  The  objective  symptoms  are  discoloration,  loss  of  the  natural  bril- 
liancy of  the  iris,  as  well  as  of  its  fibrous  appearance,  sluggishness  of  the 
pupil,  and  finally  adhesions  to  the  capsule  of  the  lens,  synechia  posterior. 
The  changed  color,  depending  much  upon  the  original  color  of  the  iris,  is 
explained  by  the  increased  amount  of  blood  in  its  texture,  and  the  extra- 
vasated  elements.  When  but  one  eye  is  aftected,  the  color  contrast  and  differ- 
ence in  the  activity  of  the  pupils  will  be  striking.  Sometimes  the  occurrence 
of  inflammatory  nodules,  near  the  pupillary  margin  or  elsewhere,  will  attract 
attention.  There  is  no  one  symptom,  or  group  of  symptoms,  that  is  so 
pathognomonic  of  syphilitic  iritis  as  these  gummy  formations.  Hypopium  is 
not  very  infrequent,  but  is  oftener  detected  in  ulcerations  of  the  cornea,  par- 
ticularly when  deep  and  threatening  perforation.  A  pinkish  zone  of  injec- 
tion around  the  cornea,  fading  in  intensity  towards  the  equator  of  the  eye,  is 
another  constant  symptom  of  acute  iritis.  Kow  and  then  inflammatory 
cheraosis,  and  extravasations  of  blood  over  the  sclerotic  conjunctiva,  are  seen, 
and  indicate  an  intense  form  with  probable  panophthalmitis.  There  is  always 
some  impairment  of  vision,  and  often  a  very  serious  one,  capable  of  being 
demonstrated  objectively  by  the  type  tests.  Blurring  of  sight  is  due  to 
cloudiness  of  the  aqueous  humor,  deposits  in  the  pupil,  and  sometimes  to 
turbidness  of  the  vitreous,  due  to  complicating  choroiditis.  Indeed,  it  often 
happens,  that  optic  neuritis  or  neu]'o-retinitis,"develops  with  an  iritis,  but  is 
overlooked. 

Subjectively,  the  patient  complains  of  intense  pain  in  and  around  the  eye, 
usually  aggravated  at  night,  or  by  lying  down.  These  severe,  circumorbital 
panis  are  characteristic.  Sometimes  the  pain  is  confined  to  the  eye ;  at  other 
times  it  is  exclusively  in  the  bones  around  ;  but  usually  it  is  in  both.  Photo- 
phobia and  weeping  are  not  strongly  marked  in  this  disease,  as  they  are  in 
keratitis.  The  sluggishness  of  the  pupil,  in  response  to  varying  degrees  of 
hght,  may  range  from  complete  immobility  to  but  slightly  diminished  motion. 
This  may  be  due  to  spasmodic  contraction  of  the  irritated  sphincter,  or  to 


628  INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

plastic  exudation,  or  to  both.  It  is  not  easy  to  tell,  by  simple  inspection, 
whether  adhesions  of  the  iris  to  the  lens  capsule  are  present,  and  to  what  extent. 
Hence  the  value  of  atropine,  in  the  diagnosis.  If  no  synechia  exists,  the  pupil 
will  dilate  circularly,  and  eventually  largely.  But  if  bound  down,  the  points 
of  adhesion  will  remain  fixed,  while  the  free  portions  dilate.  This  gives  the 
pupil  a  strikingly  irregular  form,  and  makes  their  presence  positive.  By  the 
use  of  atropine  and  oblique  illumination,  the  adhesions  can  be  seen  with  great 

satisfaction.  ^     .  .  .  mi.  ^ 

Iritis  is  practically  divided  into  plastic,  suppurative,  and  serous,  ihese 
forms  sometimes  exist  together.    The  plastic  is  distinguished  by  a  free  eftu- 
sion  of  lymph,  with  prompt  and  firm  adhesions  to  the  capsule,  and  talse 
membrane  in  the  pupil ;  the  suppurative  by  hypopium ;  the  serous  by  less 
marked  ciliary  injection,  less  pain  usually,  and  a  more  insidious  course.  Like- 
wise with  turbidness  of  the  aqueous,  and  dimmed  vision,  there  are  seen  gTOups 
of  minute,  dirty  points  of  precipitates  on  the  membrane  of  Descemet     I  hese 
are  best  seen  by  oblique  illumination,  and  through  a  magnifying  lens.  In 
serous  iritis,  there  is  often  an  associated  disease  of  the  ciliary  body  and  choroid, 
with  increased  tension  of  the  globe.    This  glaucomatous  hardness  is  a  very 
serious  complication,  and  the  surgeon  should  never  fail  to  search  for  it  every 
day     Its  possible  development  should  make  us  cautious  m  the  use  ot  atropine, 
which  increases  the  tension.   Its  actual  presence  forbids  atropine  altogether, 
and  calls  for  eserine,  which  diminishes  intra-ocular  pressure     When  this 
complication  arises  in  serous  iritis,  the  pupil  becomes  dilated  and  sluggish  but 
even  then  slio-ht  adhesions  with  the  capsule  may  form.    There  are  likely  to 
be  inflammatory  deposits  in  the  extreme  rim  of  the  anterior  chamber,  and 
peripheral  adhesions  between  the  iris  and  cornea,  with  obliteration  ot  1^  ontana  s 
spaces.    This  is  said  to  arrest  the  filtration  of  fluids  from  the  eye,  and  to  give 
rise  to  increased  tension.  .         ^  .       ^  ^  ^ 

In  sympathetic  ophthalmia,  serous  iritis  is  much  less  dangerous  and  more 
controllable  than  the  plastic  variety,  which  nearly  always  leads  to  blindness. 
The  so-called  condylomatous  variety  (gummatous)  is  nearly  always  s^^philitic 
There  may  be  but  one  nodule,  or  many.  If  numerous  and  large,  they  rest 
against  the  cornea,  and  completely  fill  the  anterior  ehamber,  as  I  have  seen 
in  a  few  cases.  They  are  always  permanently  glued  to  the  lens,  and  the 
iris-tissue  afterwards  undergoes  atrophy  to  a  high  degree.  Sometimes  hypo- 
pium is  associated  with  them,  and  may  rarely  be  the  result  of  an  abscess  ot 
the  iris  bursting  into  the  aqueous  chamber.  .       .-n  x  f^^,. 

In  the  etiology  of  iritis,  syphilis  is  by  far  the  most  prolific  cause.  Aftei 
this  come  the  Aeumatic  diathesis  and  scrofula.  Of  course  an  injury  may  occur 
and  produce  its  effect  in  any  constitution.  Iritis  from  injury  is  apt  to  be 
mildf except  when  irritated  by  a  traumatic  cataract,  or  by  a  foreign  body  in  the 
eve  As  a  syphilitic  disease,  iritis  usually  is  one  of  the  so-called  secondary 
manifestations.  It  may  be  present  with  ulcerated  throat,  eruptions  on  the 
skin,  and  falling  away  of  the  hair;  but  not  infrequently  it  precedes  all  of 
these  lesions,  while  in  other  cases  it  follows  them  at  some  distance.  Ihe 
presence  of  iritis  in  any  given  case  does  not  prove  the  existence  of  syphilis, 
but  should  always  awaken  thoughtful  inquiry. 

The  diagnosis  settled,  and  the  etiology  cleared  up  as  well  as  possible,  we 
inquire,  what  is  the  prognosis  of  iritis  when  left  to  itself?  Its  tendency  is  to 
recovery  but  with  permanent  adhesions  and  some  impairment  of  sight; 
besides,  any  remaining  synechia  increases  the  tendency  to  repeated  relapses 
and  to  final  destruction  of  vision,  giving  rise  at  a  later  period  to  choroiditis 

r^m£ro7jr  divides  itself  into  local  and  constitutional.  The 

mairM^cati^n,  of  course,  is  to  cut  the  disease  short,  if  possible,  and  save  the 


DISEASES  OF  THE  IRIS. 


629 


eye  from  permanent  lesions  and  their  consequences,  immediate  and  remote. 
The  chief  object  in  the  use  of  local  remedies  is  to  relieve  suffering  and  dilate 
the  pupil  fully,  so  as  to  prevent  adhesions  and  false  membranes.  The  mydria- 
tics must  be  used  promptly  and  heroically,  from  begimiing  to  end  of  the  treat- 
ment. If  the  pupil  can  be  dilated,  and  kept  so,  thus  preventing  adhesions — ■ 
or,  in  case  they  have  already  formed,  if  they  can  be  detached  and  kept  from 
reforming — a  great  point  is  gained  for  the  integrity  of  the  eye.  The  cheapest 
and  best  substance  of  this  class  is  the  sulphate  of  atropia.  It  may  be  used  for 
adults  in  a  four-grain  solution,  dropped  freely  into  the  eye  every  three  or  four 
hours,  or  every  hour  at  the  start,  till  the  pupil  is  freely  dilated.  The  only 
dano'er  from  its  free  use  is  constitutional  disturbance.  If  prevented  from 
entering  the  puncta  and  running  down  the  throat,  there  is  little  risk.  This 
is  done  b}^  drawing  the  lower  lid  a  little  from  the  eye,  and  holding  it  a 
few  minutes  after  each  application.  A  cloth  over  the  end  of  the  linger  is 
then  pressed  into  the  corner  to  remove  what  remains  of  the  atropia  solu- 
tion. The  frequency  of  application  should  depend  on  the  pain  and  the  resist- 
ance of  the  pupil.  As  soon  as  the  latter  yields  largely,  the  use  of  the 
atropia  may  be  less  frequent,  but  enough  to  keep  up  full  dilatation. 

The  pain  is  much  relieved,  and  the  relaxing  influence  of  the  atropine  has- 
tened, by  leeching.  Four  leeches  may  be  applied  to  the  temple,  or  side  of  the 
nose,  at  once.  Then,  as  fast  as  one  is  filled  and  falls  away,  another  may  be 
applied,  till  six,  eight,  or  ten  have  bitten.  The  bleeding  is  encouraged  by  warm 
fomentations.  The  leech  should  never  be  allowed  to  bite  on  the  loose  skin 
of  the  lids.  Of  course  the  eyeball  must  be  guarded  with  great  care.  I  prefer 
the  natural  leech  to  the  artificial,  or  to  the  ordinary  wet  cupping.  Still, 
Heurteloup's  artificial  leech,  applied  to  the  temple,  does  well.^  Loual  depletion 
is  not  generally  necessary,  but  expedites  the  cure,  when  used.  Cold  water 
applications  are  not  beneficial.  Warm  fomentations,  or  the  persistent  use  of 
warm  poultices,  in  the  obstinate  cases,  particularly  if  there  is  a  glaucomatous 
tendency,  are  often  of  great  benefit.  Of  course,  purgatives  in  the  beginning, 
and  at  times  afterwards,  with  free  anodynes  at  night  to  allay  pain  and  promote 
sleep,  are  valuable  antiphlogistics.  In  cases  of  patients  harassed  by  great 
pain,  with  resistance  of  the  pupil  to  the  action  of  leeches  and  atropine,  I 
have  often  given  immediate  relief  by  a  paracentesis.  If  preferred,  a  sub- 
cutaneous injection  of  morphia  may  serve  the  same  purpose,  but  it  has  not 
as  much  control  over  the  progress  of  the  disease.  I  often  anticipate  the 
use  of  leeches  by  the  paracentesis.  In  the  serous  variety,  atropine  must 
be  used  less  freely,  and  with  more  watchfulness,  omitting  it  at  once,  and 
resorting  to  eserine,  if  increased  tension  is  discovered.  In  such  emergencies, 
the  protracted  use  of  warm  poultices,  often  renewed,  does  great  good.  If  the 
glaucoma  resists  all  these,  a  paracentesis  should  be  tried,"and  then,  if  need 
be,  an  iridectomy.  Do  not  let  this  fatal  condition  run  on  \qvj  long.  If  the 
atropine  disagrees  or  proves  insufficient,  a  four-grain  solution  of  duboisia  is 
still  more  powerful,  but  more  care  is  needed  to  watch  against  its  general 
effects. 

Constitutional  treatment  is  directed  especialh^  to  the  diathesis  found  to  exist. 
In  the  rheumatic,  salicylate  of  sodium,  the  subcutaneous  use  of  pilocarpine, 
and  other  numerous  and  vaunted  remedies  for  rheumatism  may  be  tried. 
Great  attention  to  the  stomach,  kidneys,  and  cutaneous  function,  wnth  careful 
avoidance  of  exposure  to  cold,  is  required.  If  the  syphilitic  virus  is  present, 
mercury,  by  inunctions,  inwardly,  or  by  baths,  is  indispensable.  Following 
this,  or  from  the  start,  if  the  patient  is  deteriorated  in  blood  and  strength, 
the  iodide  of*  potassium  is  an  invaluable  remedy.    Some  form  of  general 


»  See  Vol.  I.  page  513,  Pig.  81. 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


treatment  should  be  kept  up  for  months,  to  prevent  relapses,  and  the  atra 
pine  ought  to  be  continued,  once  or  twice  a  day,  for  several  weeks  after  all 
local  symptoms  of  inflammation  have  ceased. 

If  extensive  synechia  results,  and  relapses  follow,  an  iridectomy  will, 
probably,  rescue  the  eye.    Should  the  pupil  be  closed  by  a  dense  false  mem- 
brane, and  all  communication  between  the  chambers  cut  off,  this  is  to  be 
done  at  once.    Still  greater  urgency  is  demanded  if  the  periphery  of  the  iri& 
has  bei2:un  to  bulge  forwards,  the  pupillary  area  being  drawn  back.  ^  In  syphi- 
litic intis,  the  constitutional  symptoms,  and  the  local  inflammation,  should 
be  well  controlled  before  doing  an  iridectomy,  as  otherwise  plastic  forma- 
tions will  again  close  the  pupil.  "  In  chronic  forms  of  iritis,  with  acute  relapses, 
an  iridectomy  is  often  a  valuable  antiphlogistic,  and  the  only  means  of  arresting 
the  disease.    But  there  is  room  for  great  discretion  in  deciding  that  such  an 
emergency  exists  as 'requires  iridectomy,  and  great  skill  is  needed  for  the 
execution  of  so  important  an  operation.  'People  are  always  ready  to  attribute 
the  most  absurd  and  remote  consequences  to  the  direct  action  of  a  surgical 
operation,  if  any  has  ever  been  performed.    Little  need  be  added  on  the 
method  of  this  operation,  to  what  will  be  found  under  cataract  and  glaucoma. 
I  much  prefer  the  Graefe  to  the  spear  knife,  especially  with  a  shallow  anterior 
chamber.    When  the  iris  is  free  from  all  adhesions,  and  its  tissue  not  rotten 
and  friable  from  disease,  the  operation,  after  the  incision,  is  very  easy.  ^  When 
adhesions  are  confined  to  the  pupil,  the  rest  of  the  iris  being  free,  no  difliculty 
is  usually  experienced  in  seizing  and  drawing  it  out.    But  the  entire  aggluti- 
nation of  the  posterior  surface  of  the  iris  to  the  lens  capsule,  makes  a  satisfac- 
tory iridectomy  almost  impossible.    In  such  extreme  cases  the  leiis  will  need 
to  be  extracted,  and  afterwards  the  tough  membrane,  composed  of  iris,  inflam- 
matory deposits,  and  lens  capsule,  should  be  freely  incised  with  Wecker  s 
mnce-ciseaiix}   Hopeless  as  seem  some  of  these  cases,  they  should  not  be  given 
up  till  such  thorough  operations  have  been  faithfully  tried.    Success  some- 
times crowns  a  desperate  effort. 

Tumors  of  the  Iris.— Tumors,  benignant  as  well  as  malignant,  sometimes 
develop  in  the  iris.    The  former,  when  not  too  large,  may  be  removed  with 
the  portion  of  iris  in  which  they  grow.    The  latter,  of  course,  demand  an  enu- 
cleation of  the  eye,  as  the  only  hope  for  life.   Among  the  former  are  rare  der- 
moid growths,  that  take  their  origin  from  rudiments  of  skin,  driven  m  and 
lodo-ed  on  the  iris  bv  injuries.    A  more  frequent  development  m  the  ins, 
always  following  an  injury,  is  a  cyst.    Plate  XXYII.,  Fig  2  represents  such 
a  2;rowth.    The  eye  had  been  injured  by  a  small  shot,  which  lodged  m  the 
iris.  After  long  years,  the  cyst  developed  and  grew  to  a  degree  that  destroyed 
the  sio-ht,  and  caused  great  suffering.    I  enucleated  the  eye,  and  in  making 
sections  for  microscopic  examinations,  the  shot  was  cut  through.   The  entire 
extent  of  the  cyst  wall  is  seen  in  the  illustration.   In  another  case,  m  a  boy  of 
nine  years,  the  cornea  had  been  injured  by  the  sharp  corner  of  a  piece  of 
slate     A  cyst  afterwards  grew  from  the  iris,  and  attained  a  large  size.  •  i 
removed  it  with  the  iris  from  which  it  grew,  but  in  a  few  months  another 
cyst  showed  itself.    This  was  also  extracted  in  the  same  way,  with  permanent 
relief,  ^nd  preservation  of  some  sight.    In  a  third  case,  I  extracted  a  cyst 
that  i  had  mistaken  for  a  lens  in  its  capsule,  luxated  into  the  anterior  cham- 
ber   I  made  quite  a  free  incision  in  the  cornea,  and,  finding  my  mistake,  re- 
moved the  cyst  and  iris,  as  usually  advised.    The  patient  recovered  promptly. 
Since  then  the  cyst  has  been  partially  reproduced,  but  seems  to  have  been 
obliterated  by  an  attack  of  inflammation,  and  now  appears  cured,  with  some 


»  See  Fig.  934. 


CATARACT. 


631 


vision.  Had  I  made  a  critical  examination  of  this  patient's  eye,  the  mistake 
could  have  been  avoided ;  but  the  operation  would  have  been  essentially  the 
same,  and  with  the  same  result.  The  eye  was  inflamed  and  painful,  and  the 
history  and  strong  resemblance  to  a  luxated  lens  led  me  to  operate  at  once. 

Cataract. 

The  most  striking  physical  property  of  the  refracting  media  of  the  eye,  is 
their  great  clearness.  VV^ithout  this,  neither  the  cornea,  the  crystalline  lens, 
nor  the  vitreous  could  act  as  image-producing  structures.  The  absence  of 
bloodvessels  in  them,  and  the  transparency  of  their  elementary  textures, 
secure  their  perfect  functional  action.  And  yet  they  are  vital,  animal  mem- 
branes, moulded  and  arranged  as  a  system  of  lenses.  Xutritive  changes  are 
constantly  going  on  in  them,  as  in  other  parts  of  the  body,  but  their  nutrition 
is  precarious  in  proportion  to  the  distance  of  their  source  of  supplies,  and  the 
difficulties  of  transportation.  The  wonder  is  that  their  lesions  are  so  rare. 
The  lenticular  system  is  composed  of  the  lens  proper,  the  inclosing  capsule, 
and  the  suspensory  ligament  by  which  it  is  held  in  place.  The  transparent 
capsule  closely  embraces  the  lens,  and  is  united  with  it  by  means  of  a  layer 
of  intracapsular  cells,  through  which  the  nutritive  changes  are  etfected  by  a 
sj^stem  of  endosmosis  and  exosmosis.  Of  course,  the  influx  and  efflux  of 
the  nutritive  fluids  must  be  through  the  capsule.  The  supplies  are  second- 
hand, from  the  vitreous  and  tlie  aqueous  humors.  Hence  morbid  changes  in 
the  chemical  composition  of  either  or  both  these  humors  may  afl:ect  the  nu- 
trition of  the  lens,  and  produce  cataract.  Their  supplies  also  come  from 
without,  the  aqueous  probably  being  secreted  by  the  bloodvessels  of  the  ciliary 
processes,  and  the  vitreous  mainly  from  the  choroidal  circulation.  Hence 
disturbances  in  the  free  circuit  of  fluids  through  the  capillaries  of  these  tissues 
may  indirectly  aflfect  the  lens  and  cause  cataract.  Then  again,  as  all  the 
tissues  are  fed  from  the  blood-,  an  abnormal  change  in  the  healthy  constituents 
of  this  pabulum  may  lead  to  disease  in  any  organ,  especiall}^  in  the  trans- 
parent and  bloodless  structures,  like  the  lens.  Finally,  the  daily  d^dng  of  the 
living  body,  that  begins  in  utero  and  ends  in  death,  i-esults  from  the  increasing 
stagnation  of  the  vital  currents,  with  the  progress  of  years. 

In  the  crystalline  lens,  the  gradual  changes  of  consistency,  from  hardening 
and  drying  of  its  textures,  are  indicated  by  the  progi'essive  failure  of  the 
accommodation  with  increasing  3'ears.  This  prepares  the  way  for  senile  cat- 
aract. In  childhood,  the  lens  is  soft  and  elastic,  yielding  in  form  to  the  deli- 
cate action  of  the  ciliary  muscle  in  focusing  for  very  near  objects;  but  this 
elasticity  is  slowly  lost,  till,  at  sixty  or  sixty-five  years  of  age,  no  power  of 
accommodation  is  left.  Presbyopia  then  is  due  to  pihysical  changes  in  the  lens, 
and  comes  to  all  as  age  advances.  But  its  inconveniences  diflfer  according  to 
the  refraction  of  the  eye. 

Suppose  the  subject  is  myopic  in  a  rather  high  degree,  say  one-eighth, 
which  means  that  his  farthest  point  of  distinct  vision  is  eight  inches  from  the 
eye.  In  boyhood,  by  voluntary  action  of  the  ciliary  muscle,  he  can  read,  and 
prefers  to  read,  at  three  or  four  inches,  his  nearest  point  of  easy  accommodation. 
As  he  grows  older  and  the  lens  hardens,  he  prefers  to  read  a  little  farther 
away.  The  near  point  thus  gradually  recedes  towards  his  far  point,  which 
it  reaches  when  he  is  fifty  or  sixty  years  of  age.  Then  he  reads  at  his  far 
point  (which  is  not  far),  eight  inches,  and  reads,  well  without  the  aid  of  glasses. 
His  range  or  power  of  accommodation  is  gone,  and  his  myopia  remaining  the 
same,  all  these  years,  with  the  same  imperfect  sight  for  distance,  the  failure 
of  focusing  for  near  objects  is  not  felt.    The  patient  even  imagines  that  his 


632 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


near-sightedness  has  improved  with  years,  because  he  reads  with  the  book 
farthei^away  now  than  when  young.  Actually  it  has  not,  and  he  now  needs 
a  negative  lens  'No.  8,  for  perfect  distant  sight,  as  always  before. 

Suppose  the  refraction  of  the  eye  is  emmetropic.  Then  the  patient  has  a 
range  of  accommodation,  say  from  three  inches  to  an  infinite  distance,  when 
young.  As  years  flow  on,  his  near  point  goes  away  towards  the  far  point, 
and  forty  or  forty-five  has  reached  ten  inches,  when  he  begins  to  feel  the 
need  of  glasses  to  read.  When  all  focusing  power  is  gone,  the  near  point  has 
gone  out  to  an  infinite  distance,  the  far  point  of  an  emmetropic  eye.  Such  a 
patient  must  have  magnifying  glasses  to  read,  but  sees  perfectly  in  the  dis- 
tance without  any  aids. 

Again,  let  us  suppose  that  the  refraction  is  hyj^erojnc.  In  emmetropes  the 
ciliary  muscle  is  at  complete  rest  in  all  but  close  work.  In  hyperopes  it  is 
always  on  a  strain,  except  when  the  eyes  are  shut,  as  in  sleep.  Now  yith 
years,  the  same  hardening  process  goes  on  in  the  lens,  and  the  near  point  re- 
cedes. Such  persons  often  need  convex  glasses  to  read  with,  even  when  young, 
because  the  strain  on  the  accommodation  is  excessive  and  fatiguing.  Presby- 
opia tells  on  them  much  earlier  than  on  emmetropes,  and  when  all  accom- 
modation is  o;one  at  from  forty-five  to  sixty  years  of  age,  the  sight  fails  for 
distant  as  well  as  for  close  objects,  and  they  see  badly  far  off  without  glasses, 
and  still  worse  near  at  hand.  Such  an  unfortunate  now  needs  two  pairs  of 
ma2:nifiers,  a  weaker  for  distance,  and  a  stronger  for  reading.  These  are  the 
three  ordinary  conditions  of  refraction,  two  of  them  anomalous,  and  one  perfect. 
Only  one  other  anomaly  exists,  and  that  is  astigmatism  in  its  two  forms,  hype- 
ropic  and  mvopic.  Correctible  astigmatism  is  due  mainly  to  irregularities  of 
curvature  in"  the  cornea,  and  hence  may  be  left  out  in  this  hasty  summary  of 
inconveniences  from  hardening  of  the  lens.  These  practical  observations  seem 
necessary  to  a  clear  understanding  of  the  pathology  of  cataract. 

While  cataract  is  seen  at  all  ages,  and  may  even  be  congenital,  it  is  much 
most  frequent  in  advanced  life.   The  natural,  nutritive  change  that  takes  place 
in  the  lens  of  an  elderlv  person,  supplies  a  good  soil  for  senile  cataract.    In  old 
people  the  nucleus  of  the  lens  is  large,  hard,  dry,  and  of  an  amber  color,  even 
when  clear.    Its  wear  and  repair  have  in  a  good  measure  ceased,  and  the 
nutritive  activity  of  even  the  cortical  lens  substance  is  very  sluggish.  ^  Hence, 
any  of  the  causes  that  bear  heavily  on  nutrition,  may  determine  senile  cata- 
ract.   While  any  one,  without  regard  to  parentage,  may  become  a  victim  of 
cataract,  still  there  is  a  strong  hereditary  predisposition  to  it  in  certain  fami- 
lies, which  shows  itself  in  the  young  as  well  as  in  the  old.    The  members  are 
attacked,  usually,  at  about  the  same  age.    The  etiology  of  cataract  is  often 
inscrutable.    The  hardening  and  drying  nucleus  of  old  people  is  supposed  to 
drive  out  its  quantum  of  water  into  the  softer  cortical,  producing  swelling  of 
its  lens  fibres  and  their  disorganization.    The  lens  is  then  supposed  to  give 
oif  its  soluble  albumen  freely lo  the  aqueous  humor,  and  to  absorb  from  it 
excess  of  water.    This  leads  to  the  swelling  of  the  lens  cortex,  in  the  progress 
of  cataract,  and  to  reduction  in  depth  of  the  anterior  chamber.  When  the  sub- 
stance of  the  lens  is  opaque  quite  up  to  the  capsule— when  the  cataract  is 
said  to  be  mature— a  partial  absorption  of  the  softened  cortical  takes  place, 
and  the  chamber  deepens.    If  this  process  has  gone  on  for  years,  the  capsule- 
comes  to  embrace  a  hard,  dry  nucleus,  and  adheres  to  it  as  if  it  were  waxed. 
We  call  it  then  a  hypermature  cataract.    Simultaneously  with  beginning 
senile  cataract,  patients  often  become  myopic.     Those  that  were  myopic 
before  the  changes  in  the  lens,  become  more  so.    This  is  doubtless  due  to  the 
swelling  of  the  lens  during  the  cataractous  alterations.    Old  people  who 
find  themselves  laying  aside  their  reading  glasses  for  weaker,  or  even  reading 
without  any,  have  become  myopic.    In  proportion  as  they  acquire  "  second 


CATARACT. 


633 


sight"  for  reading,  they  see  worse  in  the  distance.  Concave  glasses  then  help 
them  to  see  remote  objects  better,  as  they  do  with  any  myope.  In  many  or 
most  of  these  cases,  there  will  be  found  incipient  cataract,  and,  not  mfre- 
quently,  floating  corpuscles  in  the  vitreous,  showing  disturbed  nutrition  from 
choroidal  irritation. 

Congenital  Cataract.— So-called  cases  of  congenital  cataract  doubtless 
often  beo;in  very  soon  after  birth,  and  before  the  infant  shows  any  indication 
of  how  It  sees.  Congenital,  or  early  infantile  cataract,  may  be  partial  or 
complete.  The  partial  embraces  two  varieties,  the  polar  and  the  lamellar. 
The  volar  is  nearly  always  at  the  anterior  pole  of  the  lens.  There  is  seen  a 
small,  round,  whitish  opacity,  in  or  near  the  centre  of,  and  just  withni,  the 
anterior  capsule.  When  the  anterior  polar  cataract  is  large  and  prominent, 
projecting  beyond  the  plane  of  the  pupil  into  the  anterior  chamber,  it  is  called 
pyramidal.  It  was  once  thought  that  these  opacities  were  deposits  on  the 
outer  surface  of  the  capsule.  But  the  whole  mass  is  within  the  capsule,  which 
is  pushed  forwards.  The  pathology  of  these  cases  is  simple :  they  can  gener- 
ally be  traced  to  the  same  cause,  tliat  is,  perforation  of  the  cornea,  though  in 
very  rare  instances  they  cannot  be  explained  in  this  way.  In  ophthalmia  neona- 
torum, central  and  limited  ulceration  and  perforation  of  one  or  both  corneee, 
take  place.  The  aqueous  escaping,  the  anterior  capsule  comes  against  the 
cornea,  and  is  agglutinated  to  it.  When  the  aqueous  is  again  retained,  and, 
the  chamber  re-established,  the  two  surfaces  are  separated  aiid  the  adhesion 
severed.  By  some  means  this  temporary  union  causes  proliferation  of  the 
intracapsular  cells,  and  a  limited  and  stationary  opacity.  Most  frequently  a 
small  corneal  opacity  may  be  detected,  indicating  the  seat  of  the  perforation, 
and  oblique  illumination  will  nearly  always  reveal  it._  Of  course,  the  history 
of  purulent  conjunctivitis  will  help  to  clear  up  the  diagnosis. 

Lamellar  cataract  {Schichtstaar ,  of  Jaeger)  begins  in  very  early  life,  and 
presents  such  marked  characteristics  that  it  can  hardly  be  mistaken.  It 
corresponds  to  the  axis  of  the  lens,  and  hence  centres  with  the  pupil.  The 
sharply  defined,  circular  opacity  of  the  lens  may  be  less  or  larger  than  the 
avera2:e  size  of  the  pupil.  It  has  a  dull-grayish  look,  and  by  a  careless  exanii- 
nation  mio:ht  be  supposed  to  involve  the  entire  lens.  Dilatation  of  the  pupil, 
and  oblique  illumination,  will  show  at  once  what  it  is.  While  the  opacity  is 
nearly  or  quite  circular,  and  sharply  defined,  the  edge  is  apt  to  be  a  little 
ragged  or  serrated.  The  opaque  spot  is  back  of  the  capsule,  between  it  and 
the^nucleus.  The  laminse  next  the  capsule,  the  nucleus,  and  the  entire 
periphery  of  the  lens,  are  all  clear.  Earely  there  is  seen  a  corresponding 
opacity  behind  the  nucleus,  and  of  course  deeper  seated  in  the  lens.  Opthal- 
moscopically,  the  dilated  pupil  is  uniformly  red,  except  the  central  opacity, 
which  has  a  reddish-brown  appearance,  the  centre  letting  more  light  through 
and  looking  redder.  In  the  school  period,  such  patients  are  often  near-sighted, 
perhaps  from  the  constant  habit  of  holding  the  book  close  and  straining  the 
accommodation.  Lamellar  cataract,  after  reaching  a  certain  point,  becomes 
stationary,  and  generally  remains  so  during  life.  Rarely  its  progress  is  re- 
newed, leading  to  total  cataract.  The  patient  is  usually  brought  for  advice 
on  account  of  supposed  near-sightedness,  because  he  holds  small  objects  unduly 
close,  to  see  them.  He  brings  the  book  near  his  eyes  because  he  does  not  see 
well,  and  not  because  he  is  myopic.  Still,  he  often  becomes  so,  as  proved  by 
the  usual  tests. 

Either  beginning  in  iitero,  or  very  soon  after  birth,  a  soft,  milky-white, 
total  cataract  is  sometimes  seen,  which  usually  involves  both  eyes.  It  has  a 
tendency  to  become  liquid,  in  later  years,  and  may  undergo  partial  or  com- 
plete absorption,  leaving  only  a  dense,  opaque  capsular  membrane.    If  neg- 


634         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

lected  until  the  child  is  ten  or  more  years  old,  and  then  removed,  good  sight 
is  seldom  restored,  although  the  vivid  response  of  the  iDupil,  and  the  quick 
perception  of  light,  may  have  led  the  operator  to  expect  and  promise  a  good 
result.  The  retina  never  having  exercised  its  functions,  rapidly  loses  its 
capacity  for  perfect  sight. 

In  youthful  subjects,  another  form  of  cataract  is  occasionally  seen,  partial 
ill  the  beginning,  but  progressing  rapidly  and  leading  to  blindness  of  one  or 
both  eyes.  Sometimes  it  starts  in  the  nucleus  and  extends  to  the  cortex.  In 
other  cases  it  is  just  the  reverse,  and  the  cataract  has  a  peculiar,  radiating,  star- 
like appearance  in  the  anterior  cortical.  In  such  persons  the  lens  is  more 
solid,  and  has  sometimes  a  quite  firm  nucleus,  especially  if  not  operated  on 
for  many  years. 

Senile  Cataract. — This  is  by  far  the  most  frequent  variety,  and  the  name 
indicates  that  it  has  for  its  victims  people  of  riper  years.  The  sclerosed 
nucleus  in  old  persons  is  amber-colored,  very  firm,  and  dry,  and  it  undergoes 
little  change  in  senile  cataract.  The  alteration  is  chiefly  in  the  cortical 
portion,  and  begins  usually  at  the  periphery,  in  the  form  of  little  strise,  some- 
times called  arcus  senilis  lentis.  ^oi  affecting  the  sight  in  this  incipient 
form,  the  stride  are  not  perceived  by  the  patient,  nor  seen  by  the  examiner, 
except  rarely.  At  a  later  period  they  send  out,  towards  the  pole  of  the  lens, 
little  prolongations,  like  feathery  frost  crystals.  These,  reaching  the  area  of 
the  pupil,  begin  to  disturb  vision.  In  examining  a  great  many  people,  I  find 
that  the  marginal  opacities  usually  begin  at  the  lower  and  inner  edge  of  the 
lens,  and  thence  extend  to  the  rest  of  its  circumference.  Little  by  little  these 
marginal  striae  multiply  and  extend  towards  the  centre  of  the  pupil,  producing 
slowly  increasing  dimness  of  vision.  As  they  widen,  become  confluent,  and 
involve  the  whole  cortical,  which  in  the  mean  time  becomes  perceptibly 
swollen,  the  amber  nucleus  is  more  obscured,  and  the  cataract  is  at  last  mature. 
We  say  that  maturity  is  attained  when  the  opacity  involves  the  entire  cortical, 
up  to  the  capsule,  so  that  the  iris  throws  no  visible  shadow.  In  this  stage,  the 
opaque,  soft  cortical  undergoes  slow  absorption  ;  the  anterior  chamber  deepens, 
and  the  amber  nucleus  again  shows  itself  more  plainly.  Left  so  for  a  long 
time,  the  cataract  becomes  hypermature. 

The  progress  of  cataract  in  different  patients  is  variable,  but  nearly  always 
slow,  requiring  often  many  years  to  reach  completion.  Senile  cataract  attacks 
both  eyes,  but  usually  not  at  the  same  time.  One  is  apt  to  progress  faster,  and 
get  blind  before  the  other.  Cataract  is  never  attended  by  pain  or  any  inflam- 
matory symptom  whatever.  If  pain  accompanies  its  development,  glaucoma 
or  some  other  grave  complication  is  its  explanation.  The  only  discomfort, 
aside  from  the  trouble  in  seeing,  is  manifested  by  shrinking  from  light,  and 
eftbrts  to  turn  the  back  towards  it.  Thus  the  eyes  are  shaded,  the  pupils 
dilate,  there  is  less  diffusion  of  light,  and  the  patient  sees  better.  He  often 
finds  relief  in  a  broad-brimmed  hat  well  down  over  the  eyes.  When  the  nu- 
cleus is  more  opaque  than  the  margin,  the  patient  sees  better  on  cloudy  days, 
before  sunrise,  or  after  sunset.  If  the  reverse  obtains,  he  sees  better  in  the 
bright  light.  The  pupil  will  be  found  active  in  response  to  light,  the  iris 
natural,  and  the  tension  of  the  globe  normal ;  in  short,  no  evidences  of  disease 
are  present,  except  the  cataract.  In  old  people  the  pupil  is  smaller  and  less 
active  than  in  early  years,  but  it  varies  in  different  persons.  While  the  ready 
response  of  the  pupil  to  light  is  a  good  indication  of  the  state  of  the  retina, 
it  is  not  infallible.  In  some  cases  of  retinal  detachment,  its  movements  are 
energetic  and  misleading,  while  in  other  persons  with  a  sound  fundus,  the 
pupil  does  not  respond  at  all.  There  may  be  motor  paralysis  of  the  fibres  of 
the  third,  or  of  the  sympathetic.    The  degree  of  dilatability  under  atropine 


CATARACT. 


varies,  but  it  is  always  less  than  in  youth.  Large  dilatation  with  mydriatics, 
in  old  people,  is  favorable. 

Traumatic  Cataract. — This  class  embraces  all  cataracts  that  directly  fol- 
low injuries  of  the  eye.  There  is  nearly  always  a  wound  or  rent  in  the  capsule, 
by  which  the  lens  substance  is  exposed  to  the  action  of  the  aqueous.  The 
dangers  of  traumatic  cataract  are  much  less  in  young  people  than  in  old.  In 
the  former,  the  absorbents  are  more  active,  and  the  lens  is  soft  and  ready  to 
dissolve.  The  hard,  dry  lens  of  the  aged,  is  not  capable  of  absorption.  In 
all  cases,  the  course  of  the  cataract  will  be  influenced  by  the  complications. 
If  the  cornea  and  iris  have  both  been  wounded,  or  if  the  injury  be  through  the 
ciliary  region  especially,  there  will  be  great  danger  of  loss  of  the  eye.  The 
additional  lodgment  of  a  foreign  body  in  the  eye,  enhances  the  risks  very 
greatly,  unless  the  foreign  body  be  lodged  in  the  lens  and  can  be  extracted 
with  it,  when  the  prospect  is  far  better  than  under  other  circumstances.  If 
the  lens  has  been  luxated,  as  it  is  more  apt  to  be  in  old  subjects,  the  prognosis 
is  most  unfavorable.  A  very  protracted  course  is  certain,  except  when  im- 
mediate extraction  is  effected.  There  is  great  danger  of  loss  of  vitreous,  in 
such  cases,  if  an  operation  is  attempted,  but  without  an  operation,  glauco- 
matous disorganization  is  very  sure  to  follow.  Even  a  free  iridectomy  often 
does  not  prevent  loss  of  the  eye,  with  endless  suffering,  and  enucleation  may 
at  last  become  necessary.  Prolapsus  of  the  iris  in  traumatic  cataract  is  a 
common  and  troublesome  complication.  If  no  other  serious  injury  be  present, 
and  the  patient  be  young,  the  cataract  may  entirely  disappear,  in  a  few  weeks 
or  months,  by  absorption,  with  recovery  of  useful  vision.  Even  then  the  rent 
in  the  capsule  may  close,  and  a  tough  secondary  cataract  remain  to  seriously 
obstruct  sight.  Altogether,  the  prognosis  of  traumatic  cataract  is  very 
unfavorable. 

Treatment  of  Cataract. — The  question  of  diagnosis  and  ripeness  of  cataract 
being  settled,  we  interrogate  the  retina  with  a  view  to  treatment.  IN^othing 
but  surgical  interference  can  do  any  good.  If  the  retina  be  sound,  even  in  the 
most  dense  cataracts,  there  will  be  prompt  perception  of  light  and  accurate 
projection.  We  test  these  points  in  a  dark  room,  with  the  use  of  a  candle,  as 
follows:  The  room  should  be  from  fifteen  to  twenty  feet  long,  and  well  dark- 
ened. A  single,  lighted  candle  is  held  at  one  end  of  the  room,  and  the  patient 
faces  it  from  the  other,  the  eye  not  tested  being  well  closed.  If  he  can  tell 
quickly,  when  the  candle  is  darkened  by  the  hand,  and  suddenly  uncovered, 
his  central  perception  is  good.  But  that  is  not  enough.  Enforcing  stillness 
of  the  eye  in  one  direction,  the  covered  candle  is  carried  to  the  left,  right,  above 
and  below,  in  the  field  of  vision.  In  each  new  position,  the  light  is  suddenly 
uncovered.  If  he  sees  and  can  point  to  it,  without  turning  the  eye,  the  field 
is  intact  and  the  projection  good.  Defects  in  the  field,  more  or  less  complete 
and  large,  indicating  detachment  of  the  retina,  choroidal  patches,  or  other 
serious  lesions,  excite  great  doubts  as  to  the  probable  success  of  an  operation, 
or  perhaps  forbid  it  entirely.  Slow  and  uncertain  perception  in  the  line  of 
vision,  is  a  very  bad  indication.  The  distance  at  which  a  candle  can  be  dis- 
cerned, is  a  good  test  of  central  acuity.  If  the  light  must  be  brought  very 
close  before  it  can  be  recognized,  the  prc^gnosis  is  bad,  and  if  not  perceived 
at  all,  hopeless.  The  ophthalmoscope  may  be  used  for  the  same  trial.  By 
turning  the  lamp  low,  and  then  throwing  the  light  on  the  pupil,  from  differ- 
ent directions,  the  ready  perception  and  integrity  of  the  field  may  also  be 
established. 

^ot  only  must  an  intelligent  diagnosis  of  the  state  of  perception,  and  the 
integrity  of  the  visual  field,  be  made  out;  but  other  questions  must  be  settled, 


636         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPE^'DAGES. 


before  resorting  to  a  surgical  operation.  Let  us  assume  that  cataract  exists 
and  is  fully  matured,  and  that  the  functional  examination  of  the  retina  is 
satisfactory.  But  only  one  eye  is  involved.  Monocular  cataract,  unless  trau- 
matic, is  not  common,  and  it  is  always  wise  to  wait  a  year  or  more,  to  see  if 
the  other  eye  will  remain  unaffected.  If  it  do,  and  if  the  subject  be  young, 
an  operation  may  be  advisable.  In  senile  cataract,  with  one  eye  still  intact, 
I  would  emphatically  decide  against  any  operation,  till  incipient  lenticular 
chano^es  had  be2:un  in  the  sound  and  seeing  eye.  After  that,  I  should  leave 
it  tolhe  choice'"  of  the  patient,  whether  to  wait  till  it  too  was  nearly  or  quite 
blind,  or  not.  It  must  be  remembered  that  no  operation  for  cataract  is  free 
from  'serious  risks.  A  patient  advanced  in  years,  with  one  good  eye,  had 
better  endure  the  inconvenience  of  one-sided  blindness,  to  which  he  soon 
becomes  accustomed,  than  incur  the  dangers  of  an  extraction.  Should  all  go 
well,  and  the  best  possible  result  be  secured,  the  sight  is  so  much  inferior  to 
that'of  the  other  eye,  that  the  patient  does  not  usually  appreciate  the  gain. 
Should  an  unforeseen  accident  occur  during  the  operation,  or  should  disastrous 
reaction  follow  it,  the  eye  will  probably  be  lost,  with  sympathetic  danger  to 
the  other.  In  a  young  person,  with  a  prospect  of  long  life,  and  where  a  less 
risky  procedure  may  be  resorted  to,  one  may  cautiously  advise  it  for  the  sake 
of  looks,  and  to  relieve  the  patient  from  the  inconvenience  of  a  blind  side. 

Another  question  is,  whether  if  both  eyes  are  blhid  and  ready  for  operation, 
it  is  wise  to  operate  on  both  at  the  same  sitting.  In  children  it  is  proper.  In 
adults,  as  a  rule,  it  is  safer  to  take  one  at  a  time,  leaving  a  few  days,  or  longer, 
between  the  operations.  Still  another  point  of  conscience  is  this.  Suppose 
one  eye  has  been  operated  on  with  success,  the  patient  being  able  to  read  well 
and  conduct  his  business:  Is  it  then  advisable  to  operate  upon  the  other?  I 
would  say  no,  unless  at  the  urgent  request  of  the  patient,  and  after  fully  ad- 
visins;  him  of  the  possible  disasters.  I  shall  never  forget  the  case  of  an  old 
gentleman  from  one  of  whose  eyes  I  extracted  the  lens  with  perfect  success. 
One  week  after,  at  his  instigation,  I  repeated  the  operation  upon  the  other 
eye.  All  went  well,  at  the  time,  and  for  a  few  days.  Then  iridocyclitis  set 
in,  from  which  he  lost  this  eye,  and  was  soon  blinded  in  the  other  from  sym- 
pa'thetic  ophthalmia.  The  same  thing  may  happen  to  an  eye  not  yet  operated 
on,  and  not  even  cataractous,  from  a  painful  failure  in  the  first  operation. 
Who,  of  large  experience,  has  not  met  with  this  misfortune?  Surgeons  and 
physicians  generally  have  very  trivial  notions  of  the  delicacy  and  serious- 
ness of  cataract  operations— an  opinion  which  is  confirmed  by  the  publication 
of  successful  cases  only,  as  personal  advertisements,  rather  than  in  the  interest 
of  the  healing  art. 

Operation  by  Solution,  or  the  Needle  Operation.— There  are  but  two  operations 
now  practised  for  cataract:  solution  and  extraction.  The  former  is  appli- 
cable only  to  soft  and  absorbable  cataracts,  as  they  are  met  with  in  children, 
and  in  persons  under  twenty  years.  The  subject  young  and  healthy,  the  entire 
lens  involved,  and  the  little  patient  reasonably  tractable,  this  operation  is 
attended  by  slight  risks  and  promises  well.  The  pupil  is  to  be  well  dilated 
by  atropine,  and  the  patient  put  in  a  good  light,  on  a  lounge,  bed,  or  operating 
table,  and  rendered  thoroughly  insensible  with  ether;  the  stop-speculum' 
is  then  introduced,  and  the  eye  fixed  by  the  large,  toothed,  fixation  forceps^ 
held  by  the  left  hand.  The  right  holds  the  small  stop-needle  (Figs.  923,  924), 
passes  it  carefully  through  the  cornea,  about  half  way  between  its  centre  and 
external  margin,  towards  the  lens  capsule,  carefully  watching  the  point  to  see 
when  it  pierces  the  latter,  and  to  avoid  going  deeply  into  the  lens.  Then  by 
a  quick  elevation  of  the  handle,  the  cornea  acting  as  fulcrum,  the  capsule  is 


1  See  Fig.  921,  page  591,  supra. 


2  See  Fig.  922,  page  591,  supra. 


CATARACT. 


637 


divided  transversely  to  a  short  distance.  Then  the  needle,  being  slightly 
retracted,  may  be  advanced  so  as  to  make  a  second  incision  in  the  capsule, 
at  right  angles  to  the  first.  In  that  way,  the  elastic  capsule  being  incised 
crucially,  the  points  retract  and  leave  a  small  portion  of  the  lens  exposed 


Fig.  923.  Fig.  924. 


Bowman's  stop-needles,  curved  and  straight. 


to  the  contact  of  the  aqueous.  The  lens  imbibes  the  humor,  swells,  breaks 
down  slowly,  and  at  last  is  dissolved  by  the  aqueous,  leaving  a  clear  pupil 
where  the  capsule  was  opened.  Usually  the  rent  closes,  after  a  few  weeks  or 
months,  and  the  solution  ceases.  Then  the  manoeuvre  must  be  repeated  till 
the  pupil  is  free  from  obstruction.  The  needling  process  may  need  to  be 
repeated  several  times,  and  the  restoration  to  sight  can  only  be  expected  in 
the  course  of  many  weeks  or  even  months. 

It  must  be  remembered  that  the  intra-capsular  cells  always  swell,  multiply, 
and  produce  a  thickening  of  the  capsule  around  the  rent,  as  the  lens  sub- 
stance itself  dissolves.  A  grayish-white  opacity  will  be  seen  in  the  capsule, 
and,  in  case  the  rent  closes,  it  will  be  found  much  tougher  at  the  second  and 
third  punctures,  than  at  the  first.  Indeed,  it  will  often  be  found  necessary  to 
use  two  needles,  in  order  to  tear  it  sufificiently,  introducing  one  inwards  and 
the  other  outwards,  passing  them  through  the  tough  membrane  at  the  same 
place,  and  then  separating  their  points  by  suitable  movements  of  the  handles. 
If  the  first  incision  be  too  large,  and  the  lens  swell  rapidly,  pressing  against 
the  iris  and  giving  rise  to  acute  plastic  iritis,  with  perhaps  glaucomatous 
hardness  of  the  eyeball,  an  incision  must  be  made  in  the  cornea  with  a 
spear-knife,  and  the  softened  lens  must  be  extracted.  It  will  readily  come 
out  with  the  aqueous,  assisted  by  a  spoon. 

For  a  few  days  or  even  weeks  after  a  needle  operation,  the  patient  must  be 
kept  quiet  in  a  moderately  darkened  room,  for  fear  of  dangerous  reaction. 
If  pain,  tenderness  to  light,  weeping,  and  ciliary  injection  conie  on,  cold  appli- 
cations, and  the  energetic  use  of  atropine,  are  the  best  remedies.  In  all  cases, 
the  eye  must  be  daily  tested  as  to  tension.  If  that  becomes  excessive,  repeated 
paracentesis  must  be  employed,  and,  if  need  be,  a  linear  extraction  of  the  soft 
and  swollen  lens.  The  pupil  must  be  kept  well  dilated  during  the  whole 
course  of  treatment,  so  as  to  withdraw  the  iris  from  contact  with  the  swelling 
lens. 

Traum.atic  cataract^  in  young  subjects,  may  be  treated  in  the  manner  above 
described,  but  if  a  foreign  body  be  lodged  in  the  eye,  the  danger  of  the  opera- 
tion is  greatly  increased.  Should  the  foreign  body  be  seen  in  the  lens,  they 
may  both  be  extracted  together  by  a  linear,  corneal  incision.  In  lamellar  and 
polar  cataracts,  the  vision,  if  possible,  should  be  improved  by  a  small  iridec- 
tomy, which  is  almost  free  from  danger.  If  dilatation  of  the  pupil  improves 
the  sight  materially,  a  well-executed,  small  iridectomy  will  help  still  more. 
As  these  cases  are  partial  and  stationary,  if  reading  vision  can  be  secured,  it 
is  vastly  safer  and  surer  than  a  cataract  operation,  in  which  the  danger  of 
excessive  swelling  is  very  great.  If  the  entire  lens  is  liquid,  a  broad  needle* 
may  be  used  to  puncture  the  capsule.  Before  being  withdrawn  it  should  be 
slightly  rotated,  and  the  fluid  lens  allowed  to  escape  with  the  aqueous.  A 
grooved  needle  (Fig.  925)  may  also  be  employed. 

In  older  subjects,  where  the  nucleus  is  a  little  firmer,  but  not  hard,  a 


A  See  Fig.  920,  page  591,  supra. 


638         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

linear  extraction  is  preferable.  For  this  purpose  the  pupil  must  be  widely 
dilated,  the  stop-speculum  introduced,  and  the  eye  well  fixed,  the  patient  being 
ander  ether.  A  broad  spear-knife,  or  keratome  (Figs.  926,  927),  is  passed 
through  the  cornea,  midway  between  centre  and  margin,  so  as  to  open  the 


Fig.  925.  Figs.  926,  927. 


Fig.  928. 


Cystotome.  Jaeger's  keratomes. 

chamber  by  an  incision  five  or  six  mm.  in  length.  A  cystotome  (Fig.  928), 
passed  very  carefully  through  this  incision,  opens  the  capsule  freely.  Then 
while  the  outer  lip  is  pressed  gently  back  by  a  small  curette  (Fig.  929),  an- 

Fig.  929. 

^^^^^ 
Paracentesis  needle  and  curette. 

other  is  lightly  pressed  on  the  opposite  side  of  the  cornea,  and  the  lens  made 
to  come  slowly  out  in  fragments.  If  discission  has  previously  been  practised, 
or  if  a  traumatic  cataract  demands  this  operation,  the  cystotome  is  usually 
not  needed  at  all.  Great  care  must  be  taken  to  avoid  prolapsus  of  the  iris 
during  this  operation.  If  it  occurs,  and  is  not  readily  reduced  with  the  spud,^ 
or  by  gentle  closure  of  the  lids  and  rubbing  over  the  cornea  with  the  finger, 
aided  by  eserine,  it  must  be  gently  drawn  out  and  snipped  ofi*  close  to  the 
cornea.  The  future  welfare  of  the  eye  demands  that  no  iris  shall  be  left  in 
the  corneal  incision ;  and  this  provision  applies  to  all  forms  of  extraction. 

Graefe's  Operation,  hy  Modified  Linear  Extraction.  —  In  senile  cataracts^ 
extraction  is  the  only  allowable  operation.  Since  the  general  abandonment 
of  the  old  corneal-flap  method,  some  form  of  Graefe's  modified  linear  extraction 
is  usually  adopted.  But  each  one  practises  the  method  of  the  great  innovator 
with  his  own  favorite  deviations.  This  operation  necessitates  an  iridectomy, 
which  is  a  mutilation  much  to  be  regretted.  But  as  its  advantages  more 
than  compensate  for  the  resulting  deformity  and  less  perfect  vision,  it  should 
be  accepted.  The  unanimous  opinion  of  operators  is  that  an  incision  at  or  a 
little  in  front  of  the  sclero-corneal  junction,  is  safer  than  one  farther  back  and 
very  close  to  the  iris,  as  originally  practised.  Prof.  Arlt,  and  a  few  others, 
still  prefer  to  cut  out  under  the  conjunctiva,  so  as  to  get  a  protecting  flap 
from  it.  The  tendency,  however,  is  to  come  out  more  in  the  cornea,  and 
two  methods  are  practised  in  which  the  deviation  from  the  original  operation 
is  very  great. 

My  own  experience  leads  me  to  operate  about  as  follows :  I  greatly  prefer 
not  to  give  ether,  and  only  resort  to  it  with  extremely  nervous  or  cowardly 
patients.  The  best  preparation  for  this  operation  is  no  preparation,  taking 
the  patient  in  his  usual  health,  and  without  waiting  for  him  to  work  himself 
up  into  a  mental  stew  of  anxiety.    As  the  patient  must  keep  his  bed  for  a  few 


»  See  Fig.  919,  page  591,  siixwa. 


CATARACT. 


G39 


days,  a  good  spring  mattress  should  be  provided.  The  patient  is  put  com- 
fortably in  bed,  in  front  of  an  unobstructed  window,  with  a  good  light.  There 
must  be  no  head-board,  or  the  head  of  the  patient  must  be  put  to  the  foot  of 
the  bed,  so  that  the  operator  or  assistant  may  stand  behind  and  meet  with  no 
impediment.  The  bed  must  be  so  placed  that  a  direct  and  clear  view  of  the 
cornea,  without  any  disturbing  reflex,  may  be  secured,  and  no  hand  or  head 
must  be  allowed  to  come  before  it.  I  prefer  to  operate  without  dilatation  of 
the  pupil.    A  suitable  stop-speculum,  fixation  forceps,  a  Graefe's  knife  (Fig. 


Fig.  930.  Fig.  932. 


Graefe's  tortoise-ahell  spoon.  Different  forms  of  iris  forceps. 


Fig.  933. 


980),  a  cystotome  with  a  hard-rubber  or  tortoise-shell  spoon  on  one  end  (Fig. 
931),  a  small  curved  pair  of  iris-forceps  (Fig.  982),  and  a  small  pair  of  scissors 
(Fig.  983),  curved  on  the  flat,  are  the  necessary  instruments.  Borated  cotton, 
soft  rags,  and  a  bandage  must  be  at  hand.  It  is  wise  to  have  a  stroni>; 
solution  of  boracic  acid,  into  which  all  the  instruments  should  be  dipped,  and 
with  which  the  eye  should  be  well  washed  out.  I  have  never  operated  under 
the  spray,  and  consider  it  a  vapory  relinement.  All  things  being  ready,  1 
talk  kindly  and  frankly  with  the  patient,  telling  him  what  to  do"  and  what 
not  to  do.  He  must  promise  to  keep  his  mouth  shut,  not  to  hold  his  breath, 
and  to  listen  to  what  the  operator  says,  doing  quietly  as  he  directs.  If  he 
will  keep  his  wits  about  him,  and  not  resist,  all  will  go  more  safely  and 
easily.  I  never  risk  changing  the  fixation  forceps  to  other  hands,  but  hold 
them  exclusively  myself. 

In  extracting  from  the  right  eye,  I  stand  or  sit  behind  the  recumbent 
patient's  head,  making  the  section  with  my  right  hand.  Exchanging:  the 
knife  for  the  iris-forceps,  I  draw^  the  iris  out,  to  be  snipped  off  by  the  assistant. 
That  done,  I  use  the  cystotome,  and  then  turning  the  spoon  end,  make  gentle 
pressure  at  the  lower  sclero-corneal  junction,  to  bring  out  the  lens.  To  ope- 
rate on  the  left  eye  and  still  use  my  right  hand,  I  s-it  on  the  side  of  the  patient, 
directing  him  to  put  his  left  arm  around  me,  so  that  I  can  get  close  in  to  his 
body.  The  assistant  then  stands  behind  his  head,  with  the  iris-forceps  and 
scissors,  draws  out  the  iris  with  his  left  hand,  and  snips  it  with  the  right. 


640         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


Then  exchanging  for  the  cystotome,  he  cuts  the  capsule  and  instantly  hands 
me  the  spoon,  which  I  use  in  bringing  out  the  lens.  In  this  case  I  can,  and 
sometimes  do,  use  the  iris-forceps  and  the  cystotome  myself,  the  assistant 
simply  snipping  the  iris.  But  the  position  is  a  little  constrained,  and  I  prefer 
the  first  method.  To  fix  the  eye,  I  use  the  large,  broad-toothed  forceps,^ 
without  spring  to  hold  them  closed,  opening  them  three  or  four  mm.,  and 
pressing  them  firmly  on  the  ball,  at  the  sclero-corneal  junction,  and  then 
closing  them  so  as  to  get  a  firm  and  controlling  fixation.  The  point  of  fixing 
is  not  vertically  below  the  cornea,  but  downwards  and  inwards,  the  extrac- 
tion being  usually  upwards.  I  do  this  to  better  avoid  the  rolling  of  the 
eye  on  its  visual  axis,  during  puncture  and  counter-puncture.^  In  old  people 
with  friable  tissues,  the  conjunctiva  sometimes  tears,  but  it  is  not  apt  to  do 
so  if  solidly  and  deeply  held.  I  generally  use  the  original  stop-speculum  of 
Graefe,  and  in  case  the  eye  is  prominent,  with  danger  of  pressure,  I  direct  a 
second  assistant  to  hold  the  instrument  near  its  temporal  end  and  lift  it 
slightly  forwards.  The  smaller  speculum,  turned  towards  the  nose  side,  is 
less  in  the  way  of  the  operator. 

It  is  difiicult,  in  describing  this  operation,  to  designate  accurately  the  pomts 
of  puncture  and  counter-puncture.    Assuming,  as  an  average,  that  the  hori- 
zontal diameter  of  the  clear  cornea  is  twelve  mm.,  I  would  say,  let  them  both 
be  exactly  at  the  sclero-corneal  junction,  and  one  mm.  above  this  diameter. 
In  that  way  an  incision  of  ten  or  ten  and  one-half  mm.  may  be  obtained,  even 
if  the  knife  cuts  out  a  little  in  the  transparent  cornea.    In  passing  the  knife, 
I  go  straight  through,  without  changing  the  direction  of  the  point,  simply 
watching  it  closely  so  as  to  make  the  counter-puncture  at  the  right  place. 
One  is  apt  to  make  it  further  back  than  the  point  of  entrance.  ^  This  is  a  less 
dangerous  mistake  than  the  opposite,  which  gives  too  small  an  incision  for  the 
easy  exit  of  the  lens.   The  extent  of  the  incision  may  be  somewhat  regulated 
by  the  approximately  determined  hardness  of  the  lens  and  size  of  the  nucleus. 
But  there  are  always  much  greater  dangers  and  difiiculties  connected  with  a 
too  small,  than  with  an  unnecessarily  long  incision.    These  preliminaries 
settled,  the  steps  of  the  operation  may  be  briefly  described.  The  knife  should 
be  introduced  and  kept  with  its  surface  parallel  with  the  iris,  being  pushed 
far  forwards,  after  the  counter-puncture  is  made,  so  as  nearly  to  complete  the 
section,  which  is  then  finished  as  the  blade  is  slowly  withdrawn._  Holdmg 
the  cornea  straight  forwards  or  a  little  divergent,  aids  very  much  in  this  act. 
If  the  point  of  ^the  knife  catches  slightly  in  the  iris  as  it  passes  through  the 
chamber,  or  if  the  iris  falls  over  the  edge,  it  is  better  to  go  right  on  and  finish, 
than  to  hesitate  and  retract.  Just  before  finishing  the  flap,  it  is  best  to  turn  the 
edge  of  the  blade  slightly  forwards.  In  rare  cases,  where  the  eye  is  very  deep- 
seated,  the  knife  may  be  passed  in  with  the  edge  inclined  somewhat  forward 
from  the  start,  and  made  to  cut  out  in  the  same  plane,  so  as  to  prevent  hag- 
gling of  the  wound.    In  that  case  we  cut  out  farther  forwards  in  the  cornea. 
The  section  completed,  we  proceed  at  once  to  the  iridectomy.    If  the  ins 
prolapses,  as  it  nearly  always  will,  it  needs  only  be  seized,  held  firmly,  drawn 
slowly  out,  and  snipped  oft*  at  one  angle  of  the  wound  as  close  as  possible. 
It  is  then  drawn  on  a  little  more,  carried  towards  the  other  angle  and  again 
snipped.    On  completing  the  excision,  the  angles  of  the  wound  are  quickly 
inspected,  and  if  any  trace  of  iris  hangs  in  either,  it  must  be  carefully  seized 
with  the  fine  forceps,  drawn  out  again,  and  snipped  close  to  the  surface.  It 
neither  branch  of  the  iris  is  drawn  into  the  cornea,  the  straight,  cut  edges  can 
be  quickly  recognized  in  the  anterior  chamber. 

The  next  step,  discission  of  the  capsule,  should  be  done  quickly,  so  as  to 


1  See  Fig.  -.12,  Ma;;e  591,  supra. 


CATARACT. 


641 


anticipate  hemorrhage  into  the  chamber.  The  very  sharp  cystotome,  inserted 
flatwise  with  its  point  slightly  upwards,  is  passed  carefully  down  on  the  ante- 
rior capsule,  till  it  reaches,  or  even  passes  behhid,  the  lower  edge  of  the  pupil. 
Then,  turning  the  point  towards  the  capsule,  it  is  drawn  lightly  upwards  to 
the  edge  of  the  lens,  making  a  vertical  and  long  incision.  This  done,  the 
curette  or  tortoise-shell  spoon  is  placed  with  its  convex  surface  against  the 
lower  edge  of  the  cornea,  and  gentle  pressure  is  made  backwards.  If  in  a 
moment  the  wound  gapes,  showing  that  the  lens  is  engaging,  the  scoop  may 
be  slid  slowly  upwards  over  the  cornea,  till  the  lens  escapes.  "Great  gentleness 
is  required  at  the  last,  to  avoid  loss  of  vitreous  before  the  speculum  can  be 
removed.  The  moment  the  lens  escapes,  the  stop  must  be  loosed,  the  branches 
carefully  brought  together,  and  the  speculum  removed  with  great  quickness 
and  skill,  so  as  not  to  press  the  eye.  As  a  rule,  I  hold  the  eye  with  the  fixa- 
tion forceps  till  the  lens  escapes,  and  then  instantly  let  go.  In  prominent 
eyes,  or  when  escape  of  vitreous  is  imminent,  Ave  may  let  go  the  eye  and 
remove  the  speculum  the  moment  the  iridectomy  is  finished  and  the  capsule 
divided.  Then  closing  the  eye  with  a  wad  of  charpie  or  cotton,  for  a  few 
seconds,  the  lids  are  cautiously  separated  by  the  fingers,  and  by  means  of 
pressure  through  the  lower  lid  the  lens  is  made  to  escape.  Or,  the  lower  lid 
being  well  drawn  down,  the  scoop  may  be  used  for  pressure. 

After  the  exit  of  the  lens,  the  eye  is  shut  for  a  few  minutes,  with  a 
mass  of  cotton  gently  pressed  on  the  closed  lids.  Then  carefully  opening  it, 
a  critical  inspection  of  the  pupil  is  made,  to  see  if  any  soft  cortical  is  left 
behind.  If  so,  it  must  be  carefully  worked  out,  so  as  to  secure  a  clear  black 
pupil.  To  do  this,  request  the  patient  to  turn  the  eye  down  and  try  to  hold 
it  there.  Then  raising  the  upper  lid  above  the  incision,  make  careful  sliding 
movements  over  the  cornea  from  below  upwards,  through  the  medium  of  the 
lower  lid.  In  this  way  the  fragments  may  be  slowly  and  very  carefully 
coaxed  out.  If  one  or  two  trials  do  not  succeed,  let  the  eye  be  closed  w^ith  a 
soft  compress  and  bandage,  for  half  an  hour  or  more,  till  the  aqueous  reaccum- 
alates.  Then  the  same  manoeuvre  will  probably  float  out  the  soft  trao-ments. 
The  success  of  the  operation  will  depend  largely  upon  the  ability  to  get  away 
all  the  fragments  from  the  chamber,  and  secure  the  most  perfect  coaptation 
of  the  incision.  If  any  strings  of  coagulum,  or  shreds  of  capsule,  liani>;  in  the 
wound,  they  must  be  removed  with  the  small  forceps.  Without  all  these 
pi;ecautions,  union  by  first  intention  cannot  be  expected,  and  the  operation 
will  be  a  more  or  less  complete  failure.  The  section  should  be  ample  and 
regular,  and  no  iris  or  prolapsed  capsule  should  be  left  in  the  cut. 

If  a  black  pupil,  free  from  blood,  is  secured,  it  is  wise  to  test  the  vision  by 
letting  the  patient  count  your  fingers.  Finally,  both  eyes  should  be  closed  by 
a  roller  so  as  to  preserve  their  most  perfect  rest.  A  piece  of  old,  soft  cloth, 
large  enough  to  cover  both  eyes,  and  torn  at  one  edge  to  adapt  it  to  the  nose, 
IS  first  adjusted.  Then  pellets  of  cotton  are  put  over  the  eyes,  to  fill  out  the 
inequalities  and  make  uniform  pressure,  and  are  followed  by  the  application  of 
the  roller,  which  must  not  be  tight  enough  to  cause  pain.  For  five  or  six 
hoars,  the  patient,  if  possible,  must  lie  very  still,  and  flat  on  his  back.  If  by 
that  tmie,  the  bandage  is  at  all  deranged,  let  it  be  readjusted,  without  opening 
the  eyes,  and  let  the  patient  be  kept  quietly  on  his  back  till  morning.  Fresh 
dressmgs  and  bandage  are  then  applied.  On  removing  the  soiled  ones,  if  the 
lids  are  free  from  pufiiness  and  the  pads  dry,  all  is  wftll,  and  the  eye  should  not 
be  opened.  Some  swelling  of  the  lids  and  yellowish  discharge  indicate  dan- 
gerous reaction,  and  the  eye  should  then  be  opened  and  inspected.  In  case 
the  patient  sufters  little  or  no  pain,  and  all  looks  promising,  the  dressino-s 
should  be  changed  twice  a  day  for  two  or  three  days,  before  openino-  and 
inspecting  the  eye.    A  careful  night-nurse  should  watch  the  patient  in'lleep, 

VOL.  IV.— 41  ^' 


642         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

to  see  that  he  does  not  hurt  the  eye.  In  a  week  or  ten  days  the  bandage 
may  be  removed,  and  a  double  compress  be  hung  over  the  eyes,  or  a  broad 
shade  substituted.  The  room  should  be  kept  comfortably  dark  for  some  days 
after  the  operation,  and  the  eye  gradually  accustomed  to  light  it  all  goes 
well,  the  patient  may  leave  his  room  in  about  two  weeks  If  now  a  three 
and  one-half  inch  lens  improves  the  vision  greatly,  a  good  result  is  almost 

certain.  ,  .  ,  ,    ^         .  ^ 

There  are  some  troublesome  accidents  which  no  amount  of  experience  and 
skill  can  always  avoid.  One  of  these  is  obstinate  hemorrhage  into  the  chamber, 
causing:  great  difficulty  in  dividing  the  capsule,  and  perhaps  preventing  im- 
mediate vision.    If  the  blood  gathers  in  the  chamber  before  the  capsule  has 
been  opened,  it  may  perhaps  be  coaxed  out  by  a  few  strokes  of  the  moistened 
curette.    If  not,  the  capsulotomy  must  be  made  by  guess,  carefully  avoiding 
iniury  to  the  iris.     If  the  chamber  fills  with  blood  after  the  exit  of  the  lens, 
it  will  perhaps  escape  with  the  lens  fragments  under  the  sliding  movement. 
If  not,  It  can  be  safely  left  to  the  absorbents.   Loss  of  vitreous  before  the  escape 
of  the  lens  is  a  very  serious  disaster,  as  it  necessarily  displaces  the  lens  and 
makes  its  removal  extremely  precarious.    A  slight  loss  of  vitreous  following 
the  lens,  or  in  the  sliding  manoeuvre  to  clear  the  chamber,  is  not  so  serious. 
Still,  such  loss  always  increases  the  immediate  and  remote  risks.    W  hen  the 
catamct  is  hypermature,  or  the  incision  too  small,  or  both,  ih^  ^presentation 
may  not  be  prompt.  If  this  be  due  to  the  smallness  of  the  section,  that  must 
be  enlarged  with  the  knife  or  the  iris  scissors,  a  procedure  requiring  great 
coolness  and  skill.    Should  the  incision  be  free  enough,  and  should  the  edge 
of  the  lens  yet  not  come  forward  and  open  the  wound,  on  moderate  pressure 
with  the  scoop,  the  cystotome  may  be  lightly  passed  in,  its  edge  well  forward, 
and  drawn  along  the  Vound  so  as  to  divide  the  anterior  capsule  freely  along  the 
lens  maro-in.    Then  the  same  pressure  will  eliminate  it  without  serious  trou ble. 
lisuvvnmtive  reaction  comes  on  in  twenty-four  hours  after  an  extraction,  the 
eye  will  generally  be  totally  lost.    A  milder  reaction,  at  a  later  period,  always 
protracts  the  cure,  and  generally  leads  to  a  membranous  formation  in  the 
pupil,  with  imperfect  vision.    The  suppuration  begms  m  the  corneal  wound, 
at  either  end  or  in  the  middle,  and  thence  proceeds  to  the  ins  and  even  the 
ciliary  body.    Careful  springing  of  the  incision  once  or  twice  a  day,  the  free 
use  of  boracic-acid  solution  in  the  eye,  the  instillation  of  atropia  two  or  three 
times  a  day,  and  the  application  of  cold  compresses  externally,  seem  to  be  the 
best  means  of  checking  this  sad  process.  In  very  old  or  feeble  Patients,  warm 
fomentations  or  poultices  do  better  than  cold.    Such  cases,  at  best,  end  m 
closed  pupil  and  a  retracted  cicatrix.    In  the  worst  forms,  Bhrinking  of  the 
eyeball  and  even  sympathetic  danger  to  the  fellow  eye,  may  be  the  result. 
There  is  a  well-grounded  fear  of  sympathetic  ophthalmia  followmg  the  origi- 
nal operation  of  Von  Graefe,  where  the  section  is  made  m  the  anterior  part 
of  the  sclera,  close  to  the  periphery  of  the  iris.    The  ^^^^..^.^^^J 
wound  to  the  dangerous  ciliary  region,  leads  to  greater  risk  of  eyditis  and 
consequent  sympathetic  inflammation.   Experience  has  led  most  operators  to 
deviate  from  the  classic  method,  and  to  make  the  incision  at  the  base  of  the 
clear  cornea,  or  even  further  forwards.  +1,^ 
There  is  a  popular  impression  that  even  after  the  most  perfect  success  the 
cataract  may  return.    This  belief  is  based  on  the  fact  that  sometimes  the 
sight  fails  again  hi  a  year  or  two,  very  seriously..  For  example,  with  a  vision 
of  one-half,  and  the  ability  to  read  the  finest  prmt  with  ease,  ^ J^^f  f^^^^^^^^^^ 
comes  over  the  eye  till  the  patient  can  only  see  to  walk.    This  gradual 
doudinS  of  sight  is  explained  when  the  pupil  is  inspected  by  the  ophthalmo- 
scope, fnd  by  obliqui  illumination.    A  thin,  grayish,  filmy  membrane  is 
seen  covering^the  originally  clear  pupil.    This  is  not  a  reproduction  of  the 


CATARACT. 


643 


lens,  but  a  thin  formation  filling  the  rent  in  the  capsule.  In  some  cases  this 
condition  calls  for  relief,  but  if  fair  reading  capacity  is  still  left,  I  prefer  to 
let  the  eye  alone;  otherwise,  another  operation  is  required. 

These  secondary  02:)erations  to  clear  the  pupil  are  by  no  means  free  from  the 
risk  of  dangerous  reaction.  The  thicker  this  capsular  obstruction,  and  the 
longer  it  has  existed,  the  tougher  it  will  be,  and  the  greater  the  difficulties  and 
dangers  of  the  operation.  A  very  sharp  sickle-needle  may  be  passed  through 
the  cornea,  and  made  to  penetrate  the  capsule  and  incise  it  centrally.  Or  a 
Graefe's  knife  may  be  used  for  the  same  purpose.  A  safer  and  better  method 
still,  is  that  of  Bowman's  two  stop-needles.  One  is  passed  through  from  the 
outer  side,  the  other  from  the  inner,  both  being  made  to  pierce  the  obstruction 
at  the  same  central  point;  then  by  a  leverage  motion  of  the  handles,  the  needles 
are  made  to  separate,  each  supporting  the  capsule  for  the  other,  and  a  central 
rent  is  made,  with  immediate  clearing  of  sight.  To  do  this  with  the  greatest 
precision  requires  artificial  oblique  illumination.  When  the  obstruction  is 
thick,  tough,  and  on  a  level  with  the  iris,  to  which  it  may  be  adherent,  a  free 
incision  with  Wecker's  scissors  is  the  safest  and  surest  remedy.    A  narrow 


Fig.  934. 


Wecker's  scissors,  modified  by  Keyser. 

Spear-knife  is  made  to  puncture  the  cornea,  and  the  closed  scissors  passed 
through  the  incision.  As  they  are  opened  in  the  chamber,  the  pointed  blade 
backwards,  the  obstruction  is  pierced  and  the  blades  pushed  forwards,  and 
then  closed,  so  as  to  incise  it  freely  in  its  centre.  If  it  is  cut  at  right  angles  to 
the  direction  of  the  greatest  traction,  the  incision  will  open  enough  by  its  own 
elasticity.  In  some  cases,  with  closed  pupil  and  dense  false  roembrane  ad- 
herent to  the  iris,  an  iridectomy  may  be  practised.  In  that  event,  however, 
a  firm,  pigmented,  false  membrane  is  seen  behind  the  new  pupil,  and  another 
operation  will  be  required.  I  prefer  to  cut  the  whole  structures  at  once  by  a 
free  sweep  of  Wecker's  pince-ciseaux. 

In  all  these  secondary  operations,  the  danger  of  violent  reaction  comes  from 
traction  on  the  ciliary  processes,  in  efi:brts  to  tear  or  incise  the  tough  obstacle. 
For  that  reason,  a  skilful,  two-needle  operation,  or  an  incision,  is  the  least 
risky.  After  any  of  these  operations  the  eye  must  be  closed  with  a  soft  pad 
:and  bandage,  and  the  patient  kept  quiet  in  a  darkened  room  for  a  few  days. 
Cold  water  applications,  and  anodynes  internally,  are  the  best  remedies. 
Atropine,  except  in  very  filmy  obstructions,  without  synechia  posterior,  is 
not  beneficial.  If  persistent  iridocyclitis,  with  pain,  tenderness  to  the  touch, 
and  threatening  sympathetic  indications  in  the  other  eye,  result  from  a  cat- 
aract extraction,  the  offending  organ  must  be  enucleated.  All  these  observa- 
tions, based  on  the  facts  of  experience,  show  that  cataract  operations  of  all 
kinds  are  not  free  from  o^rave  risks. 

The  lens  in  all  cataract  operations  is  destroyed ;  the  eye  is  deprived  of  its 
accommodation,  and  is  rendered  extremely  hyperopic.  Suitable  cataract  lenses 
must  then  be  worn  for  all  purposes.  If  the  proper  glass  does  not  help  the 
sight  very  greatly,  the  pupil  is  not  free  from  obstruction,  or  the  visual  capa- 
city is  impaired.  Practically,  two  lenses  suffice— one  w^eaker  (3i  to  4  inches 
focus),  for  distance,  and  one  stronger  (2  to  2 J),  for  reading  and*'  other  close 
work.    If  the  curvature  of  the  cornea  has  been  changed  by  the  operation,  a 


644         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


cyliadrical  lens  may  often  be  combined  with  the  spherical  with  very  great 
benefit  Cataract  glasses  are  worn  in  heavy  frames,  as  any  other  spectacles. 
It  is  better  to  wait  six  weeks  or  more  before  accurate  trials  are  made  to  adapt 
the'o-lasses,  but  a  walking  lens  of  four  inches  may  be  worn  till  that  time  if 
necessary.  Great  prudence  in  the  use  and  the  exposure  of  the  eyes  is  re- 
quired for  months  after  the  operation. 

As  already  mentioned,  the  lens  may  be  luxated  in  the  eye,  either  from  an 
iniury  or  spontaneously.  If  this  displacement  takes  place  m  the  vitreous, 
leaving  a  free  pupil  and  causing  no  destructive  irritation,  useful  vision  may 
be  enioyed  bv  the  aid  of  a  cataract  glass.  If  increased  tension  results,  the 
crlaucomatous  hardness  and  threatened  loss  of  sight  may  be  relieved  by  a  very 
careful  iridectomy.  Even  an  extraction  may  sometimes  be  practised,  but 
at  the  risk  of  ^reat  loss  of  vitreous.  In  case  all  saving  measures  tail,  the 
painful  eye  must  be  enucleated.  Should  the  lens  be  knocked  into  the  anterior 
chamber,  or  fall  through  the  pupil,  extraction  is  imperative  Spontaneous 
luxation  of  the  lens  is  often  seen  hi  coloboma  of  the  ins,  with  defective  devel- 
opment of  the  zone  of  Zinn.  I  recall  several  curious  cases  of  this  kind.  I5ut 
even  in  the  absence  of  any  congenital  deformity  of  the  eye,  family  peculiar!- 
ties  exist  which  predispose  to  spontaneous  luxation. 

I  have  now  under  treatment  a  man,  48  years  old.  He  felt  some  trouble  in  the  right 
eye  after  liftincr,  and  called  for  advice.  There  was  ectopia  of  the  lens  downwards,  the 
edo-e  showing  hi  the  pupil,  but  with  no  pain  or  irritation.  With  a  weak  cataract  lens 
the  vision  was  two-fifths.  At  first  the  edge  of  the  lens  was  at  the  centre  of  the  pupil 
but  in  three  or  four  days  the  displacement  downwards  was  complete  ;  the  eye  remained 
comfortable,  and  the  sight  the  same,  for  some  months.  Then  one  day,  while  he  was 
stoopinc  over  a  shrub,  the  eye  was  struck  by  the  end  of  a  twig  ;  four  days  afterwards  the 
eye  wa^  painful,  tender  to  hght,  and  weeping,  the  ball  sore  to  the  touch  with  marked 
ciliary  in  ection  and  discoloration  of  the  iris,  but  no  increase  of  tension.  I  prescribed  a 
weak  solution  of  atroping,  and  enjoined  quiet.  Next  morning  the  eye  was  much  better  in 
all  respects  ;  but  the  same  afternoon,  while  stooping  for  a  book,  he  felt  something  give 
wav  ''  and  was  suddenly  blind.  I  found  the  lens,  inclosed  in  its  capsule  and  partially 
cataractous,  in  the  anterior  chamber.  He  was  kept  quiet  for  twenty-four  hours,  under 
the  local  use  of  eserine,  and  then  the  lens  was  extracted  by  a  large  corneal  incision 
downwards.  No  vitreous  was  lost,  but  the  iris  prolapsed  very  shghtly,  the  protruciing 
portion  being  then  snipped  off.  For  some  days  the  patient  was  kept  in  bed,  and  suffered 
L  ..ood  deal  of  pain,  but  he  recovered,  with  extraordinary  vision,  by  the  aid  of  a 
.  S  9  d  3  d  A4.5,Y=j\.    In  his  left  eye,  with  a  myopia  of  b  d.,  he  lias  a 

vision  of  X.  the  iris  being  tremulous,  and  there  being  some  strioe  of  opacity  in  the  lower 
and  inner  edae  of  the  lens.  Luxation  will  take  place  in  this  eye  at  some  future  time,  in 
his  family  are  five  brothers  and  five  sisters,  seven  of  the  ten  having  perfect  eyes.  One 
brother  has  a  healthy  emmetropic  right  eye,  but  in  the  left  there  is  a  complete  luxation 
outwards,  with  confirmed  glaucoma  and  hopeless  blindness,  the  eye  remaining  comfort- 
able    A  sister  has  also  one  good  eye,  and  one  with  luxation  of  the  lens  into  the  vitreous. 


Glaucoma. 


The  essential  characteristic  of  the  fatal  group  of  symptoms,  c^Wed  glaucoma , 
is  increased  hardness  of  the  globe.     The  strong  maintaining  tunic  is  com- 
posed of  the  sclera  and  cornea.     These  two  parts  physically  so  diflerent 
histologically  are  directly  continuous,  the  fibres  simply  becoming  t^^^^ 
when  mssing  hito  the  cornea,  and  vice  versa.     When  naturally  distended  by 
the  inclosed  transparent  media,  and  the  blood  pressure  of  the  choroidal^  and 
retinal  vessels,  the  sensation  given  to  the  finger  is  called  "  normal  tension 
The  healthy  tone  or  elasticity  of  the  eye,  and  the  various  deviations,  can  only 


GLAUCOMA. 


G45 


be  recognized  by  an  educated  finger.  Education,  bere  and  elsewhere,  is  a 
tedious  process,  acquired  and  preserved  only  by  constant  practice.  But  how 
is  tbe  touch  to  be  applied  in  this  delicate  investigation?  The  eye  to  be  tested 
must  be  gently  closed,  turned  towards  the  floor,  and  the  head  held  slightly 
backwards.  In  this  quiet  way,  the  surgeon,  sitting,  facing  the  patient  and  in 
easy  command  of  his  own  hands  and  arms,  places  the  two  index  fingers,  close 
together,  on  the  globe  of  the  eye  above.  The  undivided  attention  must  now 
be  transferred  to  the  pulps  of  these  two  fingers.  While  one  is  pressed  with 
some  firmness  on  the  ball  and  held  still,  intermitting  pressure  is  made  with  the 
other,  as  in  feeling  for  fluctuation.  The  quiet  finger  detects  the  rise  and  fall 
of  the  fluctuating  contents  of  the  globe.  The  pressure  sliould  be  directed  per- 
pendicularly to  the  surface,  but  not  hard  enough  to  produce  pain.  The 
natural  eye  is  yielding  and  elastic.  In  high  degrees  of  morbid  tension  it  may 
be  stony  hard. 

A  convenient  system  of  abbreviations  has  been  adopted,  to  express  the 
degree  of  tension  :  T  n,  tension  normal ;  T ?,  tension  doubtful ;  T  -i- 1,  T  +  2,  T  +  3, 
indicate  increased  tension;  T— ,  tension  diminished;  and  T  — 1-2  — 3,  three 
degrees  of  softening.    When  there  is  great  increase  of  intra-ocular  tension,  or 
the  reverse,  it  is  easily  recognized.    But  slighter  variations  require  great  tact 
and  attention.     Both  eyes  should  be  examined  in  quick  succession,  trans- 
ferring the  lingers  from  one  to  the  other.    The  hardness  of  glaucoma  often 
varies  at  short  intervals.    The  test  should  be  applied  every  day,  or  oftener,  so 
as  to  surely  detect  this  important  symptom  at  the  earliest  possible  period, 
and  watch  its  varying  degrees.    It  is  difficult  to  conceive  how^  this  pathog- 
nomonic symptom  is  brought  about,  except  by  hypersecretion  of  intra-ocular 
fluids,  or  by  diminished  exosmosis,  or  by  both  together.    When  these  two 
processes  are  balanced  in  the  nutritive  changes  within  the  eye,  normal  tension 
results.    A  natural  secretion,  with  obstructed  outward  current,  might  produce 
increased  tension.    Hypersecretion,  with  free  outward  flow,  might  cause  the 
same  thing.    But  these  tw^o  diseased  conditions  are  usually  united.  What 
is  the  immediate  cause,  and  whence  the  source,  of  this  excessive  secretion? 
Where  is  the  seat,  and  what  is  the  pathology,  of  the  retarded  exosmosis  ? 
Theories,  Sind  facts  to  suit,  are  by  no  means  wanting.    But  none  yet  proposed, 
explains  all  the  conditions  of  the  glaucomatous  process.    Even  the  essential 
fact  of  glaucoma,  increased  tension,  urged  by  Yon  Graefe  as  a  satisfactory  ex- 
planation of  all  the  phenomena,  has  recently  been  denied.    While  perhaps 
always  present  in  the  advanced  stage,  it  is  said  tobenot  essential  to  the  existence 
of  glaucoma,  and  not  an  initial  symptom.    The  immense  weight  of  authority, 
however,  is  on  the  other  side,  the  differences  of  opinion  being  as  to  the  origin 
of  the  increased  pressure.     Is  the  process  a  neurosis,  or  an  inflammation," or 
both?    The  first  was  assumed  by  Bonders  as  the  best  explanation.  Others, 
claiming  to  have  found  traces  of  inflanmiation  in  the  uveal  tract  and  in  the 
optic  nerve,  have  put  this  forward  as  the  forming  stage,  antedating  increased 
tension.     Increase  in  size  of  the  lens,  swelling  of  the  ciliary  processes, 
and  diminution  of  tlie  marginal  space  between  the  two,  have  been  considered 
the  first  step  in  this  disease.    Eetardation  in  the  outflow  of  fluids  from  the 
eye,  at  the  angle  of  the  anterior  chamber,  followed  necessarily  by  increased 
tension,  explains  the  other  phenomena.    It  is  generally  conceded  that  in  most 
cases  of  glaucoma,  there  is  compression  of  the  angle  of  the  anterior  chamber, 
by  a  drawing  forward  and  adhesion  of  the  outer  rim  of  the  iris  to  the  trabe- 
culee  of  Fontana's  spaces.    In  this  way  a  check  of  the  current  of  intra-ocular 
fluids  towards  the  canal  of  Schlemm  and  the  surface  of  the  eye,  is  produced. 
But  whether  this  is  primary  and  causal,  or  secondary,  is  still  a  much  disputed 
question. 

But  with  all  this  theoretical  bewilderment,  there  is  a  sad  ireneral  ao:ree- 


G46         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


ment  in  the  prognosis,  and  the  urgent  necessity  of  surgical  treatment  in  most 
cases.  Just  how  an  iridectomy  or  sclerotomy  permanently  relieves  this  fatal 
pressure,  is  as  little  understood  now  as  in  the  time  of  Von  Graefe.  For  accu- 
racy of  description,  glaucoma  is  divided  into  simple,  acute,  chronic  inflam- 
matory, secondary,  and  hemorrhagic. 

Simple  glaucoma  is  chronic  and  insidious  in  its  course,  with  very  slow 
failure  of  sight,  and  is  not  attended  by  pain  or  inflammatory  indications. 
For  these  reasons  it  generally  escapes  detection  till  the  sight  of  one  or  both 
eyes  is  much  impaired.  The  patient  has  always  had  an  unaccountable 
difficulty  in  getting  satisfactory  glasses,  has  had  to  change  them  often  for 
stronger  ones,  and  at  last  cannot  see  much  with  any.  If  before,  or  at  this 
time,'^he  has  sought  medical  advice,  he  has  probably  been  told  that^  his 
disease  was  cataract,  and  that  he  could  not  be  operated  upon  till  he  was  blind  1 

As  glaucoma  and  cataract  often  exist  together,  and  are  both  especially  dis- 
eases of  advanced  years,  this  fatal  error  of  diagnosis  is  all  the  more  easy  and 
common.  The  senile  change  of  color  in  the  lens  to  a  grayish  or  amber  hue, 
whether  the  eye  is  glaucomatous  or  not,  readily  imposes  on  the  careless  or 
incompetent  surgeon.  _  .  i  i 

In  addition  to  rapid  failure  of  accommodation  and  trouble  with  glasses, 
smokinessof  vision,  fluctuating  but  slowly  increasing,  comes  on,  and  the 
patient  remarks  a  colored  halo  around  the  lamp  or  candle  at  night.  These 
vao'ue  troubles  often  persist  for  years  before  he  seeks  competent  advice,  and 
is  told  that  he  is  going  hopelessly  blind.  If  vision  is  already  greatly  reduced, 
the  pupil  will  be\induly  large,  and  sluggish  in  response  to  light.  The  ante- 
rior chamber  is  shallow,  the  tension  exaggerated,  visual  acuity  diminished, 
and  the  field  of  vision  contracted,  sometimes  concentrically,  but  usually  more 
on  the  nasal  side.    Rarely  there  may  be  a  central  scotoma. 

In  this  form  of  glaucoma,  the  humors  are  perfectly  clear,  and  a  most 
important  ophthalmoscopic  symptom  is  detected.     I  mean  cypping  of  the 
optic  disk.    The  eye  end  of  the  optic  nerve  yields  to  the  increased  internal 
pressure,  and  gives  rise  to  this  characteristic  symptom.    The  cup  or  excava- 
tion involves  the  entire  disk,  or  nearly  so,  and  looks  very  diflferent  from  the 
small  central  pit  present  in  all  healthy  eyes.    The  edges  are  abrupt,  and  the 
main  trunks  of  the  retinal  vessels  seem  suddenly  cut  off,  as  though  cut  out 
with  a  punch.    Those  who  explain  this  symptom  by  a  retraction  of  the  optic 
nerve  from  previous  inflammation  in  its  sheath  and  texture,  of  course  attach 
less  importance  to  the  pressure.    As  the  few  large  trunks  of  the  retinal  ves- 
sels radiate  from  the  optic-nerve  centre,  when  this  surface  is  pressed  back 
and  converted  into  a  pit,  these  vessels  will  be  suddenly  bent  as  they  dip  down 
into  it.  The  bottom  of  this  pit  being  out  of  focus  when  the  edges  are  m  focus, 
they  seem  to  be  cut  offi    But  when  the  bottom  is  focused,  they  are  distinctly 
seen  going  to  its  centre,  and,  by  looking  obliquely,  they  may  be  traced  down  the 
abrupt  sides.   The  diflerence  in  the  glasses  required  to  bring  into  sharp  view 
the  retinal  margin  of  the  excavation  and  the  bottom  of  the  cup,  is  an  accu- 
rate measure  of  its  depth.    Another  symptom,  often  present,  is  visible  pulsa- 
tion of  the  arterial  trunks  on  the  disk.    If  this  is  not  seen  spontaneously,  it 
may  be  developed  by  very  slight  pressure  on  the  ball  with  the  finger.  Swell- 
ino-  and  falling  of  the  veins,  synchronous  with  the  heart's  movements,  may 
offen  be  seen  in  healthy  eyes,  but  pulsation  of  the  arteries  is  never  seen 
except  in  disease.    Undoubted  hardness  of  the  eye  to  the  finger,  cupping  of 
the  disk,  and  pulsation  of  the  retinal  arteries,  are  infallible  evidences  of 
p-laucoma.    Of  course,  the  history  and  other  symptoms  mentioned,  must  not 
be  forgotten.    The  lamina  cribrosa  of  the  sclera  resists  more  in  some  than 
in  others,  and  hence  the  cup  varies  in  depth  even  with  the  same  pressure. 


GLAUCOMA. 


647 


At  times  enormous  cups  may  be  detected,  with  slight  increase  of  tension, 
and  at  others  exti-erae  hardness  and  great  damage  to  siglit,  with  little  or 
no  pit.  If  the  pressure  has  come  on  very  slow^ly,  the  vision  fails  less 
rapidly.  The  damage  to  sight  is  due  to  the  paralyzing  effect  of  undue 
pressure  on  the  conducting  libres  of  the  optic  nerve,  their  sudden  flexure  in 
the  pit,  and  the  impaired  retinal  blood  supply.  Mauthner  denies  this  usual 
explanation,  and  insists  that  the  functional  failure  is  due  to  disease  of  the 
choroid  affecting  the  rods  and  cones  of  the  retina.  Sometimes  the  natural 
brilliancy  of  the  iris,  the  activity  and  average  size  of  the  pupil,  and  the  out- 
ward appearance  of  the  eye  are  so  little  changed,  that  the  increased  hardness, 
cupping  of  the  disk,  and  failure  of  vision,  are  the  only  positive  symptoms. 
But  these  are  sufficient  to  settle  the  diagnosis.  While  glaucoma  simplex  may 
last  for  years  and  lead  to  total  blindness  without  any  inflammation  at  all, 
this  painful  complication  is  apt  to  occur,  especially  in  the  advanced  stages  of 
the  disease,  when  it  adds  to  the  torment  of  the  hopeless  loss  of  sight. 

Acute  glaucoma  is  always  inflammatory,  and  often  excessively  painful, 
extinguishing  sight  in  a  few  hours  or  days.  The  epithelium  of  the  cornea  is 
altered,  the  aqueous  turbid,  and  the  vitreous  cloudy  and  showing  floating  cor- 
puscles, so  that  the  fundus  cannot  be  seen  with  the  ophthalmoscope.  Intense 
episcleral  injection,  chemosis,  pufliness  of  the  lids,  and  excruciating  pains  in 
the  eye,  circumorbital  region,  and  head,  with  perhaps  nausea  and  vomiting, 
make  up  the  frightful  picture.  Of  course  the  ball  is  intensely  hard,  with  in- 
sensibility of  the  cornea  to  light  touches  with  a  brush  or  probe.  Indeed, 
ansesthesia  of  the  cornea  is  present  in  greater  or  less  degree  in  all  forms  of 
2:laucoma.  It  is  due  to  paralysis  of  the  sensory  corneal  nerves  from  pressure. 
Acute  glaucoma  is  sometimes  preceded,  for  wrecks  or  months,  by  prodromic 
svmptoms,  such  as  temporary  blurring  of  vision  with  increase  of  tension,  some 
vague  feeling  of  discomfort  or  actual  pain,  and  more  or  less  injection.  These 
significant  symptoms  intermit,  leaving  the  sight  better  in  the  intervals.  But 
they  come  oftener,  last  longer,  leave  the  sight  each  time  worse  than  before, 
and  end  at  last  in  a  destructive  attack  of  acute  inflammation.  More  rarely, 
the  disease  bursts  out  in  all  its  violence  without  previous  warning,  in  glaucoma 
fulminans. 

Chronic  inflammatory  glaucoma  develops  slowly  like  the  simple  variety, 
but  always  with  symptoms  of  vascular  reaction.  With  the  peculiar  hardness 
of  the  eye,  there  are  cupping  of  the  disk  and  pulsation  of  the  arteries,  if  the 
humors  are  clear  enough  to  admit  of  ophthalmoscopic  examination.  Beginning 
in  one  eye,  it  finally  attacks  both,  but  sometimes  after  a  very  long  interval. 
Yon  Graefe  believed  that  the  occurrence  of  the  disease  in  the  second  eye  was 
hastened  by  iridectomy  in  the  first.  I  believe  this  to  be  a  mere  coincidence,  but 
the  non-affected  eye  should  be  constantly  w^atched,  so  that  an  iridectomy  may 
be  resorted  to  at  once,  if  the  necessity  should  arise.  The  varicose,  inosculating 
loops  of  bloodvessels  around  the  cornea,  are  very  striking  in  the  inflammatory 
forms  of  glaucoma.  The  advanced  stages  of  all  the  varieties,  when  sight  is 
extinguished,  the  ball  stony  hard,  the  pupil  widely  dilated,  the  iris  atrophied 
and  reduced  to  a  narrow  rim,  the  sclera  of  a  grayish,  leaden  color,  wnth 
large  loops  of  tortuous  veins,  loss  of  tactile  feeling  in  the  cornea,  and  often 
cataract,  are  called  glaucoma  absolutum.  In  this  pitiable  condition,  repeated 
and  painful  intra-ocular  hemorrhages  take  place,  the  insensible  cornea  may 
slough,  and  the  eyes  may  be  reduced  hy  atrophy  of  the  globe.  In  the  absolute 
glaucoma  which  follows  the  simple  variety,  the  deep  excavation  of  the  optic 
nerve  and  excessive  tension  may  be  the  only  means  of  distinguishing  it  from 
hopeless  atrophy  of  the  optic  nerve. 


G48.       INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

Secondary  Glaucoma.— Jn  the  former  varieties,  the  destructive  hardness, 
with  its  long  list  of  fatal  consequences,  seems  to  be  primary.  In  this  it 
develops  in  the  course  of  numerous  other  diseases,  and  is  hence  called 
t^econdari/  A  frequent  causal  connection  exists  between  increased  tension 
and  synechia  anterior  from  perforating  ulcers  of  the  cornea.  Luxation  of 
,1  _      .  .  4-^^r.r.,.a  r^r^  +vunmQfin  filrYioRt  surclv  Icads  to  fflaucomatous  mani- 


cutting 


and  so  may  fragments  ot  a  DroKen-up  lens.  sjuecuia  pv.^uoii^.,^^..x.x5 

off  communication  between  the  two  aqueous  chambers,  generally  leads  to 
destruction  of  sight  from  glaucoma.    Serous  iridochoroiditis  is  very  apt  to 
lead  to  secondary  glaucoma.    Intra-ocular  tumors  -ot  all  kiiids  give  rise 
z  -   ^„:,.  fVirv^T.  n-i^z-.wfVi      In  nil  forms  ot  ecta 


lead  to  secondary  glaucoma,    intra-ocuiar  tumors -oi  aii  k  nxi«  giv«  ii^c 
increased  tension  at  a  certain  stage  of  their  growth.    In  all  forms  of  ectasia 
of  the  eyeball,  congenital  or  not,  leading  to  great  enlargement  ot  the  eye— 
hydroplithalmus-the  sight  is  surely  destroyed  in  the  end  by  glaucoma.  In 
such  cases,  enormous  excavations  of  the  optic  disk  are  usually  tound. 

Hemorrhagic  Glaucoma.— The  most  hopeless  form  of  glaucoma,  primary  or 
secondary,  is  the  hemorrhagic.  The  retinal  hemorrhages  are  apt  to  take  place 
suddenly  in  the  central  region  and  around  the  optic  disk.  At  first  it  is  dilh- 
cult  to  foresee  what  the  ecchymoses  indicate,  but  the  increased  hardness  tells 
the  story  Such  hemorrhages,  often  seemingly  without  cause,  m  persons  ot 
advanced  years,  are  very  apt  to  be  the  forerunners  of  this  most  pernicious  and 
unmanageable  form  of  glaucoma. 

Treatment  of  Glaucoma.— Every  glaucomatous  eye,  when  left  to  itself, 
terminates  in  hopeless  blindness.   The  immortal  discovery  of  Von  Graefe  made 
an  epoch  in  the  history  of  human  sorrow.    Till  iridectomy  was  found  to  be  a 
reasonably  certain  remedy  for  the  morbid  hardness  of  the  globe  but  the  one 
sad  fate  awaited  every  such  case.    But  we  know  as  little  still  about  the  way 
in  which  this  operation  permanently  reduces  the  mtra-ocu  ar  tension,  as  we 
do  of  the  immediate  cause  of  the  increased  pressure.    The  success  ot  the 
treatment,  however,  in  the  majority  of  cases,  is  not  now  disputed.  Since 
that  forward  stride  in  the  therapeutics  of  this  process  was  made,  it  has  been 
discovered  that  eserine  and  pilocarpine,  in  addition  to  their  action  m  con- 
tracting: the  pupil,  possess  the  power  of  reducing  the  tension  of  glaucoma, 
and,  in  rare  cases,  permanently.    Usually,  however,  the  action  is  transient, 
and  in  the  chronic  forms  not  even  temporary  relief  is  afforded  ;  so  that  we  are 
forced  to  fall  back  upon  surgical  treatment  at  last.    The  earlier  iridectomy 
is  practised,  the  -reater  is  the  certainty  of  savmg  useful  sight;  hence  the 
immense  importance  of  an  early  diagnosis.    Eveij  surgeon  and  pbysician 
should  be  able  to  make  the  diagnosis  promptly  and  thus  avoid  delay  Ihe 
section,  for  cosmetic  and  visual  reasons,  is  generally  made  upwards,  so  that  the 
mutilation  of  the  iris  shall  be  covered  by  the  upper  hd.    An  incision,  of  from 
6  to  8  mm.,  is  to  be  made  at  the  sclero-corneal  junction,  as  near  the  periphery 
as  possible.    This  is  best  done  by  a  Graefe's  cataract  knife,  especially  where 
the  chamber  is  very  shallow,  as  it  certainly  will  be  m  many  cases  The 
puncture  and  counter-puncture  must  be  made  as  m  the  incision  for  extraction 
of  cataract,  and  the  point  of  the  knife  closely  watched  as  it  traverses  the 
chamber,  close  in  front  of  the  iris.    If  the  ins  prolapses  on  completing  the 
section,  it  may  be  seized  by  the  fine,  toothed  forceps,  drawn  well  out,  and 
held  steadily  till  cut  off  with  scissors  close  to  the  sc  era.    Two  snips  are 
required,  beginning  at  one  end  of  the  incision  and  finishmg  at  the  other,  the 
Assistant  pulling  the  iris  a  little  tighter  after  the  first  snip.    The  object  is  to 
excise  a  broad  portion  of  the  iris  reaching  quite  to  the  P-j^^l^^^'  ^1^^^^^^^^ 
prolapsus  occur,  the  closed  forceps  must  be  passed  caretully  into  the  chambei, 


GLAUCOMA. 


649 


opened  well  and  closed  again,  thus  seizing  and  slowly  drawing  out  the  iris. 
The  previous  use  of  eserine,  to  contract  the  pupil  as  much  as  possible,  facili- 
tates the  operation,  and  diminishes  the  risk  of  wounding  the  lens  capsule. 
After  the  iris  has  been  properly  snipped,  the  eye  should  be  instantly  shut,  and 
gentle  compression  made,  to  avoid  intra-ocular  hemorrhage.  After  a  few 
minutes  let  the  eye  be  carefully  opened  and  inspected.  If  any  iris  remain 
imprisoned  in  either  angle  of  the  cut,  it  must  be  seized,  stretched,  and  snipped 
off.  If  the  scleral  section  is  not  freed  from  iris,  trouble  and  doubtful  relief 
are  to  be  expected.  Of  course,  the  wire  speculum  and  the  fixation  forceps 
are  always  necessary,  and,  in  most  cases,  etherization.  The  same  steps  and 
precautions  are  to  be  taken  as  in  Graefe's  method  of  extraction,  except  that 
the  incision  into  the  anterior  chamber  is  shorter.  The  suspensory  ligament 
and  capsule  of  the  lens  must  not  be  injured  ;  the  eye  should  be  kept  lightly 
bandaged,  and  the  patient  quietly  in  bed,  for  a  few  days. 

In  acute  glaucoma^  this  operation,  executed  properly,  and  within  a  few  days, 
shows  its  greatest  triumphs.  The  longer  it  is  delayed,  the  greater  doubt  as  to 
success.  In  most  cases  of  chronic^  simple  glaucoma^  it  fails  to  save  useful  vision, 
but  the  patient  should  have  the  only  chance.  In  chronic^  wjiammatory  glau- 
coma it  promises  better,  but  often  fails  to  afford  permanent  benefit  to  sight. 
It  relieves  tension  generally,  and  saves  the  patient  from  much  suffering  in  the 
future,  at  all  events.  In  both  these  varieties,  it  is  sometimes  necessary  to 
do  a  second  iridectomy,  below  and  opposite  the  first,  to  achieve  permanent 
softening  of  the  eye.  In  secondary  glaucoma^  in  addition  to  removing  the 
cause  as  far  as  possible,  an  iridectomy  should  always  be  done,  and  will  often 
succeed  in  saving  the  eye.  For  heinorrhagic  glaucoma,  the  operation  should 
never  be  risked.  Immediate  extinction  of  sight  from  profuse  intra-ocular 
hemorrhage  w^ould  be  almost  sure  to  follow,  and,  even  if  it  did  not,  the  vision 
would  be  lost  at  last.  Of  course,  in  confirmed  glaucoma,  where  no  hope  of 
sight  can  be  entertained,  the  operation  should  be  avoided,  except,  it  may  be, 
to  relieve  extreme  pain.  Its  execution  is  then  very  difficult,  and  enucleation 
will  at  last  give  the  safest  and  surest  relief  from  suffering.  In  rare  cases  of 
glaucoma  simplex,  and  in  other  more  promising  forms,  the  best  executed  ope- 
ration may  be  followed  by  rapid  and  complete  loss  of  sight.  While  this 
possibility  should  be  remembered,  it  should  not  deter  us  from  a  resort  to  the 
only  hope  of  relief. 

The  theory  that  explains  the  mechanism  of  operations  for  the  cure  of 
glaucoma  by  the  filtration  cicatrix,  has  suggested  sclerotomy.  A  larger 
experience  with  this  method  must  decide  on  its  comparative  merits.  If  any 
operation  is  to  be  performed  in  hemorrhagic  glaucoma,  this  is  the  safest  and 
the  only  one  to  be  recommended.  In  the  chronic  and  doubtful  forms,  it  may 
also  be  tried,  as  well  as  in  confirmed  cases.  It  certainly  removes  the  peculiar 
hardness  of  the  globe  in  some  cases,  and  may,  on  fair  and  large  trial,  replace 
iridectomy.  But  the  latter  has  the  firmest  hold  on  the  confidence  of  all  but 
a  few  operators.  The  object  in  sclerotomy  is  to  avoid  mutilating  the  iris, 
and  to  prevent  it  from  prolapsing  into  the  incision.  To  avoid  this,  eserine  is 
freely  used  before  the  operation.  The  first  steps  are  precisely  the  same  as  for 
iridectomy.  After  counter-puncture,  the  knife  is  moved  slowly  backwards 
and  forwards  till  the  scleral  incision  is  nearly  completed.  Then  it  is  slowly 
withdrawn,  allowing  the  aqueous  to  trickle  out  very  gradually,  so  that  the 
iris  may  not  be  w^ashed  into  the  wound.  If  it  prolapses,  the  rubber  spatula 
may  be  used  to  replace  it.  Eserine  and  friction  over  the  cornea,  through  the 
medium  of  the  lid,  may  reduce  it.  If  this  cannot  be  done,  it  will  be'better 
to  draw  the  ins  out  and  snip  it  off.  The  eserine  treatment  may  be  beneficial 
in  relieving  any  hardness  that  sometimes  persists  after  the  surgical  treatment. 


650 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES, 


Again  I  would  warn  against  the  unpardonable  sin  of  mistaking  glaucoma 
for  cataract,  and  of  using  atropine  in  its  treatment. 


Strabismus. 


Definition  and  Varieties.— Strabismus  consists  in  an  inability  to  fix  both 
eyes  on  the  same  point,  at  the  same  moment,  not  due  to  paralysis.    The  two 
eyes  move  freely  together  or  separately,  but  one  deviates  constantly  m  the 
same  direction  and  to  the  same  degree.    Convergent  squint,  m  which  one 
eye  turns  too  far  inwards  while  the  other  fixes,  is  the  most  frequent  variety. 
Divergent  strabismus,  in  which  the  deviation  is  outwards,  is  next  m  frequency. 
Deflection  upivards  or  dowmvards,  is  of  rare  occurrence.     Strabismus  is  a 
deformity,  and  excludes  the  benefits  of  binocular  vision.    The  constant  direc- 
tion and  degree  of  deviation  in  all  possible  positions  of  the  eyes,  establish  the 
most  important  diagnostic  difterence  between  squint  and  faulty  fixation  from 
paralysis.    In  the  one,  the  erratic  eye,  when  solicited,  turns  freely  m  every 
direction.    In  the  other,  it  cannot  be  budged  in  the  direction  of  the  para- 
lyzed muscle.  -,     -,  ^  -1.4- 
Let  us  assume  a  convergent  squint,  m  the  left  eye.    Cover  the  right 
with  a  card  and  compel  the  faulty  eye  to  act.    It  will  fix  and  follow  the 
finder  wherever  normal  fixation  is  possible.    But  the  right  eye  will  now 
squint  behind  the  card.    This  forced,  secondary  deviation  will  be  exactly  the 
same  in  direction  and  quantity,  as  the  primary.    But  simultaneous  fixation 
is  nowhere  possible.    In  paralysis,  binocular  fixation  may  be  easy  m  all  direc- 
tions but  one,  and  the  secondary  displacement  will  be  much  greater  than  the 
primary.    In  no  part  of  the  body  are  delicate  disturbances  of  muscular  equi- 
librium so  quickly  detected,  and  so  annoying,  as  in  the  rotary  muscles  of  the 
eyes.    The  constant  double  vision  cannot  be  ignored. 

Should  a  given  convergence  be  due  to  paresis  of  the  external  rectus,  not  only 
distressing  diplopia,  but  more  or  less  limitation  in  the  outward  movements  of 
the  eye  will  be  detected.  As  before,  suppose  that  the  left  eye  converges  when 
both  are  open.  Cut  off  the  right  with  a  card,  and  the  left  will  follow  the 
finger  readily,  except  when  moved  to  the  left.  While  soHciting  movement 
in  this  direction,  and  without  avail,  notice  the  right  eye  behind  the  card.  It 
will  turn  in  excessively,  almost  burying  itself  behind  the  nose.  Both  eyes 
being  open,  the  patient  will  see  double  in  all  points  to  the  left,  but  single 
to  the  right.  Instinctively,  he  learns  to  avoid  the  horrible  diplopia,  by  turn- 
ino-  the  head  constantly  to  the  left,  thus  bringing  objects  to  his  right.  In 
deviation  from  paralysis,  there  are  constant  errors  of  projection  and  conse- 
quent o-iddiness,  except  when  the  faulty  eye  is  closed.  If  the  patient  tries  to 
walk  with  the  perfect  eye  closed,  he  will  stagger.  In  the  case  assumed,  close 
the  right  eye,  and  holding  your  finger  to  the  left  of  the  patient,  tell  him  to 
touch  it  quickly  with  his  index  finger.    He  will  constantly  thrust  to  the  left 

of  it.  J    •  ^-       -p  + 

The  degree  of  strabismus  may  vary  from  a  mere  cast,  to  a  deviation  ot  ten 
mm.  or  more,  constituting  a  hideous  deformity.  The  linear  deviation  may 
be  measured  with  sufficient  accuracy,  as  follows :  Shut  the  non-squmtmg  eye, 
and  request  the  patient  to  fix  your  finger,  steadily  held  about  ten  inches  m 
front  of  his  nose.  Then,  with  a  pen,  mark  with  ink  the  point  of  the  lower  lid 
that  corresponds  to  the  centre  of  the  pupil.  This  done,  open  tlie  other  eye 
and  tell  him  to  fix  the  same  finger,  held  in  the  same  position.  Ihe  eye  will 
now  deviate  and  an  ink  spot  is  again  made  to  correspond  to  the  centre  ot  the 
pupil.  The  distance  between  these  two  ink  spots  will  be,  m  millimetres,  the 
linear  deviation.    In  the  earlier  periods  of  strabismus,  when  it  is  often  inter- 


STRABISMUS. 


651 


mitteiit,  there  is  perhaps  always  double  vision.  But  by  a  mental  process  of 
abstraction,  the  patient  soon  learns  to  ignore  or  suppress  the  image  of  the 
crooked  eye,  and  thus  gets  rid  of  the  horror  of  diplopia.  This  process  is 
favored  by  a  variety  of  circumstances.  If  the  squint  begins  as  early  as  the  lirst 
or  second  year,  before  the  habit  of  binocular  vision  is  solidly  formed,  the 
habit  is  soon  broken  up  in  the  interest  of  single  vision.  Children  learn  and 
unlearn  habits  far  more  readily  than  older  persons.  Then  one  eye  is  often 
much  more  imperfect  in  sight  than  the  other.  It  is  a  fact  that  many  children 
are  born  with  this  ditference,  and  that  many  such  become  strabismic.  In  that 
case,  the  child  squints  with  the  naturally  defective  eye.  The  more  marked 
the  difference  in  distinctness  of  vision  between  the  two  eyes,  the  easier  it 
becomes  to  fix  the  attention  exclusively  on  the  sharp  image,  and  to  ignore 
the  dim  one. 

In  the  great  majority  of  cases  of  confirmed  squint,  except  when  it  is  alter- 
natinij,  the  constantly  deviating  eye  will  be  found  defective  in  sight.  The  am- 
blyopia is  often  so  great  that  the  patient  cannot  read  even  capital  letters.  The 
fixing  eye  will  be  found  better,  and  generally  perfect  in  sight.  It  has  long  been 
assumed  that  the  defective  vision  in  such  cases  is  due  to  disuse  of  the  eye — aiii- 
blyopia  ex  anopsia.  While  this  may  be  true  in  part,  there  is  reason  to  believe 
that  in  many  cases  the  defective  sight  has  existed  before  the  deviation,  and  has 
played,  perhaps,  an  important  part  in  determining  it.  According  to  Scliweig- 
ger,  for  one  hundred  and  seventy-seven  strabismic  patients  with  one-sided 
amblyopia,  there  will  be  found  ninety-eight  with  a  similar  visual  defect  in  one 
eye,  without  strabismus.  Of  these  ninety-eight  patients,  forty-seven  per  cent, 
will  be  found  hyperopic,  showing  that  hyperopia  and  amblyopia  may  exist 
together,  without  giving  rise,  necessarily,  to  squint.  It  is  quite  probable 
that  the  long-continued  disuse  of  the  squinting  eye  may  increase  a  natural 
and  pre-existing  defect  of  vision.  In  consequence  of  this  disparity,  binocular 
vision  may  never  have  been  learned  at  all,  or  but  imperfectly,  and  in  case  of 
squint,  it  is  readily  unlearned.  Strabismus  is  essentially  a  disease  of  childhood 
or  early  life,  while  paralytic  affections  prevail  more  among  adults,  where 
single  vision  with  two  eyes  has  become  a  long  and  imperious'habit.  A  con- 
firmed habit,  good  or  bad,  is  hard  to  shake  off",  however  important  the  interests 
involved.  Hence  the  diplopia  of  paralysis  is  constant  and  very  harassing,  and 
it  persists  as  long  as  the  cause  endures.  In  intra-uterine  paralysis  or  congenital 
absence  of  one  of  the  recti  muscles,  diplopia  never  occurs.  Persons  thus  affected 
learn  to  blend  the  images  where  both  eyes  command  the  field,  and  to  suppress 
that  of  the  lagging  eye  in  other  directions.  I  recall  the  case  of  a  woman,  forty 
years  old,  whom  I  treated  for  retinitis  alb  ii mini  erica,  from  which  she  recovered 
with  perfect  vision  in  both  eyes.  I  discovered  that  the  right  eye  could  not  be 
rotated  outwards  at  all,  and  expected  to  find  corresponding  diplopia  with  ex- 
aggerated secondary  deviation  of  the  left  eye.  But  neither  symptom  had 
ever  been  present.  It  had  always  been  so,  and  I  found  binocular  vision  in  the 
median  line  and  to  the  left,  and  monocular  single  vision  to  the  right.  In 
looking  at  objects  to  the  right,  she  used  the  left  eye  and  suppressed  the  image 
of  the  right.  I  have  recently  examined  a  young  man  whose  eyes  present  a 
similar  condition  of  aftairs. 

Causes  of  Strabismus.— Till  the  time  of  Bonders,  the  etiology  of  squint 
was  a  matter  of  vague  conjecture.  The  most  absurd  explanations  were  often 
detailed  with  great  assurance,  and  still  are,  even  by  some  physicians.  Bonders 
demonstrated  that  in  two-thirds  of  the  cases  of  convergent  squint,  there  was 
hyperopia,  an  anomaly  of  refraction  imposing  constant  strain  of  accommodation. 
The  constantly  associated  actions  of  convergence  and  accommodation,  and  the 
possibility  of  exaggerating  either  by  emphasizing  the  other,  were  so  fully 


652 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


elucidated  by  him,  that  little  positive  knowledge  has  since  been  added.  His 
theory,  based  on  the  physical  fact  of  hyperopia,  was  that  the  excessive  con- 
vergence of  one  eye  enabled  the  other  to  focus  successfully  for  close  work,  in 
spite  of  the  hyperopia.     The  theory  demands  that  all  hyperopes  should 
become  cross-eyed,  and  in  proportion  to  their  degree  of  hyperopia.    But  this 
does  not  prove  true  in  fact.     As  a  rule,  the  degree  of  hyperopia  in  convergent 
squint,  is  not  excessive.    Some  patients,  with  extreme  degrees  of  hyperopia 
squint,  and  some  do  not,  but  hold  the  book  very  close,  as  if  myopic. ^  There 
are  many  persons  with  hyperopia  in  varying  degrees,  and  often  with  con- 
genital defect  of  sight  in  one  eye,  who  never  squint.    Again,  some  emmetropes 
are  victims  of  strabismus,  both  convergent  and  divergent.     Even  hyperopes 
are  found  affected  with  divergent  strabismus,  and  myopes  with  convergent. 
Hence  there  must  be  some  other  cause,  besides  an  anomaly  of  refraction,  which 
determines  it  in  one  case  and  not  in  another.     What  can  this  be,  and  where 
can  it  attach,  except  to  the  raiiscles  themselves?     In  many  cases,  marked  in- 
sufficiency of  one  rectus  muscle  exists,  and  yet  no  manifest  strabismus  ever 
develops  in  its  antao:onist.    The  impulse  to,  and  predominating  interests  of, 
binocular  vision,  dominate  the  want  of  balance,  and  keep  the  eyes  straight. 
Eut  exclude  one  eye  from  the  visual  act,  and  the  disturbed  muscular  equili- 
brium will  show  itself  at  once.    Direct  the  eyes  to  be  fixed  on  the  point  of 
a  pencil,  at  eight  or  ten  inches,  and  then  slip  a  card  in  front  of  one  eye.  The 
excluded  eye  will  swing  inw^ards  or  outwards,  and  twitch  quickly  back  into 
position  when  the  card  is  removed.    As  a  rule,  the  preponderance  falls  on  the 
side  of  the  internus  in  childhood,  and  of  the  externus  in  later  years. 

Such  cases  of  insufficiency  are  sometimes  called  latent  squint,  but  improperly. 
So  it  seems  that  disturbance  of  the  natural  muscular  balance  alone,  is  not 
enouo:h  to  determine  strabismus,  especially  when  the  vision  is  perfect  in  both 
eyes.'^  Again  in  adults,  associated  with  hyperopia  we  often  find  insufficiency 
of  the  interni,  but  without  strabismus.    Such  patients  complain  of  pain  and 
fatigue  on  close  application  of  the  eyes,  and  often  shut  and  press  on  them  for 
relief.    This  is  muscular  asthenopia,  aggravated  by  hyperopia,  and  yet  with 
no  manifest  squint.    Binocularly,  they  fix  and  see  single,  but  exclude  one  eye, 
and  it  deviates  outwards.    Direct  such  a  patient  to  fix  both  eyes  on  a  pencil, 
constantly  approaching  the  nose.   At  six  inches  or  perhaps  nearer,  one  eye  will 
swing  outwards  and  the  pencil  appear  double,  with  crossed  images.  Tried 
by  other  tests  the  same  insufficiency  of  the  internus  will  show  itself,  and  yet 
the  patient  does  not  squint.    Physiologically,  the  relative  power  of  the  two 
muscles  is  largely  in  favor  of  the  internus.    In  ordinary  avocations,  the 
interni  are  in  almost  constant  use,  converging  the  eyes  for  finite  distances. 
The  external,  at  most  are  only  called  on  to  reduce  the  eyes  from  convergence 
to  parallelism.    Hence  the  far  greater  strength  of  the  internal  recti  muscles. 
A  glass  prism  before  one  eye,^with  its  refracting  angle  towards  the  nose, 
produces  double  vision  by  deflecting  the  image  towards  its  base.  Single 
vision  can  only  be  restored  by  an  extra  action  of  the  internal  rectus,  converg- 
ing the  eye  behind  the  prism.    If  the  prism  be  reversed,  diplopia  will  again 
ensue,  and  the  external  rectus  is  called  on  to  relieve  it.    The  strongest  prism 
that  either  muscle  can  thus  overcome,  in  the  interest  of  single  vision,  will  be 
a  reasonable  measure  of  its  strength.    It  is  much  easier  to  overcome  strong 
prisms  at  ten  or  twelve  inches,  than  at  twenty  feet.    Ulrich  suggests  that  it 
is  well  to  test  the  eyes  for  an  object  at  twenty-five  centimetres  (about  ten 
inches),  and  at  six  metres  (nearly  twenty  feet).    In  emmetropes,  a  ^o.  six  or 
seven  prism  can  be  neutralized  by  the  externus,  but  one  very  much  stronger 
by  the  internus.    Ulrich  gives  the  average  normal  power  of  the  converging 
muscles  at  forty-five,  and  assumes  pathological  weakness  when  they  cease  to 
neutralize  a  prism  of  twenty-five  to  thirty.    Starting  from  these  premises  to 


STRABISMUS. 


653 


investigate  the  relative  muscular  strength  in  hyperopes,  where  convergent 
strabismus  does  not  exist,  Ulrich  concludes  that  all  patients  with  hyperopia, 
who  do  not  squint,  have  insufficiency  of  the  internal  recti  muscles. 

This  original  difterence  in  muscular  balance  would  seem  to  account  for  the 
fact  that  a  blind  eye,  in  course  of  time,  will  sometimes  converge,  at  others 
diverge,  and  at  others  remain  straight.    The  same  explanation  applies  to  the 
occasfonal  occurrence  of  either  convergent  or  divergent  scpiint  in  emmetropes. 
Even  hyperopes  sometimes  become  victims  of  divergent  strabismus.    I  am 
treating  a  young  man  who,  when  he  came  to  me,  had  a  divergence  of  ten  mm., 
and  who  habitually  lixed  with  the  right  eye,  for  all  distances.  ^  In  that  eye  he 
was  myopic  three  dioptrics  (twelve  inches).    Of  course  his  vision  for  distance 
was  very  imperfect,  and  he  had  never  worn  glasses.  AVith  a  correcting  concave 
glass,  the  remote  vision  was  perfect.    To  my  surprise,  when  the  right  eye  was 
covered,  and  the  divergent,  left  eye  brought  to  bear,  his  distant  sight  was  found 
perfect,  and  the  eye  enimetropic.  Yet  he  constantly  fixed  Avith  the  right  eye  and 
suppressed  the  imao-e  of  the  left,  seeing  very  poorly  at  a  distance,  and  reading 
well  and  exclusively  with  the  myopic  right  eye.    I  have  frequently  seen 
patients  with  one  near-sighted  and  one  long-range  eye.    But  they  fix  distant 
objects  with  the  one  andV^ad  with  the  other.    How  shall  we  account  for  the 
reinarkable  exception  presented  in  tliis  case?    I  can  explain  it  by  supposing 
that,  when  the  strabismus  developed  ten  years  ago,  both  eyes  were  emmetropic 
and  equal  in  vision.  But  the  patient  learned  to  fix  constantly  with  the  right 
eye,  and  to  suppress  the  image  of  the  left.    At  last  myopia  developed  in  the. 
eye  constantly  used,  and  the'"old  habit  of  exclusively  fixing  with  it  persisted. 
He  remembers  that  distant  vision  has  become  very  much  impaired  in  the  last 
three  years.    I  have  divided  in  succession  both  external  recti,  and  have  thus 
irreatlv  reduced  the  degree  of  divergence.    Since  the  last  operation  he  has 
fearned  to  fix  distant  objects  with  the  left  eye,  while  he  still  reads  with  the 
right,  having  o-ained  very  greatly  in  range  of  vision.    By  an  advancement  of 
the  internal'i'ectus  of  one  eye,  I  expect  to  correct  the  remainhig  divergence. 

A  long  experience  has  taught  me  that  insufficiency  of  the  interni  is  one 
of  the  most  troublesome  complications  in  non-squinting  hyperopes.  In  them 
we  have  to  combat  muscular  and  accommodative  asthenopia  at  the  same  time. 

Etiology  of  Divergent  Strabismus.— In  the  great  majority  of  cases,  diverg- 
ence of  the  eyes  is  seen  in  myopic  subjects.  In  these,  the  increased  size  of. 
the  globe  antero-posteriorly,  is  caused  by  bulging  of  the  back  part  of  the  eye. 
The" direction  of  this  stai)hyloma  posticum  is  such  as  to  favor  the  power  of 
the  externi.  Such  persons  have  little  use  for  their  accommodation.  Hence 
convergence  is  not  dominated  by  the  focusing  impulse,  as  in  other  forms  of 
refraction.  Myopes  of  high  degree  must  bring  objects  very  near  in  order  to 
see  them  sharply.  The  resulting,  painful  degree  of  convergence,  unaided  by 
impulses  of  accommodation,  cannot  be  maintained  for  protracted,  close  work. 
Soon  one  or  the  other  eye  turns  outwards,  and  monocular  vision  is  adopted. 
The  amount  of  myopia,  as  well  as  the  acuity  of  vision,  often  difters  in  the  two 
eyes,  making  prolonged  binocular  fixation  still  more  difficult.  The  most 
myopic  and  defective  soon  yields  to  the  pressing  tendency,  and  diverges.  But 
heVe  again  some  other  factor,  besides  the  state  of  rd:raction,  is  required  to 
explain  the  occasional  presence  of  myopia  without  divergent,  or  even  with 
convergent,  strabismus.  The  original,  relative  length  and  strength  of  the 
externus  and  of  the  internus,  have  something  to  do  in  bringing  about  stra- 
bismus. The  chapter  on  the  etiology  of  strabismus,  in  all  its  details,  is  not 
yet  written. 

Treatment  of  Strabismus. — It  is  well  to  remember  that  some  cases  of  squint 
recover  spontaneously.   In  my  observation,  however,  such  cases  are  very  rare. 


654 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


The  few  recoveries  that  I  have  seen,  have  been  only  partial,  some  appreciable 
deviation  being  still  detected.  It  is  chiefly  in  convergent  strabismus  that  these 
favorable  changes  take  place,  with  the  progress  of  years  and  the  disappearance 
of  active  accommodation,  and  though  I  cannot  agree  with  De  Wecker,  who 
asserts  that  the  majority  of  cases  of  convergent  strabismus  get  well  spontane- 
ously, if  let  alone,  still,  the  dominating  influence  of  accommodation  over  con- 
vergence  in  early  years,  and  its  subsidence  in  advanced  years,  should  not  be 
forgotten.    In  intermittent  squint,  beginning  in  childhood,  and  being  the  first 
stage,  often,  of  fixed  deformity,  it  is  sometimes  possible  to  efl:ect  a  cure  without 
operation.    The  cross  is  only  noticed  when  the  child  looks  closely  at  small 
objects,  or  is  embarrassed,  or  perhaps  deranged  in  health.    Appearing  more 
and  more  frequently,  at  length  permanent  contraction  of  the  prevailing  muscle 
is  the  result.    This  variety  is  frequent  in  hyperopic  children,  and  shows  itself 
about  the  time  they  are  put  to  school.    If  the  sight  is  equal  and  perfect  in  each 
eye,  the  prospect  of  cure  by  hygienic  and  medical  treatment  is  greatly  enhanced. 
But  equality  or  perfection  of  sight,  at  this  early  age,  before  the  child  knows 
its  letters,  is  very  diflacult  to  determine.     Still,  an  effort  at  cure  should  be 
attempted.  The  well-known  influence  of  spasm  of  the  ciliary  muscle  in  exag- 
gerating convergence,  should  be  neutralized.   This  is  best  done  by  instillations 
of  atropia.    One  or  two  drops  of  a  one-grain  solution,  may  be  safely  dropped 
into  the  eyes  of  the  child  twice  a  day.     Often  little  or  no  tendency  to  squint 
will  show  itself  while  this  treatment  is  kept  up,  and  by  perseverance  for  weeks 
or  months  a  permanent  cure  may  be  brought  about.    Homatropine  in  stronger 
solution  (four  grains  to  the  ounce)  can  be  used  in  the  same  way,  and  is  less 
likely  to  produce  constitutional  disturbance.    Eserine  has  likewise  been  tried 
for  the  same  object.    Its  action  is  to  stimulate  the  accommodation,  and  thus 
enable  the  eyes  to  overcome  the  hyperopia  without  excessive  convergence.  But 
in  children  under  five  years,  in  which  this  treatment  promises  best,  one  cannot 
risk  the  constant  use  of  convex  glasses  to  neutralize  the  hyperopia  while  the 
atropine  treatment  is  carried  out,  and  afterwards.  Strabismus  that  can  be  con- 
trolled by  atropine  or  by  glasses,  or  both,  if  operated  on,  will  probably  show 
divero-ent  eyes  in  after  years.    All  close  use  of  the  eyes  for  study  must  be 
interdicted,  and  the  use  of  tonics,  aided  by  fresh  air  and  good  regular  diet, 
enforced.    Goggles  and  other  devices  cannot  correct  the  squint,  but  may  be 
of  use  in  compelling  separate  exercise  of  the  eyes. 

Training  with  the  stereoscope,  as  recommended  by  Javal,  involves  a  degree 
of  intelligence  and  attention  not  possible  in  children.  Confirmed  strabismus, 
not  controlled  at  all  by  atropine  and  convex  glasses,  demands  surgical  inter- 
ference, and  the  earlier  it  is  resorted  to  the  better  the  success.  There  is  no 
deformity  where  a  timely  and  skilful  operation  is  so  certainly  successful.  In 
the  few  cases  in  which  tenotomy  produces  little  or  no  effect,  a  proper  advance- 
ment of  the  antagonist  muscle  secures  the  end  desired.  These  two  operations 
may  often  be  happily  combined.  But  great  circumspection,  skill,  and  patience, 
are  required  to  secure  an  abiding,  good  result.  The  zeal  of  inexperienced  opera- 
tors to  obtain  an  immediate  and  complete  correction,  often  leads  them  to  do  a 
double  tenotomy  at  once.  This  may  be  very  gratifying  to  the  parents  or  friends, 
and  secure  a  cheerful  honorarium,  and  yet  may  be  a  curse  to  the  patient  in  the 
ultimate  course  of  life.  Insufliciency  of  the  severed  muscles,  and  unsightly  diver- 
gence in  after  years,  may  drive  the  patient  to  wish  that  his  benefactor,  now  per- 
haps happily  dead,  had  never  lived!  Such  a  deformity  is  far  greater  and  more 
difficult  to  remedy  than  the  original  squint.  A  rightly  proportioned  and  skil- 
fully executed  advancement,  however,  may  triumph  even  over  these  unfortu- 
nate excesses.  What  operator  of  long  experience  has  not  had  these  dilemmas 
with  divergent  horns,  come  back  on  him  in  the  winter  of  his  discontent  ?  Per- 
haps more  of  them  fall  into  other  hands.    Thoughtful  operators  proceed  with 


STRABISMUS. 


655 


great  prudence,  preferring  too  little  immediate  effect  to  excessive  remote  results. 
A  slight  remaining  convergence  attracts  little  notice,  and  may  disai)pear  with 
age,  as  presbyopia  develops.  The  aim  should  be  to  attain  the  best  possible 
correction,  with  the  least  insufficiency  and  disturbance  in  tlie  binocular  move- 
ments. Then  again,  a  desire  to  correct  an  extreme  degree  of  convergence  by 
operating  only  on  the  crooked  eye,  making  the  dissection  very  extensive,  or 
repeating  the  operation  on  the  same  eye,  is  often  disastrous.  Marked  insuffi- 
ciency of  the  weakened  muscle,  undue  prominence  of  the  eye,  sinking  in  of  the 
caruncle,  and  great  disparity  l3etween  the  eyes,  will  result.  Besides,  if  the 
operator  has  not  taken  the  precaution  to  detect  and  demonstrate  to  the  parents 
the  already  defective  sight  in  the  faulty  eye,  he  will  get  the  additional  credit  of 
having  destroyed  the  sight  by  his  operations !  Slight  degrees  of  squint  may 
indeed  be  relieved  by  one  judicious  operation.  But  in  the  great  majority  of 
cases  of  higher  degrees,  it  is  far  better  to  operate  on  both  eyes,  at  intervals. 
In  very  extreme  cases,  however,  a  simultaneous,  double  tenotomy  may  be  safely 
done,  and  it  is  sometimes  the  only  way  to  get  sufficient  correction. 

As  a  rule,  it  is  wiser  to  operate  first  on  the  worse  eye,  and  then  wait  a  few 
days  or  weeks  for  the  definitive  result,  before  attacking  the  other.  In  all 
serious  undertakings,  "  make  haste  slowdy"  is  a  safe  injunction.  Of  course 
this  does  not  suit  the  itinerant  operator^  but  I  am  speaking  of  honest  and  con- 
scientious men.  The  object  to  be  secured  is  the  detachment  of  the  tendon  from 
its  scleral  insertion,  so  that  it  may  retract  and  readhere  farther  back.  We 
want  to  weaken,  but  not  to  destroy  its  rotating  influence.  The  second  insertion 
must  be  within  the  capsule  of  Tenon,  else  the  result  will  be  excessive.  But 
the  immediate  effect  of  a  skilful  tenotomy  will  vary  in  different  cases. 
When  the  eyes  are  deep-seated  and  small,  a  much  bolder  operation  may  be 
risked  than  where  the  contrary  obtains.  In  the  former  case,  some  degree 
of  exophthalmus,  especially  if  equally  divided  between  the  two  eyes,  is 
desirable.  Then  again,  the  Ijlendings  of  the  tendon  with  the  capsule  of  Tenon, 
as  it  passes  through,  vary  in  extent  and  rigidity.  The  same  is  true  of  the 
tendinous  attachment  to  the  sclera.  Moreover,  the  amount  of  correction 
depends  more  on  the  active  energy  of  the  antagonist  than  upon  the  retraction 
of  the  severed  muscle.  A  greatly  stretched  and  weakened  antagonist  is  not 
likely  to  assert  itself  and  produce  a  marked  immediate  effect.  We  must  not 
only  measure,  as  exactly  as  may  be,  the  linear  deviation,  but  the  extent  of  pos- 
sible movement  inwards  and  outwards.  In  convergence,  the  possible  rotations 
inwards  are  excessive,  and  the  outward  rotations  somewhat  limited.  In  diverg- 
ence the  contrary  obtains.  By  requesting  the  patient  to  fix  your  finger  with 
both  eyes  open,  and  moving  it  far  to  one  side  and  then  to  the  other,  you  test 
the  extent  of  rotation  in  these  opposite  directions.  The  margin  of  the  cornea 
and  the  outer  commissure  of  the  lids  are  the  external  land-marks.  The  inner 
.margin  of  the  cornea,  as  compared  with  the  lower  punctum,  will  be  the  guide 
for  inward  movements.  Sometimes  the  centre  of  the  cornea  can  be  drawn  so 
far  beyond  the  punctum,  that  it  is  nearly  buried  out  of  sight.  In  such  a 
case,  with  a  weak  external  rectus  and  marked  limitation  in  the  outward  rota- 
tions, one  can  scarcely  get  too  much  effect  from  the  tenotomy.  Indeed,  it 
may  be  necessary  to  combine  with  it,  advancement  of  the  externus.  We 
want  to  diminish  the  excessive  motion  in  one  direction,  and  increase  it  in  the 
other,  so  as  to  restore  a  natural  equilibrium.  The  nice  point  is  to  insure  the 
needed  correction  with  the  least  muscular  insufficiency.  If  you  correct  the 
position  completely,  with  marked  muscular  insufficiency,  an  opposite  deformity 
in  after  years  is  almost  certain.  The  limitations  of  the  weakened  muscle 
must  be  tested  as  soon  as  possible  after  the  tenotomy. 

If  the  patient  has  been  put  under  the  eftect  of  ether,  time  must  be  given  for 
this  to  pass  off'.    This  sometimes  causes  embarrassing  dela}'.    If  the  extreme 


656         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


possible  rotation,  noted  before,  bas  been  positively  reduced,  tbe  muscle  bas 
been  completely  severed.  Otberwise,  perbaps  not,  and  tbe  v^^ound  must  be 
explored  furtber,  and  tbe  eye  tben  tested  again.  As  a  rule,  I  desire  to  see 
enougb  power  left  in  tbe  internus  to  bring  tbe  edge  of  tbe  cornea  to,  or  even 
a  triHe  beyond,  tbe  punctum.  Sbould  tbe  movement  inwards  be  more  limited, 
tbe  judicious  use  of  a  suture  will  be  required,  but  in  most  cases  tbis  will  not 
be  needed. 

Tbe  instruments  necessary  for  tbis  operation  are  a  stop-speculum  (±ig. 
921),  a  pair  of  tootbed  forceps  for  picking  up  tbe  conjunctiva,  two  stra- 
bismus books,  a  laro:e  and  a  small  (Fig.  935),  and  blunt  but  very  sbarp  scissors 
(Fig.  936).    Tbe  scissors  may  be  straight,  or  bent  on  tbe  edge.   I  prefer  tbem 


Fig.  935.  Fig.  936. 


strai2;bt.  A  very  soft,  clean  sponge  is  likewise  to  be  provided.  Tben  comes 
tbe  question  of  etber.  For  a  great  many  years,  I  bave  very  rarely  used 
cbloroform,  and  only  wben  tbere  was  peculiar  trouble  in  securing  complete 
anffistbesia.  Etber  must  be  pusbed  rapidly,  and  tbe  air  excluded,  else  tborougb 
insensibility  cannot  be  produced.  Tbis  is  tbe  only  way  to  secure  tbe  needed 
quiet,  at  tbe  least  risk  to  life  ;  and  if  tbe  first  moment  of  sudden  unconscious- 
ness be  seized  for  tbe  operation,  tbe  ipaiieiit  need  not  take  mucb  etber,  nor  be 
kept  long  under  its  influence.  In  all  cases  in  adults,  I  urge  tbat  ansestbesia 
be  not  employed.  Tbe  operation  is  quickly  over,  not  very  painful,  and  free 
from  dan2:er,  and  we  can  tben  at  once  test  tbe  effect  secured  by  tbe  tenotomy. 
Witb  timid  people,  v/bo  bave  no  self-control  or  confidence,  and  witb  cbildren, 
we  caiinot  do  witbout  an  ansestbetic. 

Tbe  patient  sbould  lie  on  bis  back,  on  a  lounge  or  operating  cbair,  witb  tbe 
bead  tbrown  sli2:btly  backwards.  Wben  tbe  stop-speculum  is  adjusted,  tbe 
first  steps  of  tbe  operation  are  facilitated  by  forced  rotation  of  tbe  eye  directly 
outwards.  Tbis  is  effected  by  an  assistant,  wbo  fixes  tbe  eye  near  tbe  outer 
margin  of  tbe  cornea,  in  tbe  horizontal  meridian.  Great  care  must  be  taken 
not  to  rotate  tbe  globe  on  its  antero-posterior  diameter,  else  tbe  relation  of 
the  incision  to  tbe  tendon  will  be  altered.  I  generally  employ  tbe  subconjunc 
tival  operation.  Tbe  conj  unctiva  is  seized  witb  tbe  small  tootbed  forceps,  about 
tbree  or  four  mm.  from  tbe  inner  edge  of  tbe  cornea,  and  as  nearly  as  pos- 
sible over  tbe  lower  edge  of  tbe  expanded  tendon  to  be  detached;  and  it  is 
then  divided  with  tbe  scissors,  horizontally  backwards,  far  enough  to  afiord 
room  for  the  further  steps  of  tbe  operation.  It  is  next  detached  by  a  few 
movements  of  the  points  of  the  scissors  over  the  seat  of  the  tendon.  Then 
letting  go  the  conjunctiva,  the  capsule  of  Tenon  is  seized  through  the  con- 
junctival opening,  the  forceps  being  pressed  with  a  little  firmness  on  the 
sclera,  and  is  opened  and  detached  to  the  same  extent.  Tbe  forceps  still 
holding  and  raising  the  detached  conjunctiva  and  capsule,  the  large  book 
is  next  passed  in,  pushed  backwards,  and  the  point  swept  from  below  up- 
wards under  the  tendon,  being  pressed  firmly  on  tbe  sclera  in  this  movement. 
Tbis  is  the  most  difi^cult  and  important  manoeuvre,  next  to  detaching  the 
tendon,  and  its  successful  execution  greatly  simplifies  the  rest  of  the  proce- 
dure. Tbe  firm  resistance  felt,  wben  the  expanded  tendon  is  thus  gathered 
in  the  concavity  of  the  book,  is  the  assurance  tbat  it  bas  been  secured. 


STRABISMUS. 


057 


Drawing  the  hook  forwards  till  it  is  arrested  by  the  tendon  at  its  insertion, 
it  is  held  firmly,  and  the  tendon  is  then  divided  by  a  few  snips  of  the  scissors 
from  below  upwards-  subconjunctival ly.  Then  the  same  or  the  smaller  hook 
may  be  swept  upwards,  to  be  sure  that  no  fibres  of  the  tendon  a))ove  have 
escaped ;  and  likewise  downwards.  If,  when  this  is  fairly  done,  the  hook 
comes  forwards  under  the  conjunctiva,  close  to  the  cornea,  meeting  no  resist- 
ance, it  is  sure  that  the  tendon  is  entirely  detached.  By  loosening  "it  between 
the  hook  and  the  sclera,  and  as  close  to  the  latter  as  possible,  there  is  no 
serious  sacrifice  of  the  tendon. 

If  ether  has  not  been  used,  the  effect  can  be  tested  after  a  few  seconds  of 
closure  of  the  lids  by  pressure  with  an  iced  sponge.  If  no  marked  limitation 
of  rotation  in  the  direction  of  the  contracted  muscle  is  perceptible,  some 
shreds  of  tendon  have  escaped,  above,  below,  or  farther  back  between  the 
tendinous  substance  and  the  sclera.  The  wound  nmst  then  again  be  explored 
carefully  in  these  directions,  and  such  filaments,  if  found,  divided.  To  do 
this  the  speculum  may  be  reintroduced,  or  the  eye  may  be  held  open  by  the 
fingers  of  an  assistant.  After  this,  another  test  of  limitation  may  be  applied. 
If  ether  has  been  used,  it  will  be  necessary  to  wait  five  or  ten  minutes  till 
consciousness  and  self-control  are  regained.  For  reasons  already  given,  the 
immediate  effect  varies  in  different  cases,  but  if  a  limitation  of  from  three  to 
four  mm.  has  not  been  obtained,  it  is  because  the  tendon  has  not  been  com- 
pletely separated.  As  a  guide  in  reaching  for  the  tendon  with  the  blunt 
hook,  it  should  be  remembered  that  the  centre  of  insertion  of  the  hiternus  is 
about  five  and  a  half  mm.  from  the  margin  of  the  cornea,  and  that  the  corres- 
ponding point  of  the  externus  is  slightly  more  distant. 

The  same  steps  are  to  be  taken  in  operating  on  the  external  rectus,  remem- 
bering, however,  that  a  complete  tenotomy  in  this  instance  does  not  accomplish 
as  much  as  in  the  former  case.  Tenotomy  of  the  superior  and  inferior  recti  is 
rarely  executed,  but  is  done  in  the  same  way.  The  hemorrhage  is  usually  \'ery 
slight,  and  the  blood  is  soon  absorbed  from  beneath  the  conjunctiva.  Quick 
removal  of  the  speculum  and  pressure  with  a  cold  sponge  readily  check  it. 
The  vision  of  a  previously  amblyopic  eye  is  sometimes  Immediately  much 
improved.  In  a  little  blonde  child,  six  years  old,  with  excessive  convergence, 
in  whose  case  I  practised  a  double  tenotomy,  the  defective  eye,  from  "being 
able  to  recognize  no  letter  at  fifteen  feet,  improved  so  that  its  vision  was  0.2, 
as  soon  as  tested.  Bat  the  improvement,  if  it  continues  at  all  afterwards, 
is  then  much  less  rapid. 

I  must  again  exhort  the  surgeon  not  to  be  too  impatient  to  accomplish  com- 
plete correction  by  the  first  tenotomy,  whether  single  or  doable.  Wait 
patiently  a  few  weeks  or  months,  enjoining  frequent  exercise  of  the  weak 
muscles,  and  using  atropine,  glasses,  stereoscope,  separate  exercise  of  the  am- 
blyopic eye,  etc.,  before  risking  a  second  operation.  This  plan  is  especially 
to  be  employed  if  the  squint  be  convergent,  and  the  remaining  deviation  slicrht. 
If  diplopia  occurs,  it  is  an  encouraging  symptom,  and  may  give  way  to  binocu- 
lar vision;  or  it  may  again  subside  by  suppression. 

In  testing  the  efi:ect  produced  by  a  tenotomy  of  the  externus,  we  must  be 
guided  by  the  outer  edge  of  the  cornea  and  the  external  commissure  of  the 
lids.  Before  a  successful  operation,  the  corneal  margin  can  be  rotated  beyond 
the  commissure,  while  now  it  falls  short  by  two  or  three  mm.  The  correcting 
efifect  of  division  of  the  externus  is  much  less  than  that  of  the  same  operation 
on  the  internus.  In  either  case  it  is  wise  to  be  satisfied  with  slight  insufficiencv, 
and  not  to  make  extensive  dissections  or  incisions  in  the  capsule.  After  teno- 
tomy, especially  of  the  internus,  there  is  some  increased  prominence  of  the 
globe.  This  is  one  of  the  numerous  reasons  for  operating  on  both  e,yes,  rather 
than  attempting  to  accomplish  the  wbole  correction  on  one  side.  The  o-reater 
VOL.  IV. — 42  * 


658 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


or  less  effect  produced  by  a  perfect  tenotomy  depends  more  on  the  activity 
of  the  antagonist,  and  its  subsequent  shortening,  than  on  the  elongation 
of  the  divided  muscle.     Hence,  in  cases  of  contraction  from  paralysis  of 
the  antagonist,  or  from  a  previous  and  excessive  operation,  tenotomy  has 
no  effect  except  to  increase  the  already  unsightly  exophthalmus.    A  well- 
timed  and  extended  advancement  is  the  only  rational  interference  in  such  cases. 
While  tenotomy  sets  the  tendon  back,  and  vv^eakens  its  effect,  advancement 
sets  it  forwards  and  increases  its  action.    Tenotomy  produces  exophthalmus  ; 
advancement  helps  to  diminish  it.    Tenotomy  is  always  practised  on  the  too 
much  contracted  muscle,  while  advancement  is  employed  for  that  which  is 
elongated  and  weakened,  on  purpose  to  shorten  it  and  increase  its  power.  Ad- 
vancement seems  a  more  rational  way  of  restoring  equilibrium  between  muscles 
than  tenotomy.    But,  owing  mainly  to  the  difficulty  in  its  execution,  it  is  not 
often  resorted  to,  except  to  correct  over-eff'ects  or  deviation  from  paralysis. 
In  most,  if  not  in  all  cases,  however,  of  so-called  latent  strabismus,  or  insuffi- 
ciency, advancement  promises  more  certain  relief  than  tenotomy.  Theoretic- 
ally, the  new  insertion  may  not  be  symmetrical  with  the  original  attachment, 
and  may  result  in  diplopia  and  other  binocular  inconveniences.    But  this  has 
not  been  realized  in  practice.    Whether  the  advanced  tendon  has  been  spread 
a  little  more  or  less,  or  whether  the  upper  edge  has  been  advanced  a  little  more 
than  the  lower,  seems  not  to  exercise  any  serious  influence  on  the  future  use  of 
the  eyes.    Even  in  extreme  cases  of  insufficiency  from  excessive  tenotomy,  and 
in  those  of  rigid  contraction  from  paralysis,  it  is  astonishing  how  much  may 
be  gained  by  this  operation.    I  have  advanced  totally  inactive  muscles  left  by 
excessive  strabismus  operations,  twenty  years  before,  with  very  great  improve- 
ment in  appearance,  and  with  reasonable  restoration  of  nciotor  activity.  It 
seems  that  complete  severance  of  a  tendon  from  all  connection  with  the  globe, 
even  for  long  years,  does  not  lead  to  atrophy  and  uselessness  of  the  muscle. 
When  reunited,  in  a  favorable  position,  it  soon  discharges  its  functions  well. 
My  own  advancements,  and  many  others  which  I  have  seen,  have  given  very 
gratifying  results.  Indications  for  this  operation  will  certainly  increase  with 
further  experience.    The  little  more  time  and  trouble  required  for  executing 
a  successful  advancement,  should  not  weigh  against  the  best  interests  of  the 
patient  and  of  enlightened  surgery. 

The  operation  is  performed  as  follows:  The  patient  havmg  been  rendered 
thoroughly  unconscious  with  ether,  and  the  eye  being  held  open  by  a  spec- 
ulum, as  in  strabotomy,  the  ball  is  seized  by  strong  fixation  forceps  near  the 
margin  of  the  cornea,  directly  opposite  the  muscle  to  be  advanced.  It  is  then 
firmly  rotated  in  that  direction,  so  as  to  expose  the  region  to  be  dissected. 
Held  thus  by  an  aid,  the  surgeon  seizes  a  fold  of  conjunctiva,  about  two  mm. 
from  the  corneal  margin,  and  divides  it  vertically  for  five  or  six  mm.,  and 
with  repeated  touches  separates  it  from  the  sclera  over  the  muscular  inser- 
tion, and  farther  back.  When  the  tendinous  attachment  is  found,  the  blunt 
hook  is  passed  under  the  tendon,  so  as  to  raise  it  and  make  it  tense.  Holding 
it  thus  firmly,  one  blade  of  a  toothed  forceps  is  passed  behind  and  one  in 
front  of  it,  so  as  to  seize  and  hold  it  tightly.  Then  with  the  scissors,  it  is 
detached  close  to  the  sclera  and  held  and  lifted  forwards,  so  that  it  may  be 
pierced  with  the  needle  from  behind  forwards.  A  well-waxed  thread  eighteen 
inches  or  two  feet  long  is  sufficient.  This  is  armed  with  a  needle  placed  in  the 
middle,  and  with  another  needle  near  each  end.  The  main  needle,  fixed  with 
Sands's  holder  (Fig.  937),  is  then  passed  through  the  middle  of  the  raised 
and  stretched  teiidon,  from  behind,  and  about  four  mm.  from  the  forceps. 
The  needle  may  be  passed  forwards  under  the  conjunctiva,  finally  piercing  it 
near  the  cut  edge.  The  holder  removed,  the  needle  is  seized  and  drawn 
through  five  or  six  inches.    Then  one  of  the  other  needles  is  fixed  and  care- 


STRABISMUS. 


659 


fully  passed  under  the  conjunctiva  next  the  cornea,  avoiding  piercing  the 
sclera,  and  brought  out  about  three  mm.  from  the  centre  of  the  upper  maro-in 
of  the  cornea;  the  thread  is  drawn  through,  and  the  needle  is  removed. 
Then  the  other  is  secured  and  passed  in  the'same  way  below.    These  needles 

Fig.  937. 


Sands's  needle-holder. 


being  removed,  and  the  threads  cut  off  close  to  the  first  needle,  the  surgeon 
is  ready  to  tie  the  knots.  The  tendon  is  now  held  by  two  threads,  Avhich 
are  to  be  tied,  one  by  the  operator,  and  the  other  by  his  assistant.  They 
must  be  gently  and  evenly  tightened,  and  firmly  knotted.  Before  tying  the 
threads,  it  is  better  to  remove  the  speculum.  In  this  way  the  tendon  is 
(h-awn  firmly  forwards  and  spread  out  over  the  denuded  sclera.  If  the  an- 
tagonist muscle  is  much  contracted,  its  tendon  should  be  divided,  after  the 
tlu'ciids  are  placed  and  before  tying  them.  In  this  way  the  efi'ect  may  be 
greatly  increased.  Then  the  amount  of  advancement  may  be  intensified  by 
piercing  the  tendon  farther  back  towards  the  caruncle,  for  the  internus,  and 
towards  the  equator  for  the  externus.  In  very  high  deviations,  a  piece  of  the 
tendon  may  be  sacrificed  before  knotting  the  threads. 

In^  the  extreme  cases  to  which  this  thread  operation  has  been  usually 
restricted,  it  is  desirable  to  adopt  every  means  of  increasing  the  efiect,  and 
even  then  a  second  advancement  may  be  necessary.  In  one  of  the  worst 
cases  which  I  have  ever  seen,  produced  by  tenotomy  of  the  internus  twenty 
years  before,  a  second  advancement  was  made  a  year  after  the  first,  and  the 
result  was  admirable. 

The  operation  having  been  completed,  the  patient  should  be  put  quietly  to 
bed,  with  the  eyes  bandaged,  and  cold  water  dressings  should  be  used  for  a  few 
hours.  The  next  day  the  eye  may  be  gently  opened,  but  not  allowed  to  move 
much,  and  then  closed.  At  the  end  of  forty-eight  hours  of  quiet,  the  threads 
may  be  carefully  removed,  but  the  eyes  must  be  immediately  rebandaged,  and 
kept  so  for  several  days  longer  till  the  adhesions  are  firm.  The  success  of  this 
very  important  operation  depends  largely  upon  the  absolute  stillness  of  the 
eyes  for  the  first  four  days,  xls  the  method  of  advancement  is  more  perfected 
and  made  easier,  its  application  will  become  more  general.  In  moderate  cases 
of  strabismus,  and  in  all  cases  of  insufficiency  requiring  surgical  treatment, 
the  muscular  balance  may  be  restored  by  advancing  the  elongated  muscle 
instead  of  setting  back  the  contracted  one.  The  dano-ers  of  muscular  insuffi- 
ciency, sinking  of  the  caruncle,  and  unsightly  exophthalmns,  will  be  thus 
entirely  avoided.  The  only  instruments  needed  in  this  operation  more  than 
m  an  ordhiary  strabotomy,  are  the  three  needles.  A  double  hook,  as  devised 
by  De  Wecker,  facilitates  the  operation,  but  is  not  indispensable.  I  recently 
made  a  thread  advancement  of  the  externus  in  a  vouno;  medical  student. 
He  first  had  very  troublesome  insufficiency  of  the  uiterni,  for  the  relief  of 
which  I  employed  division  of  the  externi,  first  of  one,  and,  a  few  days 
.atter,  ot  the  other.  Relief  was  only  partial,  and  the  externi  Avere  divided"  a 
second  time.  Then  convergence  with  distressing  diplopia  followed.  All 
objects  beyond  eight  inches  Avere  doubled,  with  homonymous  images,  and  any- 
tliing  held  nearer  than  four  inches  Avas  seen  double,  Avith  crossed  imao-es.  I 


660         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

then  made  a  careful  advancement  of  one  externus,  with  complete  relief  In 
such  a  case  again,  I  would  advance  the  internus  in  the  hrst  place. 

There  are  but  few  accidents  possible  after  a  strabotomy.    Ihere  may,  in 
rare  cases,  be  profuse  hemorrhage,  which  is  easily  controlled  by  cold  com- 
presses, and  which  does  not  interfere  with  the  i-^sult.    \  ery  rarely,  endocap- 
ulitis  With  some  suppuration  occurs.    With  blunt  scissors,  or  lv 

iiarv-  care,  there  is  no  danger  of  cutting  through  the  sclera.    A  few  times  i 
havi  seen' pretty  severe  inlammation,  and  marginal  ulceration  of  th^  com 
follow  an  advancement,  but  they  were  always  controllable,  and  resulted  in  no 
damage  to  sight.  . 


Diseases  of  the  Eyelids. 


BLEPHAElTls.-Inflammation  of  any  part  of  the  eyelid  is  called  blepharitis. 
Having  regard  to  the  texture  first  and  chiefly  involved,  it  is  called  Wephai-itis 
ciliaris^lfpharitis  marginalis,  or  simply  blepharitis.  All 
tion  of  the  conjunctiva  is  attended  by  more  or  less  blepharitis.  Eijsipelas 
of  the  face  is  apt  to  invade  the  lids,  as  elsewhere  described.  Abscesses  of  these 
parts,  their  importance  and  special  treatment,  have  been  considered  m  connec- 
lion  with  injuries  of  the  orbit.    The  worst  ca.es  of  ectropium  foUow  deep 
and  extensive  burns  of  the  lids,  or  sloughing  from  ^ryBipelas.    A  leserved 
prognosis  in  such  cases  is  always  wise    The  common  stye  is  often  attendecl 
by  Ireat  pain  and  alarming  swelling,  but  is  easily  diagnosed  by  a  point  ot 
g^ettest  tenderness  to  pressure.    It  d  scharges  «Pon!*f  ously  or  by  j^uncture 
fike  a  furuncle,  and  soon  recovers.    A  succession  of  .styes  and  bo^s  indicates 
bad  assimilation,  and  is  best  treated  by  constitutional  tonics    «  *  costive 
habit  be  present,  it  must  be  relieved  by  laxatives     Locally,  coi  tn  ued  w  a.  m 
poulticing  is  all  that  is  required.    Syphilitic  and  cancroid  ulcerations  of  the 
lyelids  are  always  alarming.   They  readi  y  Ica.l  to  destruction  ot  tissue  e^^^^^^^^ 
lire  of  the  eye.  ectropium,  painful  loss  of  sight,  and  even  loss  ot  life.  Epitheli- 
oma and  other  destructive  processes  in  the  upper  hd  are  vastly  more  d  a 
trous  than  in  the  lower.    While  the  entire  lower  lid  may  be  destioyed,  or 
r^oved  by  operation,  without  serious  deformity  or_ danger  to  the  integrity 
ofZe  eye,  a  very  small  defect  in  the  upper  lid  both  excites  remark  and  becomes 
^-rave  in  it's  consequences.    Epithelioma  of  the  eyehds  requires  promp^  and 
'radical  operative  treatment.    It  is  in  these  cases  especially,  that  the  melari- 
choly  eftLts  of  the  caustic  applications,  so  much  in  ^og- ~g  merce^^^^^ 
quacks,  are  witnessed.    As  soon  as  a  syphilitic  sore  ^^-^f  "^^^no  oneratfon 
lids,  antisyphilitic  treatment  must  be  heroically  adopted,  and  no  operation 
resorted  to,  except  perhaps  at  a  later  period,  .^r  Plastic  purpose^ 

The  most  common  form  of  inflammation  is  that  which  is  limited  to  the 
free  edges  of  the  lids,  and  is  called  blepharitis  margmahs  ov^^^^^^^ 
confined  mainlv  to  scrofulous  children,  seldom  occurring  for  the  fiist  timein 
E  except  as  a  complication  of  dacryocystitis.  The  exclusive  vie  inis  of 
this  disease  strumous  children,  are  likely  to  Ij'^ve  also  phlyctenula^^^^^ 
titis,  with  eczematous  eruptions  on  the  iace  and  «cfp,  behind  the  eais,  and 
in  a'nd  around  the  nose,  and  enlargement  ot  the  glands  of  the  neck  The 
children  of  indigent  and  dissipated  parents  of  dirty  habits,  are  the  most 
frequent  sufferers,  and  their  successful  treatment  is  almost  impossible 

^  e  i4«o.,,;.  of  this  disease  is  very  simple.  The  redness  and  B^^l  nig  ot 
the  margins  of  the  lids  are  not  striking,  and  often  very  partial.  But  mo  e 
or  leTscabbing  in  the  region  of  the  eyelashes  is  a  co.,stant  phenomenon. 
Su,  purXn  "n  the  individual  hair  follicles,  and  the  formation  of  crusts  by 
d  ykig  Tat  unite  the  lashes  in  tufts  and  sometimes  accumulate  for  months, 


DISEASES  OF  THE  EYELIDS. 


661 


becoming  large  and  almost  horny,  are  the  characteristic  symptoms.  These 
scabs  adhere  very  closely,  and  are  hard  to  remove.  When  they  are  fully 
detached,  the  lid  bleeds  from  ulceration  of  the  skin,  a  process  that  may  be 
limited  to  a  few  cilia,  or  may  extend  the  entire  length  of  the  lid.  The  scab- 
bing, burrowing  of  pus,  and  destruction  of  the  hair  bulbs,  contiime  for  years, 
till  the  patient  is  at  last  deprived  of  eyelashes,  seriously  disfigured,  and  annoyed 
for  life. 

Treatment — Absolute  cleanliness  must  be  enforced.  The  lids  are  to  be 
bathed  with  warm  water,  for  half  an  hour  or  longer,  twice  a  day.  When  the 
scabs  are  thus  softened,  they  must  be  thoroughly  removed  by  rubbing  with 
a  soft  rag  over  the  end  of  the  finger.  This  failing,  they  must  be  detached  by 
a  small  spatula,  or  with  cilia  forceps,  no  matter  at  what  cost  of  screaming 
and  bleeding.  Firmness  on  the  part  of  the  surgeon  is  demanded,  as  the  nurse 
is  always  timid  and  fails  to  do  the  work  fully.  The  child  must  be  held 
across  the  nurse's  lap,  face  upwards,  and  the  head  firml}^  clasped  by  the  sur- 
geon's knees.  He  is  thus  master  of  the  situation  if  he  have  already  mastered 
the  mother  or  nurse.  When  every  trace  of  the  scabs  has  been  removed,  it 
greatly  expedites  the  cure  to  trim  the  lashes  as  closely  as  possible  with  a 
small  pair  of  scissors,  and  to  repeat  this  at  least  once  a  week.  The  raw 
surfaces,  thus  exposed  and  dried,  are  now  to  be  touched  quickly  and  lightly 
with  a  pointed  stick  of  nitrate  of  silver.  A  solution  of  from  ten  to  twenty 
grains  may  be  used  in  preference,  applied  carefully  with  a  small  brush,  and 
limited  strictly  to  the  ulcerated  portion.  Great  care  must  be  exercised  to  pre- 
vent its  flowing  into  the  eye.  When  the  surface  is  slightly  whitened,  the  free 
use  of  water  will  remove  the  surplus.  This  may  be  repeated  once  or  twice  a 
week,  as  long  as  there  is  any  manifest  ulceration.  In  the  evening,  before  bed- 
time, warm  ablutions,  cleansing,  and  drying,  must  be  followed  by  the  use  of 
some  one  of  the  mercurial  salves,  rubbed  along  the  roots  of  the  lashes  and  left 
till  morning.  These  should  be  weak,  non-irritating,  and  in  small  quantity,  but 
well  rubbed  in  with  the  finger.  Calomel,  with  vaseline  or  lard,  gr.  j  to  5j,  or 
red  precipitate,  gr.  ss  to  3j,pure  and  thoroughly  incorporated  by  rubbing,  are 
excellent  remedies.  The  yellow  oxide  of  mercury  in  the  same  strength  niay 
also  be  applied,  but  I  find  that  it  often  causes  too  much  irritation.  For  many 
years  I  have  used  the  diluted,  brown  citrine  ointment  with  almost  constant  suc- 
■cess.  On  the  lids  1  use  5j  of  the  ointment,  rubbed  up  with  3iijof  lard.  For 
the  nose,  ears,  scalp,  lips,  etc.,  it  may  be  applied  in  full  strength.  After 
thorough  washing  with  soap  and  warm  w^ater,  to  remove  all  the  dry  scabs,  the 
raw  surface  should  be  brushed  with  the  solution  of  silver  nitrate,  and  afterwards 
well  greased  with  the  salve.  This  is  best  done  at  night,  and  the  eyelids  may 
be  treated  in  the  same  way.^  If,  after  a  fair  trial,  one  of  these  salves  fails, 
another  may  be  tried.  After  a  few  days  of  such  treatment,  the  scabs  will 
oease  to  form,  and  the  force  of  the  malady  will  be  greatly  lessened.  But  the 
use  of  the  salve  must  be  kept  up  for  months,  at  longer  intervals,  in  order  to 
prevent  a  return  of  the  diseased  process. 

At  first  the  lids  must  be  freed  and  greased  every  night.  Then  every  second 
night,  afterwards  twice  a  week,  and,  finally,  at  least  one  application  of  the 
salve  every  week  must  be  continued  for  months  after  the  lids  seem  well. 
Till  the  cure  is  well  advanced,  the  surgeon  himself  should  conduct  the  treat- 
ment, even  appljdng  the  salve  in  the  day  himself,  if  he  cannot  be  sure  of  its 
proper  use  at  night.  Combined  with  these  necessary,  local  measures,  the  long- 

'  The  citrine  ointment  maybe  made  according  to  the  following  formula  :  ^.  Hydrargyri,  §jss; 

Acid,  nitrici,  ^iijss  ;  Olei  morrhufe,  §xvjss.  Dissolve  the  mercury  in  the  acid;  then^lieat  the 
*il  in  an  earthen  vessel,  and,  when  the  temperature  reaches  200*^  F.,  remove  it  from  the  fire.  To 
this  add  the  mercurial  solution,  and,  with  a  wooden  spatula,  stir  constantly  as  long  as  efferves- 
cence continues,  and  afterwards  occasionally  until  the  ointment  stiffens.  ° 


662  INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

continued  use  of  iron,  iodine,  and  cod-liver  oil,  inwardly,  must  be  enforced. 
A  favorite  remedy  with  me,  is  the  syrup  of  iodide  of  iron,  long  continued. 
As  a  dose  after  each  meal,  I  give  as  many  drops  as  the  child  is  years  old 
Bathinff  the  child  at  least  twice  a  week,  at  bedtime,  m  tepid  water,  tollowed 
bv  lively  friction  ;  good  nutritious  food  at  regular  intervals  ;  healthy  hygienic 
surroundings  ;  and  free,  daily  exercise  in  the  open  air,  with  proper  attention 
to  clothing  and  cleanliness,  must  be  enforced  as  a  religious  duty.    1  cannot 
too  strongly  emphasize  the  necessity  for  long  perseverance  m  invigorating 
general  treatment,  in  this  class  of  patients.    Present  relief  and  improved 
health  for  life,  will  be  thus  gained.    Unsightly  loss  of  the  eyelashes,  blear- 
eyes  trichiasis,  ectropium,  weeping,  and  a  train  of  other  torments,  are  prevented 
by  proper,  early  treatment.    The  management  of  phlyctenular  keratitis,  and 
of  the  skin-diseases  so  often  associated  with  blepharitis  ciliaris,  has  been 
described  under  another  head.    I  wish  only  to  call  special  attention  here  to 
the  prompt  relief  afforded  by  the  mechanical  removal  of  the  thickened  epithe- 
lium at  the  seat  of  the  phlyctenula,  and  along  the  bands  of  vessels  leading  to 
it  in  the  so-called  "band  keratitis."   I  am  constantly  in  the  habit  of  using  a 
wooden  tooth-pick,  and  prefer  it  to  the  spud  or  probe.    The  tooth-pick  must 
be  hard,  tough,  and  sufficiently  stiff.  The  small  end  is  dipped  m  pure  carbolic 
acid,  and  then  ploughed  along  the  course  of  the  vessels  and  the  seat  of  the  phlyc- 
tenula, so  as  to  scratch  off  the  half-dead  tissues.   This  must  be  done  thoroughly, 
holding  the  lids  firmly  apart  with  the  thumb  and  finger,  without  eversion. 
The  bloodvessels  are  thus  scraped  off  with  the  other  new  products,  and  the 
free  bleeding  is  decidedly  beneficial.  The  point  of  the  tooth-pick  can  now  and 
then  be  dipped  in  the  acid,  so  as  to  whiten  and  destroy  the  diseased  tissues 
Water  can  be  held  ready,  and  put  on  if  too  much  acid  is  present.    The  ^^'X)od 
absorbs  and  holds  the  solution  better  than  a  metal  instrument     After  this  is 
thoroughly  done,  a  drop  or  two  of  atropine  solution  relieves  the  pain,    it  is 
wonderful  how  quickly  the  violent  symptoms  are  thus  controlled. 

Chalazion.— Inflammation  with  obstruction  of  the  excretory  ducts  of  the 
Meibomian  glands  of  the  lids,  is  a  rather  common  trouble.  Some  swelling,  like 
that  of  a  stye,  soreness,  and  pain,  are  present,  and  in  a  short  time  a  yellow  point 
indicates  a  collection  of  pus  and  of  the  proper  secretion  of  the  follicle.  Warm 
fomentations  at  first,  and  puncture  when  the  ripe  stage  appears,  are  the 
successful  remedies.    In  adults,  tumors  of  the  hds  often  develop  with  little 
or  no  inflammation,  projecting  under  the  skin  and  giving  the  feehng  to  the 
lino-er  of  a  hard  shot  or  bullet.    These  are  sometimes  single,  but  oftener 
multiple,  and  a  succession  of  them  is  frequently  noticed.    They  are  situated 
over  the  reo-ion  of  the  tarsus  of  the  upper  or  lower  lid,  and  sometimes  reach 
the  size  of  a  hazel-nut,  mechanically  impeding  the  free  movements  of  the  lids 
They  are  situated  in  the  thickness  of  the  tarsal  cartilage,  and  ai^e  composed 
of  a  cyst,  filled  with  a  tough,  gelatinous  substance,    i^ow  and  then  with 
more  acute  inflammation,  the  contents  are  somewhat  purulent.    This  tumor 
is  generally  called  chalazion,        requires  surgical  treatment.    One  mettiod 
is  to  evert  the  lid,  find  the  thinned  point,  and  puncture  through  the  conjunc- 
tiva.   The  incision  is  usually  made  perpendicularly  to  the  free  edge  of  the 
lid,  and  the  contents  are  scooped  out.    If  the  cyst  be  rudely  torn  m  this 
process,  in  various  directions,  complete  obliteration  from  adhesive  mflamma- 
Ln  will  be  more  certainly  secured.    If  the  everted  lid  be  firmly  squeezed 
between  the  thumb  and  finger-nail,  the  contents  and  cyst  wall  will  be  more 
surely  forced  out.    If  this  be  thoroughly  done,  no  cauterization  of  the  sac 

"^Wh^rS  cyst-wall  is  thick  and  hard,  and  the  growth  presents  itself  con- 
spicuously under  the  skin,  I  much  prefer  enucleation.    This  is  done  through 


DISEASES  OF  THE  EYELIDS. 


663 


the  skin,  and  with  the  aid  of  the  ring  forceps  (Fig.  938),  to  avoid  bleeding. 
When  the  blades  have  been  iirmly  closed  by  tightening  the  screw,  and 
the  tumor  has  been  made  to  project  sharply  through  the  ring,  the  skin  is 
incised  over  the  whole  length  of  the  growth,  longitudinally.    A  few  drops 


Fig.  938. 


Ring-forceps  for  tumors  of  eyelid. 

of  blood  escape  on  cutting  through  the  skin,  but,  this  being  sponged  away, 
no  further  trouble  from  hemorrhage  is  experienced.  The  cyst  is  now  exposed, 
and  with  a  few  snips  of  scissors  carefully  detached  from  the  other  tissues,  except- 
ing underneath:  An  assistant  then  draws  the  skin  aside  with  forceps,  when 
the  cyst  is  seized,  raised  from  its  bed,  and  detached  from  the  parts  below. 
Care  should  always  be  taken  to  remove  as  little  of  the  surrounding  structures 
of  the  lid  as  possible,  and  to  avoid  cutting  a  hole  through  the  conjunctiva. 
A  small  opening  in  the  conjunctiva  does  no  harm,  but  it  should  be  left 
entire,  if  possible.  When  the  cyst  and  its  contents  are  removed,  the  wound 
is  closed  with  one  or  at  most  two  stitches  in  the  skin.  It  heals  by  first  inten- 
tion, and  all  traces  are  gone  in  a  few  days.  This  little  operation,  when  neatly 
done,  is  very  satisfactory;  but  when  awkwardly  executed,  insufficiency  of  the 
lid,  notching  of  its  margin,  and  sad  deformity  may  result.  There  is  no  use 
in  cauterizing  these  tumors,  or  rubbing  them  with  salves,  or  taking  constitu- 
tional remedies  to  remove  them.  Such  measures  do  not  succeed,  worry  the 
patient,  and  must  yield  at  last  to  proper  surgical  treatment.  Tonics,  espe- 
cially iron  and  bitter  remedies,  may  be  useful  in  promoting  a  better  assimila- 
tion, and  preventing  the  occurrence  of  nev\^  growths. 

Sebaceous  tumors,  either  congenital  or  acquired,  sometimes  form  under  the 
skin,  about  the  edge  of  the  orbit.  They  may  reach  a  large  size,  and  some- 
times contain  hairs.  AVhere  such  a  growth  presses  upon  the  bone,  it  de- 
velops a  pit,  and  is  usually  firmly  adherent  to  the  periosteum,  making  com- 
plete removal  difficult.  Rules  for  the  direction  of  incisions  for  their  removal, 
and  other  precautions,  have  already  been  given.  They  usually  bleed  freely, 
and,  when  the  cyst  is  cut,  as  it  is  apt  to  be,  the  operation  may  become  very 
troublesome.  If  any  portion  of  the  sac  is  left,  the  tumor  is  sure  to  be  re- 
produced. After  adequate  stitching,  a  compress  is  put  over  the  pit  that  is 
left  behind,  and  a  roller  is  applied  to  prevent  hemorrhage  and  subsequent  sup- 
puration. 

Lagophthalmus. — The  name  lagophthalm.us,  or  hare^s-eye^  is  based  on  a 
romantic  notion  that  the  timid  animal  after  which  it  is  called  sleeps  with  its 
eyes  open.  Lagophthalmus  is  generally  due  to  paralysis  of  the  facial  nerve 
and  the  muscles  which  it  supplies,  but  sometimes  results  from  cicatrices  of 
various  kinds  and  degrees,  and  rarely  from  congenital  defects.  Great  dis- 
tress and  serious  danger  to  the  integrity  of  the  eye  always  result  from  para- 
lysis of  the  orbicularis  muscle.  Constant  weeping  during  wakeful  hours, 
and  dryness  from  exposure  in  sleep,  keep  the  eye  always  irritable,  and  ready 
to  take  on  destructive  inflammation.  The  necessity  for  the  constant,  healthy 
action^  of  the  sphincter  of  the  eyelids  and  of  Horner's  muscle,  shows  itself 
in  defective  function  of  the  sewer  sj'stem  of  the  eye.    Epiphora^  or  overflow 


664         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

of  tears  is  the  first  symptom  of  this  great  trouble,  and  persists  as  long  as 
any  deficiency  of  muscular  activity  continues.    Whether  facial  paralysis  be 
due  to  peripheric  or  central  causes,  or  to  disease  of  the  drum  of  the  ear,  it  may 
never  disappear,  in  which  event  surgical  .relief  is  the  only  hope.    The  lids,  in 
every  case,  should,  during  sleep,  be  kept  closed  by  a  compress  and  bandage, 
to  prevent  the  evils  of  exposure.    Even  by  day,  an  hour's  rest  with  the  eye 
thus  closed  by  a  wet  compress,  aft'ords  great  comfort  and  protection.    W  hen 
inflammation  and  ulceration  of  the  cornea  set  in,  constant  protection  by  clos- 
ino-  the  lids  must  be  enforced.    More  permanent  comfort  may  be  secured  by 
a  plastic  operation  on  the  lids.    This  is  done  by  paring  the  free  edges  of  the 
upper  and  lower  lids,near  the  outer  commissure,  and  uniting  them  by  stitches  or 
twisted  sutures.   By  leaving  the  outer  angle  itself  free,  the  union  can  be  after- 
wards severed,  in  case  the  paralysis  disappears.    The  edges  should  be  made 
raw  for  from  a  fourth  to  half  an  inch,  according  to  the  amount  of  insufficiency. 
isTothino-  need  be  cut  away  but  the  skin  covering  the  free  margins,  avoiding  the 
Meibomian  follicles  and  the  eyelashes.    The  union  thus  secured,  relieves  the 
patient's  distress,  and  greatly  improves  his  personal  appearance   In  confirmed 
cases  resulting  from  disease  of  the  ear,  I  pare  the  two  lids  half-way  between 
the  centre  and  the  outer  commissure,  for  a  short  distance,  and  secure  perma- 
nent union  with  very  great  improvement.    The  lids  are  excessively  relaxed, 
and  the  patients,  before  the  operation,  cannot  work  for  constant  weej^mg.  i 
have  done  this  and  seen  it  done  many  times,  and  always  with  benefit.  ^  J^  oi- 
lowing  the  ad^ace  of  Yon  Graefe,  I  have  several  times  practised  a  similar 
canthoplasty  in  extreme  cases  of  exophthalmic  goitre.    In  some,  relief  and 
improvement  have  been  gained;  but  in  others  the  destructive  inflammation  ot 
the  cornea  has  seemed  to  be  hastened.    In  facial  paralysis  the  operation  is 
always  beneficial. 

Ptosis.— Ptosis  is  a  drooping  of  the  upper  lid  from  paralysis  of  the  levator 
palpebrse  muscle,  or  from  congenital  absence  of  the  muscle.    As  the  other 
branches  supr)lied  by  the  third  nerve  are  usually  implicated,  we  see  at  the 
same  time  clivergence  of  the  eye  and  inability  to  move  it  m  any  direction 
but  outwards.    The  pupil  is  also  dilated,  and  the  accommodation  paralyzed. 
When  the  lid  is  raised,  of  course  there  is  harassing  diplopia.    Hence  the 
ptosis' should  not  be  corrected  till  the  divergence  and  double  vision  have 
disappeared.   If  it  then  still  persist,  it  may  be  safely  remedied  by  an  operation, 
Unsiditly  drooping,and  a  sleepy  expression  of  one  or  both  upper  lids,  generally 
accompany  bad  chronic  cases  of  granular  conjunctivitis.    Should  tins  droop- 
ing persist  as  a  serious  deformity,  after  treatmeiit  has  relieved  the  disease  it 
may  be  corrected  by  a  well-timed  operation.    Of  the  methods  recommended 
^usually  prefer  the  removal  of  a  horizontal  fold  of  skin     The  strip  removed 
should  extend  the  whole  length  of  the  lid,  and  should  be  of  the  same  width 
throughout,  at  most  not  exceeding  five  millimetres.    In  all  operations  on 
the  lids,  where  skin  is  sacrificed,  it  is  far  better  to  get  too  little  than  too  much 
effect.    The  excision  should  not  come  nearer  than  tour  mm.  to  the  free  mai- 
Sin.    We  seek  to  raise  the  whole  lid  equally,  and  naturally,  and  not  to  chang^ 
the  normal  position  of  the  cilia.    For  a  beginner  it  is  safer  to  dot  out  w^^^^^^^ 
ink  the  piece  to  be  removed,  and  to  confine  himself  strictly  to  that.    Cai  eless 
use  of  the  forceps  and  scissors,  is  very  apt  to  lead  to  disastrous  excess  and 
insufiiciency  of  the  lid.    Too  much  caution  m  this  respect  cannot  be  enjoined 
^^^e  wound  k  closed  with  a  good  number  of  very  fine  sutures     The  elevating 
effect  may  be  increased  by  pissing  the  needle  first  through       l^^er  e^^^^^^ 
the  skin,  and  then  re-entering  it,  going^deep  enough  to  graze  the  tpsus  and 
coming  ^ut  through  the  upper  edge.    The  stitches  can  be  ^^^'f^^^^l^J^^^^^^^ 
four  hours.    The  swelling  and  increased  weight  of  the  lid  make  it  dioop 


DISEASES  OF  THE  EYELIDS. 


6(35 


almost  as  much  as  before,  and  the  final  effect  is  not  seen  until  a  later  period. 
If  necessary,  another  careful  operation  may  be  repeated  a  few  months  after. 

Other  methods  are  practised  and  may  sometimes  do  better,  such  as  the  use 
of  loops  of  subcutaneous  ligature,  recently  recommended  by  I*agenstecher.  If 
loops  of  sutures,  passed  under  the  skin  near  the  free  edge,  brought  out  above, 
and  tied,  will  accomplish  the  same  elevation,  there  will  be  less  danger  of  insuf- 
ficiency, unless  the  tlireads  are  drawn  too  tight  and  left  too  long.  In  case  un- 
sightly folds  remain  behind,  the  surplus  may  afterwards  be  removed.  I  have 
lately  had  under  care  a  case  of  congenital  drooping  of  both  lids,  to  such  a 
degree  that  the  patient,  a  young  man,  walked  with  his  head  painfully  drawn 
back,  and  chest  projecting.  Folds  were  removed  and  the  sutures  passed 
deeply  near  the  upper  edges  of  the  tarsi.    The  result  w^as  excellent. 

Entropium  and  Trichiasis. — A  frequent  sequel  of  granular  lids,  is  incur- 
vation or  troughing  of  the  tarsal  cartilage.  This  leads  to  inward  displacement 
of  the  eyelashes,  and  trichiasis.  In  the  cicatrizing  process  of  trachoma,  the 
tarsal  conjunctiva  contracts,  atrophies,  loses  its  polish  and  secreting  capacity, 
and  distorts  the  tarsus  horizontally  by  drawing  its  two  edges  towards  each 
other.  Rude  friction,  by  the  stifl:ened  lid  and  eyelashes,  on  the  cornea,  gives 
rise  to  unmanageable  keratitis  and  pannus.  Tenderness  to  light,  dimness  of 
vision,  frequent  attacks  of  painful  ulceration  of  the  cornea,  weeping,  and  end- 
less trouble,  are  the  results.  The  shrinking  process  of  atrophy  leads  also  to  oblite- 
ration of  the  reflected  folds,  and  to  much  limitation  in  the  movements  of  the 
eyes.  Moreover,  the  lids  are  slowly  united  at  the  outer  commissure,  and  trou- 
blesome phimosis  results,  greatly  aggravating  the  trichiasis.  Such  lesions  are 
permanent,  and  can  only  be  benefited  by  surgical  treatment.  Of  the  many  de- 
vices practised  for  the  relief  of  trichiasis  and  its  consequences,  the  most  unsatis- 
factory is  the  mere  excision  of  a  horizontal  fold  of  skin.  It  leads  to  insuffi- 
cient closure  of  the  lids,  without  materially  correcting  the  malposition  of  the 
lashes  and  deformity  of  the  tarsus.  Better  results  are  obtained  by  splitting 
the  lid  between  the  tarsus  and  the  bulbs  of  the  eyelashes,  excising  a  fold  of 
iiitegumeut,  and  then  stitching  so  as  to  slide  the  lashes  with  their  bulbs  up 
on  the  anterior  surface  of  the  tarsus.  Various  modifications  of  this  procedure 
may  be  practised,  but  they  all  leave  the  main  difficulty  untouched,  in  trichi- 
asis from  incurvation.  The  malfoi^mation  of  the  tarsus,  if  it  exists,  is  the 
first  and  most  important  thing  to  be  corrected.  This  is  done  in  dififerent 
ways.  An  incision  through  the  skin,  and  from  three  to  four  millimetres  from 
the  free  margin  of  the  lid,  extending  the  whole  length  of  the  tarsus,  is  first 
made.  To  avoid  bleeding  and  greatly  facilitate  the  operation,  the  ring  for- 
ceps shotdd  be  used.  The  skin  being  incised  to  the  full  length  required",  and 
the  fibres  of  the  orbicular  muscle  separated,  the  white,  firm  tarsus  is  properly 
exposed.  Then,  seizing  it  with  stout,  toothed  forceps,  and  lifting  it  up,  a 
Graefe's  knife  is  used  to  take  out  a  wedge-shaped  piece,  cutting  from  w^ithout 
inwards,  from  the  whole  length  of  the  thickened  tarsus.  Great  care  is  taken 
to  avoid  cutting  through  and  sacrificing  any  of  the  conjunctiva.  This  done, 
the  edges  of  the  skin  are  carefully  united  by  four  or  five  fine  sutures.  Instead 
of  trying  to  remove  the  whole  piece  at  once,  it  is  better  to  seize  the  tarsus  at 
difierent  points,  and  remove  a  portion  each  time,  till  the  end  is  accomplished. 
The  knife  may  be  made  to  cut  down  on  one  side  and  out  on  the  other, 
gradually  rotating  it  as  it  approaches  the  conjunctiva.  Thus  a  succession  of 
central,  horizontal  excisions  are  made. 

There  is  more  danger  of  not  removing  enough,  than  of  removing  too  much 
of  the  stifit*  tarsus.  If  one  or  more  small  holes  are  made  in  the  conjunctiva,  they 
do  no  serious  harm,  but  it  is  best  to  save  that  membrane  entire  if  possible. 
A  v^ery  narrow  strip  of  skin  is  to  be  removed,  either  before  the  tarsus  is  excised, 


666  INJURIES  AND  DISEASES  OF  THE  EYES  Al^D  IHEIR  APPENDAGES. 

or  after.    It  sbould  not  exceed  two  or  three  mm.  in  width,  and  this  should  be 
equal  throughout  its  length,  excepting  at  each  end  where  the  incision  runs  to 
a  point.    The  quantity  of  skin  removed  should  depend  on  the  surplus  present, 
but  it  is  often  very  disastrous  and  unnecessary  to  remove  much.    If  marked 
phimosis  is  present,  a  canthoplasty  at  the  outer  angle  is  to  be  made  at  the 
same  time.  A  great  change  in  the  position  of  the  lids  may  be  secured  m  this 
way     If  the  incurvation  and  trichiasis  are  slight,  a  canthoplasty  alone  may 
be  sufficient  to  relieve  the  inversion.    In  all  cases  of  troughing  of  the  tarsus, 
and  especially  where  very  little  if  any  skin  can  be  spared,  I  have  been  much 
pleased  with  the  operation  of  Dr.  Green,  of  St.  Louis.    He  everts  the  upper 
lid  holds  it  -firmly,  and  cuts  through  the  conjunctiva  and  the  tarsus  m  the 
whole  length  of  the  latter.    He  keeps  the  incision  two  mm.  from  the  line  of 
orifices  of  the  Meibomian  ducts,  and  uses  a  scalpel.  A  Graefe's  knife,  held  per- 
pendicularly to  the  tarsus,  jjlunged  through,  and  pushed  along  carefully,  does 
equally  well.  If  desired,  the  incision  can  be  prolonged  at  either  end  with  stout 
scissors.  The  ring  forceps  are  not  necessary.  The  effect  produced  by  this  inci- 
sion is  to  separate  tl^e  entire  margin  of  the  lid  from  the  body  of  the  tarsus,  and 
thus  to  allow  it  to  be  easily  everted,  and  to  be  held  without  strain  m  its  new 
position.    A  strip  of  skin  from  one  and  a  half  to  two  mm.  in  width,  is  ex- 
cised, its  lower  boundary  being  about  one  and  a  half  mm.  from  the  line  of 
eyelashes.    The  sutures  are  applied  with  a  curved  needle  m  the  usual  holder. 
The  needle  is  entered  through  the  conjunctiva,  a  little  within  the  rows  of 
lashes,  and  brought  out  through  the  wound  of  the  skin,  close  to  its  lower 
edge.  '  Drawn  through  far  enough,  it  is  again  passed  under  the  upper  hp  of 
the  incision,  deep  enough  to  graze  the  tarsus,  and  to  come  out  through  the  skin 
about  ten  mm.  above  the  point  of  entrance.   When  the  suture  is  knotted,  the 
cutaneous  wound  is  closed,  and  the  loosened  margin  of  the  lid  is  at  the  same 
time  everted  and  brought  into  proper  position.    Three  sutures  are  usually 
enough,  and  they  should  be  removed  in  twenty-four  hours.    Healing  is 
prompt,  and  the  gaping  tarsus  on  the  conjunctival  side  heals  by  granulation,, 
leaving  no  rigid  cicatrix.    Very  little  integument  need  be  sacrificed.^ 

I  have  seldom  resorted  to  this  operation  before  the  trachomatous  cicatriza- 
tion has  been  completed,  but  it  maybe  done  during  the  active  progress  of  the 
disease,  to  hasten  recovery.  If  necessary,  it  may  be  repeated.  Where  large 
losses  of  skin  from  other  previous  opei^ations  forbid  further  sacrifice,  a  simple 
incision  in  the  skin,  and  some  loosening  of  the  upper  lip  of  the  wound,  with 
careful  placing  of  sutures,  will  suffice.  In  extreme  cases  of  phimosis,  cantho- 
plasty may  be^  combined  with  this  operation.  If  the  tarsus  is  much  hypertro- 
phied,  hard,  and  prominent  under  the  skin,  I  remove  a  longitudinal,  wedge- 
shaped  portion  through  an  incision  of  the  skin,  as  above  described.  With 
one  or  the  other  of  these  operations,  all  cases  of  entropium,  incurvation, 
trichiasis,  and  distichiasis,  can  l)e  relieved.  The  orbicular  fibres  are  preserved 
in  both,  and  the  circulation  of  the  lid  margin  is  not  at  all  seriously  impaired. 

If  the  free  ends  of  the  eyelashes,  from  any  cause,  touch  the  cornea,  they 
are  popularly  called  wild  hairs,  and  must  be  removed  by  surgical  interference. 
If  they  stand  free,  however,  they  are  harmless  ornaments,  and  shou  d  be 
respected.  Spasmodic  entropium,  occurring  usually  in  old  people  with  relaxed 
integument,  is  a  serious  trouble,  and  must  be  obviated.  This  tendency  is 
increased  by  bandaging  the  eyes,  as  after  cataract  extractions  and  other 
operations.  The  reflex  influence  of  the  displaced  lid  prompts  to  still  greater 
contraction  and  firmer  inversion.  The  annoyance  is  extreme,  and  greatly  im 
creases  the  risks  of  such  operations  on  the  eyeball.  If  possible,  the  roller 
should  be  removed  in  all  such  cases,  and  the  eyes  kept  open.  By  holding  the 
lower  lid  down,  and  keeping  the  eye  open,  the  inversion  is  easily  overcome. 
Collodion  applied  to  the  skin,  and  allowed  to  dry,  will  often  suffice  to  keep 


DISEASES  OF  THE  EYELIDS. 


667 


the  lid  in  place,  till  the  spasm  ceases.  Various  surgical  operations,  comhined 
with  excisions  of  skin  from  the  lower  lid,  are  practised  for  its  permanent 
relief.  In  all  operations  for  entropium,  where  a  sacrifice  of  skin  is  thought 
advisable,  great  care  must  be  taken  to  avoid  excess.  It  is  always  easy  to 
remove  a  little  more  integument,  at  another  time,  if  needed.  In  people  of 
advanced  years  with  great  relaxation  and  excess  of  skin  folds,  a  freer  excision 
may  be  risked.  An  actual  ectropium,  or  imperfect  closure  of  the  lids,  or  both, 
after  an  operation  for  inversion,  is  always  to  be  guarded  against.  Prudent 
foresight,  here  as  everywhere  else,  may  save  the  patient's  temper  andthesur' 
geon's  remorse. 

Canthoplasty. — The  operation  of  canthoplasty  is  practised  for  opposite 
purposes  in  different  cases.  In  one  it  is  done  to  enlarge  the  too  small  com- 
missure; in  the  other  to  secure  its  diminution.  The  latter  operation  has 
already  been  described.  The  first  step  in  securing  increased  space  is  to  divide 
the  outer  angle  with  stout  scissors  or  a  bistoury.  Profuse  hemorrhage,  in  this 
operation,  cannot  be  avoided,  and  is  a  great  hindrance.  The  incision  must  be 
in  the  direct  line  of  the  canthus,  and  should  usually  extend  to  the  bony  orbit. 
Firm  pressure  with  a  sponge  will,  in  a  few  minu'-.es,  control  the  bleeding,  so 
that  the  other  steps  may  be  executed.  The  divided  corner  should  be  forced 
widely  open  by  an  assistant,  everting  it  as  much  as  possible.  The  conjunctiva 
is  then  seized  by  the  forceps,  gently  raised,  and  loosened  from  its  connections 
with  the  points  of  the  scissors.  This  causes  it  to  slide  easil}-,  and  to  cover  the 
raw  edges  better.  Then  the  conjunctiva  and  skin  are  to  be  stitched  together. 
The  first  suture  is  applied  exactly  in  the  angle.  Two  others  usually  sufiice, 
one  above  and  the  other  below.  Great  care  must  be  taken  to  secure  perfect 
coaptation.  Thus  the  raw  edges  are  kept  from  readhering.  Cold  dressings 
are  applied,  and  in  about  thirty -six  or  forty-eight  hours  the  threads  may  l)e 
removed  very  cautiously.  The  proper  execution  of  this  bloody  operation 
secures  freer  eversion  of  the  lids,  and  valuable  space.  It  may  often  be  com- 
bined with  an  entropium  operation,  and  the  degree  of  freedom  secured  may 
be  regulated  by  the  extent  of  the  incision. 

Ectropium. — Ectropium  is  an  eversion  of  the  eyelid,  preventing  perfect  coap- 
tation. It  is  seen  in  various  degrees,  due  to  various  causes.  The  most  serious 
and  frightful  cases  are  those  resulting  from  deep  and  extensive  burns  of  the  face. 
Scars  from  wounds  of  the  lids  and  adjacent  parts,  from  ulceration  in  skin- 
diseases,  from  abscesses  and  sloughing  during  facial  erysipelas,  and  from 
caries  of  the  bony  orbit,  are  all  very  likely  to  be  foUowed'^by  this  deformity. 
Chronic  blepharitis,  with  loss  of  eyelashes  and  contraction  of  the  skin,  from 
chafing  caused  by  eversion  of  the  puncta  and  constant  weeping,  is  a  common 
source  of  troublesome  eversion.  Then  the  chronic  forms  of  conjunctivitis 
with  swelling  and  hypertrophy,  lead  to  constantly  increasing  ectropium.  As 
the  edges  of  the  lids  become  thickened  and  relaxed,  with  tlie  marginal  fibres 
of  the  orbicularis  muscle,  the  bundles  over  the  orbital  edges  of  the  tarsi  con- 
tract spasmodicall}^,  and  intensify  the  displacement.  Abscess  of  the  orbit 
with  protrusion  of  the  eye,  and  extreme  exophthalnius  in  Basedow's  disease, 
are  sure  to  be  complicated  by  inflammatory  ectropium.  This  trouble. is  much 
more  frequent  in  the  lower  than  the  upper  lid,  but  not  so  disastrous  to  the 
eye.  The  weeping  from  displacement  of  the  punctum,  especially  the  lower 
one,  the  constant  exposure  of  the  everted  mucous  membrane  to  irritating 
causes,  and  the  want  of  protection  to  the  eyeball,  all  contribute  to  increase  the 
deformity  and  its  dangers.  In  facial  paralysis,  the  swagging  of  the  lower  lid 
sometimes  results  in  total  eversion  and  great  annoyance. "  "The  paralysis  of  the 
fibres  of  the  orbicularis  of  the  lower  lid,  and  the  relaxed  condition  of  the 


668         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDASES. 

same  in  old  people  with  chronic  conjunctivitis,  are  important  factors  in  the 
Droduction  of  this  disease.  m    c  i 

The<rratoe«iofectropium  is  palliative,  and  if  possible  curative     fhe  first 
point  to  be  made  out,  with  a  view  to  treatment,  is  the  etiology.^  It  cicatricial 
contraction  of  the  skin  is  the  cause,  that  must  be  relieved  in  a  way  best 
adapted  to  each  case.    General  rules  only  can  be  given :  the  special  modifi- 
cations must  be  suggested  by  the  genius  of  the  surgeon.  Extensive  dissections 
torsion  and  sliding  of  flaps,  and  especially  great  _  tension  alter  the  use  ot 
sutures  of  whateve°r  kind,  are  very  liable  to  result  m  failure  to  heal  by  first 
intention,  sloughing,  and  serious  aggravation  of  the  original  deformity,  it 
is  for  this  reason  that  skin-grafting  and  transplantation,  alter  removal  of 
scars  and  proper  preparation,  have  of  late  years  been  so  extensively  tested. 
ThereTs  no  other  Lgion  of  the  body  where  a  skilful  resort  to  this  sate  pro- 
cess is  crowned  with  such  brilliant  results.    If  the  patient  is  not  completely 
relieved,  he  is  probably  somewhat  benefited,  with  a  chance  oi  further  im- 
provement in  the  future.    At  all  events,  the  case  is  not  made  woi-se  by  the 
operation.    The  great  advantage  of  skin-grafting  is  that  it  can  be  properly 
employed  in  the  early  cicatrizing  stages,  to  prevent  as  well  as  to  relieve; 
while  plastic  operations  by  sliding,  etc.,  must  be  deferi-ed  a  very  long  t  me, 
to  diminish  the  risks  of  sloughing.  }«  ectropmm  j.ar«^yfte«m  canthoplasty, 
as  alreadv  described,  is  always  applicable,  safe,  and  beneficial.    As  a  lule, 
entropUiB^  following  trachoma  with  contraction,  or  chronic  marginal  blepha- 
rMsl  aggravated  by  blepharophimosis.    To  overcome  this  by  dividing  the 
external  fommissure,  and  stitching  the  skin  and  conjunctiva  so  as  to  prevent 
cbsu  4  thus  enlarging  the  palpebral  opening,  helps  very  much  to  relieve  the 
im-e"  im      On  thi  contrary,  in  treating  ectropium,  the  outer  commissure 
should  be  pared  and  united 'in  many  cases,  as  one  of  the  means  ot  aftordmg 
relief  to  the  deformity.  ^      .       .         ,  , 

In  some  cases,  with  great  thickening  of  the  everted  conjunctiva  and  hypei- 
trophv  of  the  tm-sus,  an  excision  of  a  longitudinal  portion  of  the  diseased 
sZctiires,  the  wound  being  closed  by  loops  brought  out  through  the  sku> 
below  and  tied  over  a  small  tent,  gives  excellent  results.  The  wise  choice,  in 
each  ca  e,  ot'the  best  method  oi-  combination  of  methods,  to  suit  the  pecu- 
Harities  present,  will  distinguish  th^surgeon  of  tact  and  experience  from  he 
mere  cutter.  Of  all  the  regions  of  the  body,  the  face  divine  calls  for  the 
most  thoughtful  and  skilf.fl  surgery.  A  bad  job,  anyvvhere  else,  may  be 
covered  up!  and  in  a  measure  concealed  from  the  gaze  ot  the  curious  and  the 
critical ;  but  a  marred  visage  is  an  open  reproach  to  the  surgeon,  and  a  source 
of  extreme  mortification  to  the  patient.  ^  4.1,   f  „^ 

The  treatment  of  the  ectropium  which  results  from  deep  burns  of  the  face 
from  caries  of  the  orbit  or  injuries  with  depressed  cicatrices  adherent  to  the 
bone  and  from  mutilations  of  various  khids,  is  a  department  of  plastic  sur- 
S  w  too  important  to  be  dealt  with  briefly.  For  the  various  methods  by 
Ifhfch  these  «.nditions  are  to  he  ameliorated,  I  can  only  refer  t^e  reader  to 
more  elaborate  works  on  ophthalmic  surgery.  Suffice  t  to  say  that,  with 
few  exceptions,  the  results  L  uncertain,  an.i  fa  lures  often  disastrous.  In 
my  ophiion,  eftbrts  to  effect  a  cure  by  skin-grafting,  combined  with  caretul 
plast  c  operations,  give  the  most  promise  for  the  future.  Merely  cosmetic 
8«rgery°  if  not  brilliantly  successful,  is  not  appreciated;  ^nd  failures  may 
likewise  be  brilliant .' 

Symblepharon.-To  avoid  nice  distinctions  and  long  names,  I  include 
under  this  head  all  unnatural  adhesions  of  the  lids  with  one  another  and 
w  th  the  globe  of  the  eye.  To  allow  the  utmost  freedom  of  rotation  and  easy 
movement  of  the  lids,  a  well-lubricated  surface  and  exuberant  folds  are  sup- 


DISEASES  OF  THE  EYELIDS. 


669 


plied  by  the  conjunctiva.  If  the  conjunctiva  is  reduced  in  its  superficial  ex- 
tent by  any  cause,  as  by  the  shrinking  process  that  follows  granular  lids,  two 
results  follow.  One  is  cupping  or  incurvation  of  the  tarsus ;  and  the  other 
obliteration  of  the .  retro-bulbar  folds.  The  foi-nier  produces  more  or  less 
rigidity  of  the  lid,  and  trichiasis ;  the  latter  limits  freedom  ot  movement. 
In  extreme  cases,  the  degenerated  conjunctiva  seems  to  pass  directly  from  the 
posterior  edge  of  the  tarsus  to  the  sclera.  This  condition  is  called  posterior 
symblepharon^  and  is  incurable.  Its  evils  are  enhanced  by  the  dryness  ot  the 
atrophied  conjunctiva,  which  when  exti-eme  is  called  xerosis.  In  this  hope- 
less degree,  the  mucous  membrane  becomes  as  dry  and  harsh  as  the  skin.  It 
is  tlie "occurrence  of  this  form  of  symblepharon  that  deters  surgeons  from 
sacrificing  a  zone  of  sclerotic  conjunctiva  in  the  operation  of  syndectomy. 
The  directions  for  that  operation  are,  to  incise  the  conjunctiva  entirely  around 
the  cornea,  dissect  it  back,  and  remove  a  broad  band,  reaching  almost  or  quite 
to  the  equator  of  the  globe.  Then  tho  sub-conjunctival  tissues  are  cut  or 
scraped  away,  baring  the  sclera  completely.  This  denuded  surface  is  allowed 
to  heal,  and,  in  doing  so,  it  contracts  and  obliterates  the  persistent  vessels  that 
traverse  the  cornea  and  keep  up  the  opacity.  The  area  of  the  conjunctiva, 
already  much  reduced  in  these  cases,  is  still  further  diminished.  For  this 
and  other  reasons,  I  greatly  prefer  inoculation  in  extreme  cases  of  pannus,  as 
already  stated.  The  use  of  jequirity,  if  equally  efficient,  would  be  still  pre- 
ferable to  inoculation,  because  freer  from  danger.  The  surface  shrinkage  of 
the  conjunctiva  and  the  arrest  of  its  secretion  are  often  increased  by  too 
severe  cauterization  in  the  treatment  of  granular  lids. 

Another  form  -of  symblepharon  is  the  result  of  destruction  of  large  por- 
tions of  conjunctiva  by  burns  or  other  causes.  If  the  palpebral  and  ocular 
conjunctiva  are  both  destro3^ed,  the  raw  surfaces  in  contact  are  sure  to  unite 
rigidly.  In  case  the  cornea  has  been  destroyed,  or  severely  cauterized,  the 
lids  may  unite  firmly  with  the  entire  front  half  of  the  ball. 

The  difficulties  in  treating  this  form  of  adhesion  are  much  increased,  if  the 
conjunctiva  is  destroyed  to  the  bottom  of  the  cul  de  sac.  In  that  case,  it  is 
impossible  to  pass  a  probe  underneath  and  around  the  adhesion,  and  almost 
impossible  to  prevent  reunion  of  the  surfaces  when  artificially  separated.  The 
burn  often  destroys  the  lid  margin,  the  puncta,  and  the  canaliculi,  thus  still  fur- 
ther complicating  the  symblepharon.  Then  again,  a  hopelessly  blind  eye,  when 
thus  adherent  and  restrained  in  its  movements,  is  often  painful  and  detrimental 
to  its  fellow.  In  that  case  it  should  be  enucleated.  A  limited  symblepharon, 
especially  when  a  probe  can  be  passed  around  it,  can  be  carefuU}^  detached 
and  kept  from  reuniting.  It  is  always  Avise  to  cover  the  denuded  eyeball, 
after  free  detachment,  by  separating  and  sliding  in  folds  of  conjunctiva  from 
opposite  sides,  uniting  them  by  fine  sutures.  Some  benefit,  and  often  very 
satisfactory  results,  are  thus  obtained  by  the  skilful  adaptation  of  means 
to  ends. 

Erectile  Tumors  of  the  Eyelids. — Vascular  tumors  of  different  kinds, 
usually  called  erectile,  often  form  in  or  under  the  skin  of  the  eyelids  and  face. 
They  are  of  serious  importance,  and,  when  far  advanced,  always  difficult  to 
cure  without  deformity.  Timely  surgical  interference  is  always  desirable. 
Whether  congenital  or  not,  these  unsightly  diseases  are  very  apt  to  increase, 
if  not  promptly  treated.  In  some  that  are  well  defined  and  subcutaneous,  a 
careful  enucleation  is  practicable.  If  cut  into,  however,  alarming  hemorrhage 
is  sure  to  follow.  Some  form  of  ligature,  either  subcutaneous,  or,  in  bad  cases, 
even  including  the  skin,  will  usually  suffice.  Acupuncture,  and  even  the 
galvano-cautery,  are  often  indicated.  Coagulating  injections  are  very  risky, 
and  I  have  seldom  used  them.    There  is  no  class  of  diseases  which  requires, 


670         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


at  the  same  time,  more  surgical  thoroughness  and  prudence.  If  the  growth 
originates  in,  or  invades,  the  conjunctiva,  the  difficulties  and  dangers  are 
o-reatly  increased.  In  the  case  of  a  young  lady  with  such  a  tumor  of  the  con- 
junctiva scleroticse,  I  resorted  to  subconjunctival  ligation  and  subsequent 
excision,  but  the  growth  again  increased.  Dr.  S.  C.  Ayres  thereupon  incised 
the  conjunctiva  and  dissected  it  from  the  tumor,  which  was  then  firmly 
li^ated  close  to  the  sclera  and  cut  away  in  front  of  the  ligature.  Afterwards 
a  Ismail  nodule  of  vessels  remained,  which  was  raised  with  forceps  and  snipped 
away.  The  recovery  was  complete.  This  case  is  illustrated  in  Plate  XXYII., 
Fig."!. 


Diseases  of  the  Tear  Passages. 

The  necessary  drainage  of  the  eyes  is  secured  by  a  system  of  sewers, 
composed  of  the  tear  sac,  nasal  duct,  and  canaliculi.  At  the  inner  end  of 
each  tarsus  is  seen  a  small  round  opening,  the  pundum  lachrymale,  which  is 
the  beginning  of  the  canaliculus  leading  to  the  sac.  The  lower  punctum, 
by  its  position,  seems  to  be  more  important  than  the  upper.  In  health,  the 
mechanism  of  the  process  of  taking  up  and  carrying  away  the  tears  is  ex- 
plained by  the  action  of  the  orbicularis  muscle,  helping  the  siphon  system 
supplied  by  the  canaliculi.  Each  panctum  rests  gently  against  the  globe, 
where  it  readily  takes  up  the  fluid. 

Epiphora. — Paresis  or  paralysis  of  the  circular  muscle  of  the  lids,  is  always 
attended  by  a  watery  eye.  This  is  particularly  troublesome  in  facial  paralysis, 
from  whatever  cause,  and  persists  as  long  as  the  impaired  muscular  activity. 
But  the  healthy  action  of  this  muscle  can  only  take  away  the  tears  through 
tlie  puncta  when  in  proper  position.  Mechanical  displacement  of  these  points 
will  lead  to  constant  weeping.  Epiphora  from  this  cause  alone  is  often  seen  in 
inflammation  of  the  conjunctiva  and  lids,  causing  swelling  and  eversion  of  the 
punctum.  The  same  result  is  produced  by  contraction  of  the  skin,  the  pre- 
sence of  lid  tumors,  hypertrophy  of  the  lachrymal  caruncle,  chronic  blepharitis 
marginalis,  or  any  other  disease  that  leads  to  displacement  of  the  punctum. 
It  is  often  seen  in  the  lax  lids  of  old  people,  and  is  explained  in  the  same 
mechanical  way.  Some  eversion  of  the  lower  punctum  and  troublesome 
weeping,  are  constant  accompaniments  of  granular  lids.  If  possible,  this 
annoyance  should  be  relieved  by  removing  the  cause.  But  the  constant 
standing  of  tears  in  the  eye  often  aggravates  and  keeps  up  the  mechanical 
cause.  Hence  relief  of  the  epiphora,  itself  a  great  boon,  may  be  a  means  of 
curing  the  disease  that  causes  and  keeps  it  up. 

Any  displacement  of  the  lower  punctum  is  exaggerated  when  the  eye  is 
turned  upward.  In  protracted  epiphora  from  this  simple  cause,  the  little  open- 
ing may  be  closed  up,  covered  with  dry  epidermis,  and  very  difficult  to  detect  at 
all.  A  faint  depression  in  the  dry  lid,  where  it  is  known  that  it  should  be,  is 
its  only  indication.  A  small  conical  probe,  gently  pressed  into  it  perpendicu- 
larly, thence  passes  on  into  the  sac.  When  the  diagnosis  is  positive,  a  very 
simple  surgical  operation  gives  immediate  and  great  relief.  I  mean  slitting 
the  lower  canaliculus.  The  punctum  must  first  be  stretched  by  a  conical  probe, 
80  as  to  admit  the  knife  or  scissors.  A  sharp,  probe-pointed  Weber's  knife 
(Fig  939),  or  a  delicate  pair  of  scissors  with  a  probe-branch,  may  be  used. 
The  latter  instrument  causes  the  least  pain,  and  is  quickest  in  its  action. 
The  probe-branch  is  passed  into  the  punctum,  and  horizontally  along  the 
canal  for  three  or  four  mm.  The  scissors  are  then  quickly  closed,  and  the 
operation  is  completed.    Twice  a  day  for  two  days,  a  blunt  probe  should  be 


PLATE  XXVII. 


DISEASES  OF  THE  TEAR  PASSAGES. 


671 


passed  along  the  slit-up  canal,  till  the  edges  cease  to  adhere.  By  this  means 
the  punctum  is  transferred  to  a  point  where  the  tears  can  reach  it.  In  very 
rare  cases,  troublesome  weeping  seems  due  to  a  hypersecretion  of  tears  alone. 
In  spite  of  the  regular  action  of  the  ducts,  the  eye  overflows  as  a  stream  in  a 


Fig.  939. 


Weber's  probo-kaife. 


freshet.  But  the  most  frequent  cause  of  persistent  weeping,  is  inflammation 
and  obstruction  of  the  lachrymal  passages.  The  force  of  the  inflammation 
seems  to  centre  in  the  sac,  but  the  stricture  is  located  in  the  nasal  duct. 
This  condition  usually  comes  on  very  slowly.  Months  and  even  years  pass 
before  it  reaches  a  climax.  The  weeping  sometimes  disappears  in  summer,  to 
reappear  the  following  winter,  and  is  always  worse  out-doors,  and  in  windy, 
cold  weather.  At  last  it  becomes  constant,  the  region  of  the  tear  sac  begins 
to  bulge,  and  pressure  over  the  sac  causes  a  reflux  of  mucus  or  pus  through 
the  puncta.  With  this  history,  and  these  developments,  the  diagnosis  of 
chronic  dacryocystitis  is  established.  By  slow  degrees  the  lachrymal  tumor 
increases.  Some  time  or  other,  pressure  will  fail  to  empty  the  collection,  and 
the  patient  will  have  acute  inflammation  and  abscess  of  the  tear  sac,  and,  these 
attacks  following  at  variable  intervals,  fistula  lachrymalis  will  finally  be  the 
result. 

Dacryocystitis  and  Lachrymal  Fistula. — Acute  inflammation  of  the  sac, 
abscess,  and  fistula,  are  rarely  seen,  except  when  preceded  by  the  above 
symptoms.  When  the  seat  and  anatomical  relations  of  the  tear  sac  are 
kept  in  view,  the  diagnosis  is  easy.  The  tendon  of  the  orbicularis  passes 
across  the  anterior  wall  of  the  sac,  and  is  always  raised  by  the  tumor. 
Pressure  over  the  known  region  of  the  sac  will  generally  empty  it,  forcing 
the  contents  through  the  nasal  duct,  or  back  upon  the  eye.  In  acute  suppu- 
rative inflammation  of  the  sac,  the  point  tender  to  pressure  is  limited  to  that 
region.  The  seat  of  greatest  swelling  and  tenderness,  the  previous  history  of 
weeping  and  other  functional  troubles,  will  make  it  impossible  to  confound 
the  disease  with  facial  erysipelas,  a  furuncle  over  the  sac,  or  anything  else. 
Lachrymal  fistula  is  always  helow  the  tendon,  and  near  the  orbital  margin.  The 
presence  of  a  fistula  above  this  tendon,  anywhere  over  the  upper  and  inner 
margin  of  the  orbit,  creates  at  once  the  suspicion  of  disease  of  the  frontal  sinus. 
Several  such  cases  have  been  referred  to  me  as  examples  of  lachrymal  fistula. 
Of  course,  periostitis,  or  disease  of  the,  os  unguis  and  other  bones  forming  the 
lachrymal  groove  and  nasal  duct,  might  be  confounded  with  the  malady  under 
consideration.  But  the  peculiar  history  and  complications  in  each  case,  will 
clear  up  the  difterential  diagnosis.  I  have  seen  two  cases  of  cyst  in  the 
ethmoid  bone,  resembling  lachrymal  tumor.  Scrofulous  subjects,  and  espe- 
cially those  with  persistent  ozsena,  are  the  most  constant  victims  of  obstruc- 
tion in  the  tear  passages.  In  all  persons  afflicted  by  chronic  inflammation  of 
the  nasal  mucous  membrane,  tear-sac  difficulties  are  liable  to  occur.  Earely, 
conjunctivitis,  acute  or  chronic,  seems  to  follow  the  canaliculi  into  the  sac, 
causino;  o-ranulations  and  obstruction.  Further  than  the  fact  that  these  local 
and  constitutional  peculiarities  predispose  to  this  class  of  diseases,  we  know 
but  little  of  their  etiology.  We  very  seldom  see  them  in  sound  people,  with 
healthy  mucous  membranes.  Troubles  of  the  tear  sac  rarely  recover  spon- 
taneously, and,  when  they  do,  it  is  after  an  acute  abscess.  The  treatment  may 
be  palliative  or  curative.    Gentle  pressure,  twice  a  day  or  oftener,  to  keep  the 


672         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

distended  sac  free  from  accumulations,  and  the  use  of  mild,  local  astringents, 
with  care  in  avoiding  exposure,  constitute  the  measures  which  may  be  em- 
ployed for  palliation.  A  surer  way  to  stave  oif  acute  abscess  is  to  sht  the 
upper  canaliculus  quite  down  to  the  sac,  so  as  to  give  free  and  easy  vent  to 
the  irritating  secretions.  This  allows  also  of  more  thorough  cleansmg  of  the 
diseased  sac  by  syringing.  These  measures,  however,  only  help  in  keepmg 
matters  from  growing  worse.  ^ 

The  radical  and  complete  cure  of  dacryocystitis  and  its  consequences,  is 
seldom  accomplished,  but  great  relief  and  comfort,  often  quite  satisfactory  to 
the  patient,  can  nearly  always  be  expected.   The  first  and  essential  step  m  the 
curative  treatment,  is  surgical.    Free  access  to  the  sac  must  be  had,  to  allow 
of  the  necessary  treatment  of  the  diseased  mucous  lining  and  of  the  stric- 
ture.    There  lingers  still,  in  the  popular  mind,  an  impression  that  a 
precious  tube,  of  some  kind,  must  be  placed  in  the  nasal  duct,  but  the  use 
of  such  an  instrument  has  long  since  been  abandoned,  as  well  as  all  means 
of  dilatation  through  an  opening  in  the  skin.    These  obstructions  are  now 
treated  exclusively  through  the  natural  channels,  and  generally  through  the 
upper  canaliculus.    This  is  slit  well  down  into  the  sac,  and  kept  open, 
as  mentioned  above.    For  this  purpose  a  Weber's  probe-knife  is  the  best 
instrument.    The  patient  should  sit  on  a  low  chair,  or,  better,  lie  on  the 
operatins:  lounge.    The  surgeon  stands  behind  the  head  for  the  right  eye, 
and  in  tront  for  the  left,  using  of  course  his  right  hand.     The  puiictum 
must  have  been  dilated,  with  a  conical  probe,  so  as  to  admit  the  knite. 
An  assistant  renders  the  canal  tense,  by  drawing  the  skin  ot  the  lid  out- 
wards and  upwards.    The  knife  is  passed  in  till  it  reaches  the  cavity  ot 
the  sac,  and  till  the  blunt  point  rests  firmly  against  the  inner  bony  wall. 
Then  keepino-  it  firmly  there,  the  hand  is  slowly  raised  and  the  mucous  mem- 
brane divided  well  down  into  the  corner.    Without  withdrawing  the  knife 
or  relaxing  the  pressure  against  the  inner  wall,  it  is  raised  to  a  vertical  posi- 
tion, pushed  gently  downwards,  the  edge  turned  a  little  forwards  and  made 
to  incise  or  notch  the  sac.    Thus  free  admission  is  secured  for  a  large  probe. 

It  is  better  that  the  sac  should  be  distended  at  the  time  of  tHe  operation. 
This  facilitates  the  different  steps,  and  shows  when  the  sac  is  well  opened, 
by  a  ffush  of  mucus.  Slight  bleeding  takes  place,  but  it  is  soon  over,  it  is 
seldom  necessary  to  give  e^ier.  Waiting  a  few  minutes,  the  probe  may  be 
passed  in  for  exploring  and  overcoming  the  stricture.  A  full  set  of  i^ow- 
man's  flexible  silver  probes  (Fig.  940)  must  be  at  hand.    But  for  safety,  and 


Fig.  940. 


Bowman's  probes, 


for  certainty  as  to  the  seat  of  the  stricture,  I  have  for  many  years  used  probes 
with  bulbous  expansions  near  the  end  (Fig.  941).  The  enlarged  end  is  about 
ten  mm.  long,  and  the  thickest  portion  in  the  middle.  The  rest  of  the  mstru- 
ment  is  decidedly  smaller.  Two  of  different  sizes,  one  two  mm.  aud  the  other 
two  and  one-half  mm.  at  the  thickest  part  of  the  bulb,  may  be  made  on  oppo- 


DISEASES  OF  THE  TEAR  PASSAGES. 


673 


Bite  ends  of  the  same  instrument,  with  a  flat  surface  in  the  centre  as  m  the 
double  probes.  The  length  of  each  probe,  from  the  flat  middle,  should  be  about 
five  and  one-half  cm.  The  probe  is  gently  curved,  so  as  the  mora  readily  to  pass 
through  the  sac  and  nasal  duct,  without  inconvenience  trom  the  prominent 


Fig.  941. 


brow.  It  is  impossible  for  such  an  expansion ,  when  once  fairly  in  the  sac  or  bony 
canal,  to  pierce  the  mucous  membrane  and  make  a  false  passage.  When  the 
stricture  is  reached  and  tbe  resistance  overcome,  the  yielding  is  sudden,  and 
indicates  its  exact  seat  and  extent.  If  the  strictures  are  multiple,  the  seat 
and  existence  of  each  are  determined. 

The  smaller  bulb  is  introduced  first.  If  the  sac  is  not  opened  enough  to 
admit  it,  the  notching  can  be  repeated.  Great  care  should  be  taken  to  get 
surely  and  fairly  into  the  sac  with  the  bulbous  end.  Then  the  probe  is 
turned  vertically,  and  pushed  gently  and  slowly  downwards  in  the  course  of 
the  nasal  duct.  When  the  obstacle  is  reached,  a  little  patience  and  slowly 
increased  pressure  will  suddenly  triumph  over  it,  and  the  probe  will  then  pass 
readily  down  into  the  nose,  where  it  is  firmly  arrested  by  the  solid  floor  of 
the  inferior  meatus.  The  instrument  is  then  gently  withdrawn  and  the  larger 
bulb  passed  through  in  the  same  way.  If  the  stricture  is  very  rigid  and  the 
canal  almost  closed,  some  blood  will  escape  from  the  nose,  but  otherwise  none 
may  be  seen.  This  part  of  the  operation,  if  skilfully  executed,  greatly  simplifies 
and  expedites  the  after-treatment.  Generally  it  is  better  to  do  nothing  more 
than  keep  the  opening  into  the  sac  free  for  a  week  or  more.  If  there  is 
much  discharge,  the  sac  should  be  ^vashed  out  each  day  with  a  syringe  from 
above.  A  dentist's  rubber  syringe  bent  at  right  angles  near  the  end,  with  a 
smooth  point,  and  tepid  water,  are  all  that  is  needed.  If,  when  the  nozzle  is 
fairly  in  the  sac  and  directed  downw^ards,  the  water  does  not  readily  flow 
into  the  nose  and  throat,  there  is  something  wrong,  and  the  parts  should  be 
re-explored.  I  venture  to  say,  from  a  large  experience,  that  if  in  all  cases  of 
dilated,  suppurating  tear  sac,  with  or  without  fistula,  this  much  were  thoroughly 
well  done,  and  the  rest  left  to  nature,  most  of  the  patients  would  be  so  much 
benefited  as  to  feel  satisfied  with  the  result.  In  some  the  troubles  will  come 
back,  but  very  seldom,  if  ever,  in  the  old,  aggravated  form.  In  Stilling's 
mode  of  treatment,  the  stricture  is  deeply  incised  in  difierent  directions,  and 
little  or  nothing  more  usually  done.  Of  course,  if  there  is  syphilitic  or  scrofu- 
lous caries,  with  the  diseased  sac,  no  very  satisfactory  result  can  ever  be 
obtained. 

In  the  hope  of  securing  better  results  m  the  long  run,  I  have  for  many 
years  used  the  bent  silver  styles,  worn  in  the  duct  for  several  months.  They 
are  made  of  pure,  virgin  silver,  four  and  one  half  cm.  long,  slightly  conical  at 
each  end,  and  of  different  sizes,  varying  from  one  to  two  mm.  in  diameter. 
One  end  is  bent  into  a  moderate  curve,  leaving  the  straight  part  three  or  three 
and  one-half  cm.  long.  Close  to  the  beginning  curve  the  style  is  again  bent 
outwards,  so  that  when  inserted,  and  the  hook  turned  forwards  over  the 
VOL.  IV. — 43 


674         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

lower  lid,  it  will  keep  its  comfortable  position.  Otherwise  it  will  be  dragged 
round  against  the  eye  by  the  lid.  The  outward  bend  is  different  for  the  two 
sides.  By  a  little  experience  in  the  use  of  the  pliers,  and  in  fitting  the  length 
to  different  eyes,  it  is  easy  to  get  the  suitable  curves  and  the  right  length,  so 
that  the  style  will  fit  close  up  in  the  corner,  rest  gently  on  the  lower  lid,  be 
touchino-  or  almost  touching  the  fioor  of  the  nostril,  and  be  worn  without  incon- 
venience or  unsightliness.  In  most  cases,  I  prefer  not  to  use  the  style.  If 
the  thorough  operation  for  freeing  the  passages,  already  described,  is  followed 
by  rapid  contraction  of  the  sac  and  diminution  of  the  discharge,  I  prefer 
occasional  syrin2:ing  with  tepid  w^ater  or  mild  astringents.  If  the  troubles 
persist,  or  frequent  relapses  occur,  then  a  resort  to  wearing  the  style  may  be 
a  great  aid.  In  one  respect  its  use  is  more  agreeable  to  the  patient.  After 
the  first  few  days  it  is  not  nearly  as  painful  as  dilatation  by  the  occasional 
passage  of  the  probe.  But  whatever  method  of  combating  the  stricture  may 
be  thou2:ht  best  in  any  case,  the  use  of  the  syringe  must  always  enter  freely 
into  the'treatment,if  thereis  much  enlargement  of  the  sac  and  profuse  secretion. 
In  that  event,  if  the  style  be  employed,  it  must  be  removed  every  day  or  two 
for  thorough  cleansing  with  tepid  w^ater,  or  the  injection  of  astringents,  if 
that  fails.  When  little  or  no  further  secretion  is  present,  the  style  can  be 
worn  for  weeks  together  without  removal.  The  style,  of  course,  must  be  com- 
fortably fitted  to^  each  case,  if  good  is  expected.  In  first  placing  it,  and 
sometimes  in  rexjlacing  it  after  removal  for  syringing,  it  may  not  readily 
enter.  Its  short,  curved,  and  awkward  shape  makes  the  manipulation  difiicult. 
When  this  trouble  is  experienced,  the  full-sized  probe  may  be  passed  and  imme- 
diately followed  by  the  style.  Its  reintroduction  is  more  apt  to  be  difficult 
after  the  use  of  astringents  to  the  sac.  To  combat  the  discharge,  if  not 
promptly  cured  by  wearing  the  style,  syringings  with  tepid  water  and  a^trm- 
p;ents  must  be  used.  About  the  best  is  a  ten-grain  solution  of  sulphate  of  cop- 
per, a  few  drops  drawn  into  the  syringe  and  passed  through  after  thorough 
cleansing  with  tepid  water.  , 

When  the  suppuration  is  controlled,  and  the  patient  is  allowed  to  go  home, 
the  surgeon  should  insist  on  his  immediate  return  if  the  discharge  grows 
worse  in  spite  of  wearing  the  style  and  the  observance  of  proper  care. 
After  the  first  thorough  operation,  if  all  the  symptoms  improved  rapidly, 
I  would  simply  cleanse  the  sac  when  nee  ied,  by  tepid  syringing,  and  wait. 
If  the  case  came  to  a  stand-still,  or  got  worse,  I  would  pass  the  probe  and  let 
it  remain  for  half  an  hour,  once  or  twice  a  week,  continuing  the  necessary 
medication  of  the  sac.  If,  after  a  few  weeks,  the  case  did  not  progress 
well,  I  would  fit  a  suitable  style  and  see  that  it  was  comfortably  adapted. 
Not  much  attention  need  be  paid  to  complaints  of  lachrymation,  as  long  as 
it  is  not  attended  by  undue  secretion  of  muco-pus.  This  can  only  be  remedied 
by  free  dilatation  of  the  stricture  and  faithful  medication  with  the  syringe. 
I  have  seldom  failed  to  find  rapid  and  great  improvement  after  the  first  free 
use  of  the  bulbous  probes.  In  cases  with  a  fistulous  opening  through  the  skm, 
I  prefer  to  pass  the  probes  through  it  into  the  sac,  and  down  to  the  nose.  As 
we  have  this  convenient  way  into  the  sac  open,  immediate  and  large  dilatation 
of  the  stricture  may  be  thus  practised,  and  is  always  followed  by  closure  of 
the  fistula  and  great  amelioration,  i^ow  and  then,  nothing  more  is  needed ; 
but,  if  required,  the  upper  canaliculus  may  be  slit  and  the  usual  treatment  con- 
tinued. Where  the  sac  is  so  large  that  no  treatment  can  be  expected  to 
bring  it  to  reasonable  dimensions,  a  large  portion,  or  the  whole  of  it,  may  be 
dissected  out.  I  did  this  recently  with  the  happiest  result.  The  patient 
had  chronic  ozjena,  and  profuse  suppuration  from  a  large  lachrymal  tumor. 
Having  etherized  her,  I  made  a  long  incision  and  dissected  out  the  sac  with 
au  enormous  diverticulum.    The  wound  was  closed  with  sutures,  and  healed 


OPHTHALMOSCOPIC  DISEASES. 


675 


by  first  intention,  and  in  a  few  days  she  was  well.  By  ''well,"  I  mean 
relieved  of  the  unsightliness  and  disgusting  suppuration.  With  this  she  was 
entirely  satisfied.  The  same  result  is  here  obtained  as  in  the  old  method  of 
destroying  the  tear  sac  by  the  actual  cautery.  In  caries  or  hopeless  closure  of 
the  bony  duct,  destruction  of  the  sac  is  the  best  that  we  can  do.  Extreme 
relaxation  of  the  sac  is  best  relieved  by  enucleation,  as  above^  It  is  sur- 
prising^ how  little  such  patients  are  troubled  with  weeping  after  the  source 
of  the  irritation  is  dried  up  by  obliteration.  Such  eyes  weep  when  exposed 
to  the  wind,  or  under  the  influence  of  the  emotions,  but  not  much  at  other 
times. 

Surgical  measures,  in  the  treatment  of  chronic  suppuration  of  the  lachry- 
mal sac,  are  thus  reasonably  successful,  but  the  complete  cure  of  the  w^eeping 
is  an  exception.  Injuries  of  the  canaliculi,  especially  of  the  lower,  are  often 
seemingly  trifling,  and  yet  are  followed  by  incurable  lachrymation.  If  cut 
across,  torn  away,  or  destroyed  in  their  whole  length  by  burns  or  bruises,  it  is 
seldom  possible  to  re-establish  their  permeability.  Great  care  is  required  in 
removing  small  tumors  or  other  growths  from  the  lids  near  the  inner  commis- 
sure, not  to  cut  away  these  delicate  but  important  structures.  Rarely,  the 
canaliculus  may  become  obliterated  without  in  jury  or  known  cause.  At  other 
times,  a  stricture  is  found  in  its  course,  that 'can  be  overcome  with  a  small 
probe,  and  the  epiphora  relieved.  The  thorough  removal  of  epithelioma  of 
the  lids  may  require  the  sacriflce  of  these  little  ducts,  and  of  course  the  weep- 
ing then  is  permanent.  Occasionally  a  little  calculus  may  form  in  the  canalicu- 
lus, causing  suppuration  and  weeping.  It  is  easily  detected  and  removed,  as  are 
the  little  mushroom  growths  that  cause  similar  troubles.  Persistent  weeping 
is  often  kept  up  by  ulceration  in  the  nose,  and  may  be  mistaken  for  stricture 
of  the  tear  passages.  I  have  a  patient  now  under  treatment,  who  came  for  an 
operation  on  the  tear  sac.  She  is  already  relieved  by  applications  to  the 
nasal  mucous  membrane.  Troublesome  weeping  may  also  be  caused  and 
kept  up  by  a  polypus  or  other  growth  in  the  inferior  nasal  meatus.  Such 
possibilities  should  never  be  forgotten,  particularly  when  long  standing  weep- 
ing is  not  attended  by  suppuration  in  the  sac  itself.  Of  cou^rse,  caries  of  the 
turbinated  bones,  or  foreign  bodies  in  the  nose,  may  give  rise  to  the  same 
trouble.  In  the  few  cases  of  suppurative  inflammation  of  the  tear  sac  in 
infants,  that  I  have  met  with,  they  have  been  relieved  by  a  single  free  dila- 
tation through  the  opened  canaliculus.  Calculi  and  other  formations  in  the 
tear  sac  are  rare,  but  must  be  recognized  and  removed. 


Ophthalmoscopic  Diseases. 

Alterations  behind  the  lens  can  only  be  made  out  by  the  aid  of  the  ophthal- 
moscope. Even  in  luxations  of  the  lens,  the  mirror  is  of  great  use  in 
diagnosis.  For  optical  reasons,  the  edge  of  the  lens,  w^hen  transparent,  is 
seen  as  a  dark  border,  and  readily  identified.  In  the  differential  diagnosis 
of  cataract,  in  its  incipiency,  fundamental  illumination  of  the  eye  must  not 
be  neglected.  Oblique  illumination  alone,  in  old  people,  except  when  distinct 
striae  are  detected  in  the  lens,  is  likely  to  lead  to  a  false  belief  in  the  existence 
of  cataract.  Ophthalmoscopic  results  may  be  positive  or  negative,  each  kind 
having  its  value.  In  growths  of  the  retina  and  choroid,  at  an  early  period, 
when  clear  diagnosis  is  very  important,  the  eye  mirror  is  indispensable.  The 
functional  test  must  not  be  omitted.  A  sharply  defined  blank  in  the  field  of 
vision  (scotoma),  in  a  suspected  tumor  of  the  fundus,  helps  to  confirm  the 
diagnosis.  Any  inflammatory  or  other  organic  lesion  in  the  retina,  choroid, 
or  vitreous,  may  give  rise  to  a  more  or  less  well-defined  scotoma,  which  is 


676         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

a  constant  result  of  detacliment  of  the  retina,  of  hemorrhages,  in  or  under 
the  retina  or  the  choroid,  of  patches  of  choroido-retinitis,  of  tumors  in  the 
fundus  and  sometimes  of  foreign  bodies,  or  extravasations  of  blood  m  the 
vitreous.  (Plate  XXVIII.,  Fig.  2.)  It  is  not  pathognomonic  of  any  one  of 
these  lesions.  Rarely,  it  is  caused  by  the  embolic  pluggmg  of  an  arterial 
branch  in  the  retina  or  choroid.  The  same  defect  in  the  field  of  vision  is 
sometimes  the  result  of  extra-ocular  alterations,  either  in  the  optic  cord  or 
the  brain.  In  such  cases,  the  finding  is  negative.  Lesions  of  the  optic 
tract,  however,  are  more  likely  to  produce  some  form  of  hemiopia  or  sector 
defects  in"  the  field.  In  such  instances  a  negative  result  may  be  of  very 
positive  value  in  fixing  the  diagnosis,  on  the  principle  of  exclusion.  The 
perimeter,  or  the  black  board,  will  enable  the  surgeon  to  map  out  the  scotoma. 

All  disorders  that  lead  either  to  cloudiness  of  the  vitreous,  or  to  profuse 
intra-ocular  hemorrhages,  make  the  illumination  of  the  fundus  diflicult  if 
not  impossible.     If  the  vitreous  is  semi-transparent,  a  red  reflex  may  be 
had  from  the  bottom  of  the  eye,  and  perhaps  glimpses  of  the  optic  papilla 
and  other  structures.    In  that  case,  numerous  floating  corpuscles  will  prob-  < 
ably  be  seen  in  the  liquefied  vitreous.    Slight  movements  of  the  eye  under 
inspection  help  to  identify  them.    If  the  hemorrhage  has  been  profuse,  and 
close  behind  the  lens,  no  red  reflex  can  be  had  from  the  bottom.    The  coagu- 
lum  may  then  be  seen  by  the  ophthalmoscope,  or  by  oblique  illumination,  m 
its  natural  red  color.    Hemorrhages  in  the  eye  are  always  of  serious  signili- 
cance,  occurring  in  the  gravest  diseases,  or  indicating  a  state  of  the  arteries 
that  make  apoplectic  eftusions  in  the  brain  very  probable.    Even  spontaneous 
ecchymosis  under  the  conjunctiva,  in  itself  harmless,  is  of  serious  import  in 
persons  of  advanced  years.    I  have  often  seen  it  as  the  precursor  of  paralysis. 
The  most  hopeless  form  of  glaucoma  is  that  which  is  complicated  by  intra- 
ocular hemorrhages.    Indeed,  the  frequent  occurrence  of  ecchymoses  m  the 
retina,  in  connection  with  any  disease,  is  an  alarming  symptom.  (Plate 
XXYIII   Fig.  6.)    In  old  people  it  portends  glaucoma.    In  the  young  it 
siOTifies  a'  fatal  hemorrhagic  diathesis.    Such  cases  should  be  closely  watched 
for  years,  lest  they  end  in  destructive  glaucoma.    Intra-ocular  bleeding,  alone 
or  complicating  local  diseases  of  the  eye,  may  be  indicative  of  organic  lesions 
of  the  heart  or  kidneys,  of  the  hemorrhagic  diathesis,  of  nialignant  ansemia, 
or  of  a  degenerated  state  of  the  arteries.    A  rigid  inquiry  in  all  these  direc- 
tions should  be  insisted  upon.    In  rare  cases,  the  phenomenon  is  unaccount- 
able    I  have  now^  under  treatment  a  temperate  and  well-preserved  man  ot 
sixty  years,  who  has  had  the  most  extensive  retinal  hemorrhages  I  have  ever 
Been  first  in  one  eye  and  then  in  the  other.    He  seems  to  be  absolutely  sound, 
but  'is,  of  course,  liable  to  an  apoplectic  attack,  of  which,  however,  there  is 
now  no  premonition  whatever.    If  he  escapes  that,  I  shall  expect  to  see 
glaucomatous  manifestations  at  some  future  day.  ^  ^    .  ^  ^  .  .     ^,  . 

In  syphilitic  choroiditis,  the  vitreous  is  often  filled  with  fine  opacities,  that 
'rise  up  like  clouds  of  dust  when  the  examined  eye  is  slightly  moved     It  the 
turbidity  is  great,  the  outlines  of  the  fundus  may  not  be  at  all  visible.    At  a 
later  period,  when  this  fluid  has  again  cleared,  extensive  atrophic  patches^ 
the  choroid  may  be  discovered.  " 

In  the  acute  forms  of  glaucoma,  the  cornea,  aqueous  and  vitreous  are  otten- 
so  hazv,  that  direct  ophthalmoscopic  diagnosis  is  impossible.  Such  diagnosis 
presupposes  perfect,  or  at  least  partial  transparency  of  the  dioptric  structures. 
Opacities  in  any  or  all  of  these,  if  large  and  dense,  preclude  the  use  of  this 
valuable  instrument.  Other  means  of  diagnosis  must  then,  especially,  be 
strained  into  service,  as  I  have  already  pointed  out  with  some  detail. 

A  false  fear  of  the  brilliant  light  in  ophthalmoscopic  examination,  prevails 
among  patients.    But  in  intelligent  hands  there  is  no  danger  whatever,  it 


PLATE  XXVIII. 


OPHTHALMOSCOPIC  DISEASES. 


677 


18  always  best  to  look  a  little  obliquely  into  the  eye,  at  first  and  at  all  times, 
except  when  the  region  of  the  macula  lutea  is  inspected.  In  this  way  the 
light  is  not  at  all  painful,  nor  even  dazzling.  In  the  diagnosis  of  delicate 
changes  in  the  direct  line  of  vision,  dilatation  of  the  pupil  is  indispensable. 

There  are  two  methods  of  examining  the  eye  with  the  ophthalmoscope 
—one  called  the  direct,  and  the  other  the  reversed.  In  the  former,  the  objects 
in  the  fundus  are  seen  in  their  natural  relations.  With  the  latter,  they  are 
reversed,  above  appearing  below,  and  right  left.  We  speak  likewise  of  the 
erect  and  the  reversed  image.  In  direct  examination,  the  examined  and 
examiner's  eye  must  be  naturally  emmetropic,  or  rendered  so  with  glasses, 
and  the  accommodation  in  both  relaxed.  Moreover,  the  surgeon  must 
approach  as  closely  as  possible  the  eye  inspected,  bringing  his  eye  almost 
in  contact  with  it.  To  do  this  successfully,  the  right  eye  must  be  trained 
to  look  at  the  right  eye  of  the  patient,  and  vice  versa.  In  this  way  alone  can 
he  avoid  colliding  of  noses.  By  the  reversed  method,  with  a  convex  lens  of 
three  or  four  inches  held  before  the  examined  eye,  there  is  greater  libert}^ 
and  all  sorts  of  cases  can  be  examined  with  more  ease.  Both  methods  should 
be  employed  in  most  instances,  the  one  helping  to  control  and  explain  the 
other.  In  ophthalmoscopic  examinations,  the  parallactic  movement  of  ob- 
jects, at  different  depths  in  the  eye,  is  very  striking  and  of  great  value. 
This  phenomenon  is  particularly  useful  in  judging  of  opacities  in  the  vitreous, 
and  estimating  excavations  of  the  optic  papilla,  as  in  glaucoma.  Beginners 
are  very  prone  to  diagnose  coiigestion  of  the  optic  nerve,  but  experts  know  the 
extreme  difficulty  of  recognizing  this  condition,  and  are  more  cautious. 
Serious  impediments  to  the  retinal  circulation  lead  to  swelling  of  the  papilla, 
tortuosity  of  the  veins,  ecchymoses,  and  other  u-nmistakable  alterations.  As 
the  percipient  elements  of  the  retina,  the  rods  and  cones,  as  well  as  the 
vitreous  humor,  are  nourished  by  the  chorio-capillaris  of  the  choroid,  it 
follows  that  in  nearly  all  the  serious  disturbances  of  the  choroidal  circula- 
tion, the  vision  is  impaired,  and  the  vitreous  becomes  cloudy.  Effusions  into 
the  vitreous,  from  the  optic  nerve  or  retina,  or  hemorrhages,  remain  close  to 
the  part  diseased.  Impairment  of  sight  from  lesions  of  the  choroid,  involv- 
yig  directly  the  terminal  nerve  elements,  is  much  greater  than  in  more  marked 
changes  in  the  vascular  layer  of  the  retina.  It  is  often  amazing  to  find  very 
slight  dimness  of  vision  in  enormous  swelling  of  the  optic  nerve,  and  in  other 
alterations  equally  grave  of  the  retina.  It  is  not  safe  to  base  an  opinion  of 
the  severity  of  slight  disturbances,  on  the  ophthalmoscopic  appearances. 
Functional  tests  must  always  be  applied  first,  and  are  often  surprising.  A 
set  of  test  types,  w^hich  is  easily  obtained,  will  enable  the  surgeon  to  try  the 
acuity  of  vision,  both  for  distance  and  for  reading,  and  to  ascertain  the  accom- 
modation. 

A  critical  examination  of  the  eye  and  its  delicate  functions,  is  often  an 
important  aid  in  the  diagnosis  of  diseases  elsewhere.  For  example,  in  tumors 
within  the  cavity  of  the  cranium,  we  often  have  optic  neuritis,  involving 
both  eyes.  Its  presence  hi  the  two  eyes  at  once,  or  in  short  succession,  directs 
suspicion  to  the  brain  immediately.  It  may  appear  at  any  period  of  the 
morbid  growth,  and  usually  persists  till  the  fatal  termination,  often  lasting 
for  years  with  its  most  characteristic  symptoms.  These  are  great  swelling  and 
prominence  of  the  papilla,  extreme  tortuosity  of  the  retinal  veins,  blurring 
of  the  natural  boundaries  of  the  disk,  and,  frequently,  patches  of  extravasated 
blood  in  the  retina.  Single  optic  neuritis  from  other  causes,  is  frequent ;  as 
in  young  women  with  suppressed  menstruation,  in  syphilitic  and  albumin- 
uric subjects,  and  in  some  instances  where  no  general  disease  can  be  made 
out.  It  is  sometimes  a  grave  symptom  of  lead-poisoning,  and  is  apt  to  lead 
to  atrophy  and  great  damage  to  vision,  if  not  to  its  total  abolition.  Single 


678         INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 

or  double,  it  is  occasionally  recurrent,  coming  or  going  with  fluctuations  in 
the  disturbances  that  give  rise  to  it.  In  children  with  tubercular  meningitis, 
neuro-retinitis  is  rarely  detected.  In  such  subjects,  tubercular  deposit^  m 
the  choroid  are  more  frequent.  Optic  neuritis  in  a  milder  lorm,  but  combined 
with  very  striking,  and  often  characteristic,  changes  in  the  retina,  is  a  trequent 
indication  of  albuminuria.  Sometimes  the  retinal  changes  alone  are  detected, 
and  these  have  often  led  me  to  the  diagnosis  of  serious  disease  of  the  kidney 
before  it  has  been  suspected  by  the  attending  physician.  A  chalky-white 
P-roup  of  deposits,  often  radiating  in  lines  from  a  centre,  and  usually  m  the 
region  of  the  macula  lutea,  at  once  suggests  a  renal  origin.  It  is  rarely 
seen  in  other  diseases,  and  in  albuminuria  is  not  always  so  characteristic. 
(Plate  XXVIII  Tio-.  4.)  Eetinitis  in  any  form  should  lead  us  always  to 
inquire  into  the  constitutional  condition  of  the  patient.  Retinal  diseases 
are  more  common  than  cataract,  in  diseases  of  the  kidneys,  but  both  may 
exist  together,  and  hemorrhages  into  the  eye  are  not  at  all  uncommon. 

In  locomotor  ataxia,  certain  eye  symptoms  are  among  the  first  to  attract  at- 
tention. Diplopia  from  disturbances  in  the  rotatory  muscles  of  the  eyes,  is 
very  common.  I  recall  the  case  of  a  man  whom  I  treated  for  paralysis  of  the 
external  rectus  of  one  eye.  He  recovered  from  this,  after  a  long  course  of 
treatment  which  lasted  about  a  year.  Some  years  after,  he  consulted  me  for  a 
failure  of  vision  in  one  eye.  My  attention  was  then  attracted  by  his  very 
small  pupils.  With  the  opthalmoscope,  I  recognized  some  pallor  of  the 
optic  papilla,  the  first  evidence  of  optic  atrophy.  This  contmued  slowly  to 
increaL,  with  failure  of  vision,  till  he  is  now  totally  b  md  not  even  perceiymg 
lio-ht  His  pupils  have  remained  very  small  from  the  begmning  As  long 
as^'useful  sight  continued,  the  size  of  the  pupils  was  uninfluenced  by  varying 
des-rees  of  feht.  But  the  moment  a  small  object,  held  near  him,  was  focused, 
the  pupils  contracted,  to  dilate  to  their  nsual  small  size  when  accomnK^dation 
ceased.  This  failure  to  respond  to  light,  and  movement  with  efforts  of 
accommodation,  are  characteristic  of  tabes  dorsalis.  This  peculiarity  of  the 
pupils  and  optic  nerve-atrophy,  with  failing  sight  often  precede,  lor  months 
and  even  years,  the  disturbances  of  muscular  equilibrium.  The  patient  just 
referred  to,  still  walks  well,  and  has  perfect  use  of  his  mental  faculties, 
though  long  since  completely  blind.  I  call  attention  to  this  state  of  the 
pupil,  in  connection  with  the  ophthalmoscopic  evidences  of  optic  atrophy,  on 
account  of  its  diagnostic  importance.  (Opacity  of  the  optic  nerve-fibres  is 
shown  in  Plate  XXYIIL,  Fig.  5.) 

iNTRA-ocuLAR  TuMORS.— I  have  Only  spoken  of  these  neoplasms  incidentally, 
in  treatino-  of  the  diagnosis  of  eye  troubles  without  the  use  of  the  ophthal- 
moscope. Whatever  be  the  nature  of  these  growths,  and  whether  conimencmg 
in  the  retina  or  choroidal  tract,  destruction  of  sight  is  the  inevitable  conse- 
quence. If  not  removed  very  early,  the  system  will  be  contaminated,  and 
fearful  suftering  with  a  fatal  result  is  sure.  Indeed,  even  when  detected  in 
their  first  development,  and  the  eye  at  once  enucleated,  relapse  and  a  lethal 
termination  are  very  apt  to  occur.  The  fact  that  an  experienced  surgeon  wiU 
not  promise  a  certain  cure,  often  leads  patients  to  wait  and  take  the  risKs, 
rather  than  submit  to  enucleation.  Mutilation,  with  a  certainty  of  saving 
life,  is  hard  to  submit  to;  but  when  no  great  assurance  is  promised  against 
relapse,  most  persons  prefer  trusting  to  Providence.  Still,  an  f  ^^^^^^^ 
may  and  often  does  aftbrd  permanent  protection.  Even  if  it  fails,  a  lespite 
is  secured,  and  the  extreme  agony  of  a  cancerous  eye  is  avoided.^  ,VX!lTv 
ocular  growth  is  often  far  advanced  before  it  is  detected.  This  is  especially 
apt  to  be  the  case  in  small  children.  Till  the  eye  is  ^^^^^^^^^^.^f^^^^^^^^' 
plasm,  there  is  little  or  no  pain.    But  glaucomatous  hardness  and  paroxysms 


OPHTHALMOSCOPIC  DISEASES. 


679 


Fig.  942. 


ot  extreme  suffering  come  at  last.  In  this  stage, 
the  diagnosis  is  usually  easy.  Still,  in  adults,  the 
case  may  be  mistaken  for  simple  glaucoma,  till 
later  developments.  Now  and  then,  I  have  seen  a 
sarcomatous  tumor  developing  in  the  ciliary  region, 
mistaken  for  cataract  or  for  a  luxated  lens.  A  very 
little  skill  will  prevent  such  a  blunder. 

The  annexed  wood-cut  (Fig.  942)  represents  the  sec- 
tion of  an  eye  removed  from  a  lady  39  years  of  age,  who, 
about  six  months  before  coming  under  observation,  acci- 
dentally discovered  that  her  right  eye  was  very  imper- 
fect. She  could  barely  see  objects  around  the  room. 
The  eye  up  to  that  time  had  never  been  painful,  and  had 
never  been  injured,  but  since  then  the  eye  had  become  entirely  blind,  and  was  now  at 
times  quite  painful.  The  eye  was  abnormally  hard.  The  iris  was  pressed  forward,  in 
contact  with  the  cornea,  and  it  was  impossible  to  obtain  more  than  a  red  reflex  from  the 
fundus,  and  that  only  on  the  inner  side.  On  the  outer  side  was  seen  the  rounded  out- 
line of  a  choroidal  tumor.  The  eye  was  enucleated  December  9,  1881,  and  after 
hardening  in  Miiller's  fluid  was  opened  by  vertical  section.  The  tumor  was  found 
attached  outwardly,  and  was  18  mm.  in  length  and  8  mm.  in  thickness.  The  retina 
was  detached  and  funnel-shaped. 


Section  of  eyeball  showing  an  intra, 
oculai-  tumor. 


[Retinoscopy  :  the  Shadow-test. 

Under  the  name  of  the  shadow-test,  a  ready  method  of  estimating  the 
refractive  condition  of  the  eye  has  been  recommended,  and  may  here  be 
briefly  referred  to.  It  has  been  ascertained  that  if  a  lamp  be  placed  above 
the  patient's  head,  and  the  fundus  oculi  illuminated  by  means  of  an  ophthal- 
moscopic mirror  of  10-inch  (25  cm.)  focal  length,  held  at  a  distance  of  four 
feet  (120  cm.),  there  will  be  seen  a  bright  area  of  the  retina,  surrounded  by  a 
dark  border  which  is  the  shadow  of'the  iris.  If  now  the  patient's  eye  be 
einmetropic,  when  the  mirror  is  tilted  the  light  area  will  be  displaced  in  the 
opposite  direction,  but  no  distinct  line  of  demarcation  will  be  observed 
between  the  illuminated  part  and  the  shadow  ;  if,  however,  the  eye  be  myopic 
there  will  be  a  distinct  linear  edge  to  the  shadow,  moving  in  the  same 
direction  as  the  mirror,  and  in  a  case  of  hypermetropia,  a  linear  edge  moving 
in  the  opposite  direction.  By  noting  the  strength  of  the  glass,  convex  or 
concave,  wdiich  will  cause  this  shadoW-edge  to  disappear,  the  observer  can 
estimate  the  degree  of  ametropia  with  sufficient  accuracy  for  all  ordinary 
purposes.] 


INJURIES  AND  DISEASES  OF  THE  EYES  AND  THEIR  APPENDAGES. 


EXPLANATION  OF  PLATES  ILLUSTRATING  INJURIES  AND 
DISEASES  OF  THE  EYES. 


PLATE  XXVIL 

Fig.  1.    Episcleral  Angeioma. 
Fig.  2.    Cyst  of  Iris,  after  removal. 
Figs.  3,  4.    Multiple  Pupils  of  both  Eyes.^ 
Fig.  5.  Buphthalmus. 

Fig.  6.    Penetration  of  Birdshot  through  Ciliary  Region. 

PLATE  XXVIIL  % 

Fig.  1.    Rupture  of  Choroid. 

Fio-.  2.    Central  Choroiditis  with  Scotoma. 

Fig.  3.    Rupture  of  Choroid  with  Pigmentation  from  Retinal  Hemorrhage. 

Fig.  4.    Retinitis  Albuminurica. 

Fig.  5.    Opaque  Optic  Nerve-fibres. 

Fio-.  6.    Acute  Neuro-retinitis  with  Hemorrhages. 


1  From  a  patient  sent  by  Dr.  C.  Kearns,  of  Covington,  Kentucky 


INJURIES  AND  DISEASES  OF  THE  EAR. 


BY 

ALBERT  H.  BUCK,  M.D., 


Examination  of  the  Patient. 

Tests  of  the  Hearing  Power.— In  all  the  ditferent  forms  of  ear  disease, 
with  the  exception,  perhaps,  of  those  of  the  auricle,  it  is  a  matter  of  great 
importance  to  ascertain  how  far  the  patient's  power  of  hearing  is  impaired. 
In  the  case  of  an  adult,  considerable  dependence  ma,y  be  placed  upon  the 
individual's  own  statement  with  regard  to  this  point ;  but  in  that  of  a  child, 
the  information  desired  must  be  obtained  from  the  parents  or  guardian.  It 
will  not  do,  however,  to  depend  entirely  upon  this  sort  of  evidence :  we  must 
supplement  it  with  that  which  may  be  obtained  by  means  of  certain  simple 
tests.    The  ticking  of  a  watch,  and  w^ords  or  sentences  spoken  either  hi  a 
whisper  or  in  an  ordinary  tone  of  voice,  constitute  the  only  tests  which  have 
ever  been  employed  to  any  great  extent.    Of  the  two,  that  which  is  based 
upon  the  employment  of  articulate  speech,  is  the  one  more  commonly 
employed,  and  the  more  satisfactory.    At  lirst  we  employ  it,  not  in  a  formal 
manner  and  with  the  consciousness  that  we  are  using  a  test,  but  unconsciously, 
in  the  simple  routine  of  ascertaining  the  patient's'history.    If  in  this  way 
we  have  learned  that  only  one  ear  is  probably  affected,  our  judgment  Avith 
regard  to  the  patient's  general  acuteness  of  hearing  cannot  safely  be  taken  as 
furnishing  a  correct  estimate  of  the  hearing  of  the  affected  ear.    A  more 
formal  test  then  becomes  necessary.    For  example,  the  patient  should  be  told 
to  close  firmly  the  unaffected  ear  with  his  finger,  and  to  sit  or  stand  in  such 
a  position  that  the  physician's  voice  may  be  directed  toward  the  afiected  ear, 
which  remains  open.  In  the  caseof  patients  who  are  decidedly  deaf  in  both  ears, 
we  must  not  forget  the  fact  that  they  often  possess  the  power  of  "  reading  the 
hps"  to  a  remarkable  degree.    Under  these  circumstances  the  patient  should  sit 
with  his  face  turned  toward  the  physician,  but  with  his  eyes  closed. 
Furthermore,  he  should  be  required  to  repeat  the  exact  words  spoken  by  the 
physician.    In  testing  the  hearing  with  the  watch,  it  is  better  to  hold  it  first 
at  a  point  which  lies  beyond  the  hearing  distance  of  the  ear  which  is  being 
tested,  and  then  to  gradually  bring  it  nearer  and  nearer  to  the  ear,  until  the 
patient  is  able  to  distinguish  the  sound  of  the  ticking.    As  a  rule,  it  is  not 
necessary  to  ask  the  patient  to  close  the  other  ear  durins;  the  progress  of  the 
test,  as  the  ticking  of  an  ordinary  Avatch  is  a  sound  of  too  great  feebleness  to 
reach  the  opposite  ear.    The  proximity  of  a  wall,  door,  or  other  reflecting 
surface,  may,  however,  render  such  a  precaution  necessary.    If  the  hearing 
IS  markedly  affected,  the  ticking  of  the  watch  may  not  be  heard  even  when 
It  IS  pressed  firmly  against  the  auricle.    In  this  connection  it  should  be 
remarked  that  a  patient  who  fails  to  distinguish  the  sound  of  the  ticking 
when  the  watch  is  pressed  against  the  auricle,  will  often  hear  the  sound  quite 

am) 


gg2  INJURIES  AND  DISEASES  OF  THE  EAR. 

distinctly  when  tlie  watch  is  pressed  against  the  temple,  or  against  the 
mastoid  process.  In  the  case  of  a  young  child,  we  are  obliged  to  depend  very 
largely  upon  the  statements  of  the  parents  with  regard  to  the  condition  ot 

the  hearing.  .     .    .       -i    x-  r 

A  tuning-fork  so  constructed  as  to  maintain  its  vibrations  for  a  compara- 
tively loni  time,  and  not  pitched  higher  than  the  middle  range  ot  the 
musical  sc?ale,  will  be  found  very  useful  for  the  purpose  of  communicating 
sonorous  vibrations  to  the  auditory  nerves  through  the  skulU    It  is  not 
always  an  easy  matter,  however,  to  determine  correctly  the  significance  of  the 
results  of  this  test.    In  a  certain  class  of  cases,  the  test  produces  results 
which  are  positive,  and  which  can  only  be  interpreted  in  one  way.  I  refer  to 
those  cases  in  which  the  sound  of  the  tuning-fork  is  heard  better  by  the  patient 
in  the  affected  than  in  the  unaffected  ear.  It  is  evident,  in  such  cases,  that  the 
deafness  complained  of  is  not  due  to  any  lack  of  power  in  the  auditory  nerve, 
and  that  we  are  simply  dealing  with  phenomena  of  reflection  and  reinforce- 
ment of  sound,  such  as  may  be  produced  by  a  swollen  drum  membrane  or  by 
cerumen  impacted  in  the  external  auditory  canal,  or  by  a  finger  placed  lightly 
over  the  outer  orifice.    In  another  class  of  cases,  however,  the  problem  is  not 
so  readily  solved.  In  these  cases,  the  patients  have  recently  become  markedly 
or  completely  deaf  in  one  ear,  and,  when  we  subject  them  to  the  tunmg-fork 
test  we  find  that  they  hear  the  sound  of  the  fork  only  m  the  unaftected  ear. 
In  such  cases  it  has  been  customary  to  maintain  that  the  auditory  nerve 
must  be  the  seat  of  the  lesion  which  has  caused  the  deafness.    This  is  not 
the  place  in  which  to  discuss  this  question  in  detail,  and  I  will  therefore 
simply  state  my  own  belief  with  regard  to  it  in  very  brief  terms.  Changes 
in  the  drum-cavity,  and  particularly  in  those  parts  of  it  which  are  known  as 
the  oval  and  romid  windows,  are,  it  appears  to  me,  competent  to  prevent  the 
perception  of  sounds  by  the  adjacent  auditory  nerve.    In  order  that  the 
auditory  nerve  may  transmit  sound-sensations  to  the  brain,  it  is  necessary 
that  a  vibratory  motion  should  take  place  in  the  cochlear  structures  among 
which  the  auditory  nerve-filaments  terminate.    No  provision  exists  m  these 
structures  for  lateral  vibration,  but  only  for  one  following  a  direction  at  right 
angles  to  the  plane  of  the  lamina  spiralis.    Such  a  mode  of  vibration,  how- 
ever can  only  take  place  when  at  the  same  time  both  the  foot-plate  of  the 
stirrup  and  the  secondary  tympanic  membrane  are  mobile  ;  or,  in  other  words, 
when  the  increase  in  breadth  of  the  column  of  fluid  occupymg^  the  scala 
vestibuli  can  be  compensated  for  by  a  corresponding  dimmution  m  breadth 
of  that  occupying  the  scala  tympani ;  for  these  changes  m  the  diameters  of 
the  two  columns  of  fluid  represent  the  mechanical  result  of  an  excursion 
inward  (toward  the  vestibule)  of  the  foot-plate  of  the  stirrup,  while  upon  the 
return  excursion  of  this  ossicle  (outward  toward  the  tympanum),  the  relations 
of  the  diameters  of  the  two  columns  of  fluid  are  reversed.    I  his  brings  us 
then  to  the  following  conclusion  with  regard  to  the  loss  of  power  to  per- 
ceive sound  under  the  circumstances  mentioned  above,  viz   that  this  loss  ot 
power  may  be  produced  by  any  one  of  the  following  conditions,  beside  that 
of  actual  paralysis  of  the  nerve  itself:—  ^ 

1.  Immobility  of  the  foot-plate  of  the  stirrup. 

2.  Immobility  of  the  secondary  tympanic  membrane. 

1  The  heavy  prismatic  tuning-forks  are  the  best,  as  they  maintain  their  vibrations  ^r  quite  a 
1  ihc  i^e^^y;  kPT>t  for  sale  by  all  the  surgical  instrument-makers,  and  may  be  used 

long  time    J^ey  are  kepUo^  sa  e  by  a  S  ^^^^.^^        ^^^^^^  f^rk  flatwise 

rilZZr^^^^^^  or  leather,  and  then,  while  the  instrument  is  still 

Xattg,"o  r^f  th^^Towex  ir'f  the  handle  against  'the  forehead,  the  top  of  the  head,  or  the 
teeth  of  the  patient. 


EXAMINATION  OF  THE  PATIENT.  683 

3.  Marked  increase  in  the  tension  of  the  fluid  contents  of  the  labyrinth 
due  to  ' 

a.  rupture  of  a  bloodvessel  and  escape  of  blood  into  the  labyrinth ; 

b.  simple  fulness  of  the  bloodvessels  ;  ' 

c.  extreme  pressure  of  the  foot-plate  of  the  stirrup  upon  the  labyrinthic 

fluid ;  all  of  which  conditions  are  competent  to  greatly  increase  the 

pressure  upon  the  contents  of  the  labyrinth. 
In  actual  practice  these  distinctions  are  of  little  value.   At  the  same  time, 
they  sometimes  help  us  to  explain  satisfactorily  those  rare  cases  in  which  the' 
hearing  is  rapidly  lost,  and  then  afterward  is  almost  as  rapidly  restored.* 

Instruments  and  Methods  of  Examination. — It  is  a  matter  of  the  first 
importance  that  the  physician  who  contemplates  studying  diseases  of  the  ear, 
should  be  provided  with  good  instruments.  Badly  devised  or  clumsily  con- 
structed instruments  will  make  it  impossible  for  him,  in  many  cases,  to  arrive 
at  a  correct  diagnosis,  and,  in  other  cases  still,  he  will,  by  their  use,  cause 
the  patient  much  unnecessary  discomfort  or  even  pain. 

In  a  few  individuals,  the  external  auditory  canal  is  so  broad  and  straight 
that  the  physician  can  see  its  walls  throughout  their  entire  length,  and  even 
the  drum-membrane,  by  direct  inspection,  without  the  aid  of  instruments  of 
any  kind.  In  the  majority  of  persons,  however,  a  satisfactory  view  of  these 
regions  cannot  be  obtained  except  with  the  aid  of  two  kinds  of  instruments, 
viz.,  one  to  push  aside  the  soft  walls  of  the  orifice  of  the  canal  (ear  specula)' 
the  other  to  illuminate  the  parts  thus  rendered  accessible  (mirrors  of  various' 
kinds). 

Of  the  difl[erent  patterns  of  ear  sj)eculum  which  ^re  oflered  for  sale  in  the 
surgical  instrument-makers'  shops,  the  cheapest  and  at  the  same  time  the 
best  is  that  known  by  the  name  of  Wilde's  ear  speculum. 
(Fig.  943.)  This  instrument  represents  a  truncated,  hollow  Fig.  943. 

cone  of  coin  silver,  polished  within  and  without.  The 
cheaper  variety,  which  is  made,  I  believe,  of  German 
silver,"  is  a  very  poor  substitute  for  that  made  of  coin 
metal.  For  all  ordinary  demands,  three  diflerent  sizes  of 
ear  speculum  will  be  found  sufi&cient.  They  should  all  be 
of  about  the  same  length,  but  their  calibres  should  differ. 
The  aperture,  at  the  smaller  end  of  the  instrument,  should 
measure  not  less  than  three  and  a  half  millimetres  in 
diameter,  for  the  smallest  of  the  three  specula,  and  not  more 
than  seven  millimetres  for  the  largest.  The  walls  of  the 
instrument  should  be  no  thicker  than  is  sufficient  to  prevent  wiide's  ear  speculum, 
them  from  bending  under  ordinary  manipulations.  It  is 
scarcely  possible  at  the  present  time  to  purchase  ear  specula  that  are  not  very 
faulty  in  this  important  respect.    It  is  necessary  to  have  them  made  to  order. 

For  purposes  of  illumination,  either  the  hand-mirror  or  the  forehead-mirror 
may  be  employed.  As  far  as  the  mirror  itself  is  concerned,  these  two  are  one 
and  the  same  thing.  In  practice  it  has  been  found  that  the  best  illumination 
IS  obtained  with  a  concave  mirror  of  circular  form,  and  possessing  a  focal 
distance  of  from  twelve  to  thirty  centimetres,  according  to  the  requirements 
of  the  visual  power  of  the  observer.    A  focal  distance  of  about  twenty 

1  I  have  recently  seen  a  case  of  chronic  congestive  catarrh  of  one  middle  ear,  in  which,  during 
some  ot  the  exacerbations,  the  hearing  power  of  one  ear  (for  sounds  of  either  the  voice  or  the 
vibrating  tiinmg-fork  pressed  against  the  forehead)  was  completely  obliterated.  With  the  sub- 
sidence of  the  more  marked  congestion  of  the  tympanic  mucous  membrane,  the  hearinc.  returned 
to  a  very  useful  degree,  the  patient  being  able  to  correctly  distinguish  words  spoken  fn  an  ordi- 
nary tone  of  voice  at  a  distance  of  ten  or  fifteen  feet.  ' 


684 


INJURIES   AND  DISEASES  OF  THE  EAR. 


oentimetres  is  that  which  is  best  adapted  to  all  the  ordinary  purposes  of  the 
lural  suro-eon    If  the  mirror  be  held  in  the  hand,  it  is  probably  better  to 
pkce  the%ye  in  the  focal  Hue,  that  is,  to  look  through  the  small  central 
aperture  with  which  these  mirrors  are  usually  provided.    It  the  instrument, 
however,  be  worn  on  the  head,  the  mirror  should  be  brought  down  so  as  to 
rest  on  the  bridge  of  the  nose,  or  in  close  proximity  to  it,  and  the  physician 
should  look  into  the  ear  over  the  upper  edge  of  the  mirror.    Here,  again,  it 
will  be  found  that  the  forehead-mirrors  kept  for  sale  m  the  instrument 
makers'  shops,  are  not  constructed  with  a  view  to  their  being_  employed  in 
Sis  fashion,  the  space  left  between  the  upper  edge  of  the  miriw  and  the 
forehead-plate  being  almost  invariably  too  narrow    They_  are  also,  as  a  rule 
defective  in  anothe?  respect,  viz.,  that  the  ball-and-socket  jomt,  by  which  the 
mirror  is  attached  to  the  forehead-plate,  allows  the  former  to  be  rotated  to 
such  a  limited  extent,  both  from  side  to  side  and  from  before  backward 
that  the  observer  will  often  find  himself  unable  to  use  the  source  of  light 
which  may  happen  to  be  available,  unless  he  changes  its  position,  or  that  of  the 
mt  ent  or  both.    This  joint  should  have  the  greatest  freedom  of  motion 
possible,  for  then  only  will  the  physician  readily  be  able  to  utilize  almost  any 
source  of  light  that  he  may  find  at  hand.    The  accompanying  cuts  (Figs.  944, 
945)  show  the  details  of  construction  so  well,  that  I  may  omit  any  further 


Fig.  944. 


Fig.  945. 


Forehead.mirror.    (Half  the  natural  size.) 


Forehead-mirror.   Profile  view. 


description  of  this  instrument,  which  I  consider  to  a  thoroughlyj^^^^^^^ 
»We  tvne  of  forehead  mirror.  As  represented  in  the  cuts,  this  rnirror  is 
S  entfXy  tL  same  as  that  first  deviseS  by  Dr.  Robert  F.  Weir,  of  this  city 
in  1869  or  1870.  At  that  time  the  forehead-plates  were  usually  made  of 
hardTubber,  but  now  the  best  are  made  of  metal,  with  an  outer  plating 
5  nicke  There  should  be  no  padding,  and  the  flexible  band_  attached  to 
the  ilate  should  not  he  made  of  any  dyed  material,  as  the  moisture  of  the 

nffL"a:'tL'ao"S:—  auditory,  canal  and  drum-membrane 

is  tonceraed,  I  shall  mention  only  the  points  which  are  ot  the  most  import 
ance    Among  tKe  readily  available  sources  of  light  for  illuminating  the 
deeper  p^ts  of  the  ear,  the  best  is  the  broad  flame  of  a  burnmg  gas-jet 


EXAMINATION  OF  THE  PATIENT. 


685 


(preferably  the  argand  gas-burner),  or  that  furnished  by  a  good  kerosene  lamp. 
Even  a  lighted  candle,  if  held  sufficiently  near,  may  suffice.  Direct  sunlight 
is  too  dazzling.  Indirect  sunlight,  such  as  can  be  obtained  if  we  direct  our 
mirror  toward  the  sky  above  the  horizon,  or  toward  the  white  wall  of  a 

Fig.  946. 


Porehead-mirror  in  actual  use.  ' 

neighboring  house,  generally  affiords  sufficient  illumination  for  all  ordinary 
purposes.  If  artificial  light  be  used,  it  should  be  placed  somewhat  above 
the  level  of  the  patient's  head,  and  a  short  distance  to  the  right  or  to  the  left 
of  a  line  drawn  through  the  heads  of  the  patient  and  the  surgeon  who  is 
making  the  examination.  At  first,  considerable  difficulty  will  be  experienced 
in  securing  a  steady  and  good  illumination  of  the  deeper  parts  of  the  audi- 
tory canal,  but  with  practice  will  come  comparative  ease  in  overcoming 
these  difficulties.  In  this  connection  I  wish  to  call  attention  to  an  important 
rule,  viz.,  that  in  his  efibrts  to  cause  the  rays  of  light  to  fall  upon  the  patient's 
ear,  the  physician  should  not  depend  upon  the  motions  of  his  neck  for  the 
attainment  of  this  object.  After  he  has  once  placed  his  head  in  the  position 
which  is  best  adapted  to  the  purpose  of  directly  looking  into  the  ear,  he 
should  keep  it  in  that  position,  and  the  satisfactory  illumination  of  the  parts 
should  be  effected  wholly  by  movements  of  the  mirror  proper,  through  the 
medium  of  its  ball-and-socket  joint  attachment  to  the  forehead-plate.  A 
strict  observance  of  this  rule  will  greatly  facilitate  the  task— by  no  means 
always  an  easy  one— of  obtaining  a  good  view  of  the  deeper  parts  of  the 
auditory  canal.  ^ 

In  making  the  actual  examination,  we  must  not  forget  one  or  two  points 
of  practical  importance.  In  the  first  place,  in  the  adult,  the  outer  third  of 
the  auditory  canal,  the  cartilaginous  portion,  usually  forms  an  obtuse  angle 
with  the  inner  portion  of  the  canal.  To  render  the  meatus  straight  through- 
out its  entire  length,  we  need  only  to  pull  the  auricle  slightly  upward  and 
backward.  In  infants,  we  may  find  it  necessary  to  pull  the  auricle  rather 
outward— away  from  the  skull— and  downward,  in  order  to  attain  the  same 
object.    In  the  next  place,  if  we  wish  to  avoid  the  dan2:er  of  wounding  the 


686 


INJURIES  AND  DISEASES  OF  THE  EAK. 


wall<  of  the  meatus,  we  should  keep  our  eyes  directed  upon  the  parfe  iUu" 
minlted  at  the  bottom  of  the  speculum,  which  is  being  gradually  pushed,  by 
r  or  o  boHn-  motion,  farther  and  farther  into  the  canal.    It  is  not  neces- 

.tv  to  msh  the  instrument  beyond  the  point  at  which  a  good  view  ot  the 
mlbiirtympanV^an  be  obtained.  If  we  meet  with  obstructions,  m  the  shape 
ceruS  bai'^^B,  scales  of  epidermis,  pus,  etc.,  we  must  remove  these  and  tor 
this  DuvDose  we  shall  find  certain  instruments  almost  mdispensable  To 
most  persons  the  syiinge  will  suggest  itself  as  the  proper  instrument  to  em- 
X  foT?be  removal  of  any  sucS  obstructions  in  the  canal.  0  hers  wil 
^m.lorbv  pXence  delicately  constructed  angular  forceps,  with  toothed 

S  L  SoCon'siderably  magnified,  ^'^^^^^^''^'^ 

Fig.  947. 


Angular  forceps ;  full  size 


lender  silver  probe,  will  be  found  very  useful  in  loosening  it  from  its  attach- 
Blender  Sliver  prooe  w  j         ^^^^^^^       important  accessory 

S'ttmei  s  Ti  very  ilTc  «"-Pl«^  1-?'^'^*^°'^  "f  the  parts  leads  us  to 
Toi  win  find  thenfof  comparatively  little  use,  either  as  aids  m  making  a 

Figs.  948,  949. 


(Turette  and  slender  prol)e. 


DISEASES  AND  INJURIES  OF  THE  AURICLE.  687 

I  never  use  this  instrument  as  a  scraper,  but  simply  as  a  dissector,  that  is  as 
a  means  of  loosening  objects  from  their  underlying  attachments. 

Diseases  and  Injuries  op  the  Auricle. 

Eczema.— The  commonest  affection  to  which  the  auricle  is  liable,  is  eczema. 
Among  the  children  of  the  poorer  classes  it  is  an  extremely  frequent  disease 
and,  on  careful  mquiry,  it  will  generally  be  found  that  the  cause  is  of  a  three- 
fold nature.  In  the  hrst  place,  some  direct  source  of  irritation  is  necessary, 
and  this  will  usually  be  found  in  the  shape  of  a  discharge  from  the  external 
auditory  canal.  In  the  next  place,  in  a  properly  fed,  properly  washed,  and 
healthy  child,  the  mere  presence  of  a  discharge  from  the  meatus  should  not 
lead  to  more  than  a  very  limited  eczema  of  the  parts  immediately  borderino- 
on  the  onhce  of  the  canal.  Hence  we  may  safely  assume,  in  cases  of  exten- 
sive eozematous  inflammation  of  the  auricle,  that  the  child  is  neither  pror.- 
erly  bathed  nor  properly  fed.  As  the  result  of  feeding  a  child,  of  from  one 
to  Hve  years  of  a,ge,  on  pastry,  tea,  coffee,  bananas,  salt  meats,  etc.,  two  thinss 
are  apt  to  take  place :  the  discharge  from  the  ear  assumes  a  highly  irritatinff 
in  some  instances  positively  corrosive,  character;  and  the  skin,  not  merely 
of  the  auricle,  but  also  of  other  parts  of  the  head,  becomes  so  prone  to  in- 
flammation that  the  slightest  irritation  from  without  suffices  to  develop  a 
small  furuncle,  or  an  inflammation  of  a  more  extended  character,  like  that 
observed  111  eczema.  In  adults  these  three  factors— the  presence  of  an  irri- 
tating discharge  from  the  ear,  lack  of  cleanliness,  and  an  improper  diet- 
which  are  so  generally  the  chief  causes  of  the  disease  in  children,  are  fre- 
quently lacking,  and  we  are  tempted  to  assume  the  existence  of  a  constitu- 
tional vice  or  predisposition— by  which  I  mean  the  circulation,  in  the  blood, 
of  certain  elements  which  keep  the  skin  in  an  irritable  condition 

A  mere  redness  and  slight  infiltration  of  the  skin  characterize  the  disease 
in  Its  siniplest  form.  When  the  affection  becomes  more  pronounced,  we  shall 
find  crusts  or  scabs  covering  the  inflamed  skin.   In  its  most  aggravated  form 

tw'ini!  '"^^  riT*  f°  ''''?nl*  continuous  mass  of  scab^  and  beneath 
them,  in  some  spots,  the  skm  will  be  found  to  be  quite  deeply  ulcerated. 

.JJ^VTT°T  f  unqualifiedly  favorable,  though  in 

both  r  ".''f  It  sonietimes  proves  rebellions.    The  treatment  should  be 

both  general  and  local.  In  children,  the  most  important  thing  is  to  secure 
strict  cleanliness,  both  with  regard  to  the  outside  parts  and  wfth  reo-ard  to 
the  auditory  canal.    The  child's  diet  should  then  be  carefully  regulated  and 

rookedTetetrw'^'  ^.^'"ll^'  1""'"^''  ^"'^'''y^  ""'^^^  ^''^'^  ™«at,  Ind  simply 
Xcb  t         -ifi^  substituted  for  the  unwholesome  articles  of  cUet 

Iho  finrHt  dp«-  n'''.  P'-'^^iO"?ly  been  permitted  to  eat.  In  adults  we  may 
beveSl  fn  r  P'f'^^'^ '^"'^  abstinence  from  alcoholic 
doL  ,mt  t;ke\  ffi  ^  of  cases,  moreover,  we  shall  find  that  the  patient 

dh^e,.  atte^.^?on^  '^^.^^''f open  air,  and  we  should  be  careful  to 
Son  of  the  bowel?"  "        ^P*"-*^"*  *°  '^'^  -g"'- 

coiSLn°b!  ^^'^T""'  be  'imployed  must  vary  according  to  the  stage  or 
rn^v  be  n    1  fl- u"*^  Thus,  for  example,  the  auricle 

"rYven  W     ^l".?^  'T''  inflammation  that  cooling  applications, 

or  even  local  blood-letting  by  means  of  leeches,  may  be  required     Such  an 

Td  Sen'we  m  '  """^'-f  '^  '^'^  P^'^  are  merely  r^d 

of  oil  of  InHp     T  ^  P';es«-'be  at  once  the  free  use  of  an  ointment  consistino-  • 
of  oil  of  cade  and  vaseline,  m  the  proportion  of  from  two  to  five  drons  o^ 
the  former  to  two  drachms  of  the  la^tte^    The  stronger  preparations,  suih  as 


ggg  INJURIES  AND  DISEASES  OF  THE  EAR. 

T  n^Pd  to  Drescribe  a  few  years  since,  not  infrequently  increase  the  existing 

ns.<l.'  riimlly,  whatever  prep.r.tioi,  we  mnj  •iecide  te  »' " 
JSeMlv-  <le»ii.to(:  the  .flteted  .kin.     lei«t  o.ice  .  i«,  w  ith  w.,m  w.ter 

sary.    Furthermore,  it  is  a  good  plan  to  continue  ^^'^  ^^'fj'ff^^^^^ 
few  days  after  tlie  parts  present  every  appearance  of  having  been  restoreu 
to  a  normal  condition. 

Si.™  BiFTOE  toi.»H«A™».-Whe»  hot  pooltiee.  k"™.  ^~ 

£7.L'x^=r/t^r^:.T^^^^^^^^ 

erysipelatous  nature,  is  at  times  impossible.    If  it  ^^'^'."X/nT  there  are 

msmrn 

reaching  a  correct  diagnosis.  .  remedy 

Cooling  applications  constitute  the  chief  and  otten  tne  oniy  j 

required. 

In  the  former  c.«,  the  patMogre.l  F;~~  °S  of  S'SS., 

;£r=rliv.T=?rn,^^^^^^^^ 


For  Hebra's  formula,  see  Vol.  III.,  page  58,  note. 


DISEASES  AND  INJURIES  OF  THE  AURICLE.  689 


ing  of  the  central  and  upper  portions  of  the  auricle.  Fluctuation  is  easily 
recognized,  and  an  incision  affords  escape  to  a  yellowish,  or  pinkish,  and  rather 
Sticky  fluid.  In  some  cases  the  tumor  is  almost  black  in  color,  and  dark 
blood  is  evacuated  by  an  incision.  If  exposure  to  excessive  heat  or  excessive 
cold  be  the  cause  of  the  perichondritis,  two  or  three  isolated  centres  of 
disease  may  be  found. 

At  a  still  later  stage  areas  of  ulceration  may  be  seen,  and  frequently,  in 
cases  of  chondromalacosis,  there  may  be  more  or  less  thickening  and  deform- 
ity of  the  intervening  parts.  I  have  known  the  auricle  to  present,  under 
such  circumstances,  every  appearance  of  being  cancerously  affected. 

The  prognosis  in  this  class  of  cases  has  reference  simply  to  the  degree  of 
deformity  which  is  likely  to  result  from  the  disease.  In  simple  perichon- 
dritis the  prognosis  is  favorable.  If  the  abscess  or  collection  of  fluid  is  opened 
early  and  freely,  very  little,  if  any,  deformity  will  be  left  after  the  parts 
have  healed.  In  chondromalacosis,  the  degree  of  permanent  deformity  will 
depend  chiefly  upon  the  extent  of  cartilage  destroyed,  and  only  to  a  slight 
degree  upon  the  inflammatory  thickening  of  the  perichondrium. 

In  the  matter  of  treatment,  we  must  be  guided  by  the  condition  or  sta^e  in 
which  we  And  the  disease.  If  a  tense,  fluctuating  swelling  exists,  we  slH)uld 
mcise  It  and  evacuate  the  fluid  contents  of  the  tumor.  Care  must  be  taken 
not  to  make  too  small  an  incision,  as  our  aim  should  be  to  place  the  diseased 
parts  in  such  a  condition  that  we  may  easily  keep  them  thoroughly  clean, 
and  at  the  same  time  may  with  equal  facility  bring  our  remedial  appli- 
cations—nitrate of  silver  or  tincture  of  iodine  (either  the  simple  or  the 
compound  tincture)— in  contact  with  them.  In  some  instances,  pressure  will 
promote  the  healmg  of  the  parts  that  have  been  kept  separate  for  some  time 
by  fluid  eftusion.  Cod-liver  oil  and  a  more  generous  diet  will  be  found  use- 
ful adjuncts  in  the  treatment  of  many  of  these  cases. 

IS'ew  Growths.— Among  the  tumors  of  which  the  auricle  may  become  the 
seat,  the  most  common  are  undoubtedly  the  fibroid  growths  of  the  lobule 
Their  origin  can  very  often  be  traced  to  the  irritation  produced  bv  the  wear^ 
ing  of  an  ear-ring.    As  a  rule,  they  do  not  attain  a  size  larger  than  that  of  a 
filbert  or  a  hazel-nut,  but  m  exceptional  cases  they  have  been  known  to  grow 
to  the  size  of  a  hen's  egg.    i^-egresses,  it  appears,  are  peculiarly  liable  to  ac- 
quire fibroid  growths  of  the  lobule  of  the  ear.    The  best  plan  of  removino- 
these  tumors  is  to  include  the  mass  in  a  V-shaped  incision,  great  care  bein? 
taken  to  remove  every  trace  of  the  growth,  as  otherwise,  in  a  short  time,  a 
second  one  may  be  looked  for  at  the  same  spot.     Relapses,  indeed,  have 
repeatedly  occurred,  after  the  greatest  care  had  been  taken  to  remove  every 
portion  of  tissue  that  seemed  in  the  sli2:htest  degree  likely  to  contain  the 
germs  of  a  new  growth  of  the  same  nature.    I  remember  a  case  of  recur- 
rent fibroid  tumor  of  the  auricle,  in  Which  the  most  careful  search  with  the 
microscope  failed  to  discover  any  cellular  elements  in  any  part  of  the  mass. 
Angeioraa  and  epithelioma  of  the  auricle  occur  with  nearly  equal  frequency, 
and  both  forms  of  tumor  are  much  less  common  than  the  fibroma.    In  the 
early  stage  of  an  epithelioma,  excision^  of  the  growth  with  a  V-shaped 
portion  of  the  periphery  of  the  auricle,  is  the  proper  treatment  to  adopt ; 
but  at  a  later  stage,  when  there  are  scattered  foci  of  the  disease— some  of  them 
too  small  to  be  distinguished  by  the  naked  eye— nothing  short  of  complete 
amputation  will  suflice  to  arrest  the  advance  of  the  malady.    In  cases  of 
angeioma,  Prof.  Politzer  recommends  the  employment  of  Paquelin's  thermo- 
cautery.   If  the  vascular  tumor  be  of  small  size,  he  says  that  it  may  be  de- 
stroyed at  a  single  sitting,  but  that  in  the  larger  tumors  the  cauterization  should 
be  confined  to  a  limited  area,  and  that  the  procedure  should  then  be  repeated, 
VOL.  IV. — 44  ^  ' 


690 


INJURIES  AND  DISEASES  OF  THE  EAR. 


Fig.  950. 


as  often  as  may  be  fomid  necessary,  at  intervals  of  five  or  six  days.^  He  also 
advises  that,  if  any  large  artery  (for  example,  the  posterior  auricular)  be 
found  acting  as  a  feeder  to  the  growth,  it  should  be  tied  percutaneously. 
The  dano-er  of  hemorrhage,  after  the  use  of  the  cautery,  must  also  be  con- 
stantly borne  in  mind.  According  to  the  same  author,  ligature  of  the  carotid 
should  not  be  resorted  to  until  after  the  repeated  use  of  the  cautery  has 
demonstrated  clearly  that  the  tumor  cannot  be  destroyed  by  its  employrnent. 
Successful  results  following  lis^ature  of  the  carotid  have  been  obtained  by 
Dupuytren,  Mussey,  and  Weinlechner.  Syphilitic  gimmata  are  sometimes 
observed  on  the  auricle.  Genuine  fatty  tumors,  hom-like  growths  {cornu 
humamm),  and  the  various  forms  of  sarcoma,  are  quite  rare. 

Contusions  and  Wounds  of  the  Auricle.— Serious  wounds  and  other  inju- 
ries of  the  auricle  are  not  as  common,  at  least  in  om;  large  cities,  as  one 
would  be  led  to  expect  from  the  exposed  position  of  this  part  ot  the  body 
Contusions  are  quite  frequently  observed,  but  they  generally  require  no  special 
treatment  beyond  the  employment  of  the  simple  measures  which  tend  to  allay 

inflammation.  In  the  few  cases  m  which  the 
damao:e  done  has  been  suflaciently  serious  to  set  up 
a  perichondritis,  the  treatment  described  as  appro- 
priate for  that  condition  is  the  proper  one  to 
pursue. 

Wounds  made  with  any  kind  of  cutting  instru- 
ment, are  apt  to  result  in  a  separation  of  a  part  of 
the  auricle  from  the  rest  of  the  organ.    This  sepa- 
ration may  be  complete  or  incomplete.   If  it  be  in- 
complete, the  opposite  raw  edges  should  be  brought 
into  exact  coaptation,  and  held  in  that  position 
either  by  sutures  or  by  a  network  of  cotton  fibres 
over  which  collodion  "is  freely  applied.    I  remem- 
ber an  instance  in  which  the  cut  extended  through 
the  entire  thickness  of  the  auricle,  from  the  fossa 
concha,  in  the  immediate  neighborhood  of  the  ori- 
fice of  the  external  auditory  canal,  to  the  outer 
edo-e  of  the  helix  (see  Fig.  950).    The  patient  was 
int'oxicated  when  the  accident  occurred,  and  re- 
mained in  bed  for  three  or  four  days  without  doing 
anything  for  the  ear.    By  that  time  I  found  the 
raw  edges  of  the  wound  granulating  and  bathed  in 
pus.  ifevertheless,  very  good  results  were  obtained 
by  simply  bringing  the  raw  edges  carefully  together  and  keeping  them  in 
position  by  means  of  cotton  fibres  and  collodion.    If  the  separation  be  com- 
plete, one  part  fallins:  to  the  ground,  union  may  still  be  expected  to  take 
place,  provided  that  the  severed  fragment  of  the  ear  be  caretully  cleansed,  and, 
as  soon  as  possible,  placed  firmly  in  the  position  m  which  it  belongs  lo 
favor  healing  as  much  as  possible,  a  covering  of  fine  cotton  or  wool  should 
surround  the  auricle,  and  thereby  maintain  the  temperature  of  the  separated 
fragment  at  a  proper  point.      Triquet^  mentions  two  well-authenticated 
instances  of  restoration  of  vitality  in  a  severed  portion  of  the  auric  e  and 
Schwabach^  says  that  this  successful  result  is  often  obtained  after  student- 
duels,  in  which  a  part  of  the  auricle  has  been  cut  off  by  the  sword.  ^ 
The  condition  known  as  cleft  lobule  (due  to  wearing  heavy  ear-rmgs)  is  ot 

I  Trait6  pratique  des  maladies  de  I'oreille.    Paris,  1857. 
«  Eulenburg,  Real-Encyclopadie.  1882. 


Auricle  (after  Urbantschitscli) . 
ah,  Antihelix ;  at,  Antitragus  ;  c, 
Conclia  (fossa  conchse);  cf,  Crura 
furcata  Fossa  intercruralis  [fs, 
Fossa  scaplioidea  ;  h.  Helix ;  i,  In- 
cisura  intertragica ;  im,  Introitus 
meatus  audit,  extern, ;  (,  Lobulus  ; 
^h,  Spina  (crista)  helicis  ;  t,  Tragus. 


DISEASES  AND  INJURIES  OF  THE  AURICLE. 


691 


common  occurrence.  The  treatment  consists  in  cutting  away  the  opposite 
cicatrized  skin-surfaces,  and  then  stitching  the  parts  together  as  accurately 
as  possible. 

Deformities  of  the  Auricle.— Autoplastic  operations  have  been  per- 
formed for  the  relief  of  various  defects  and  deformities  of  the  auricle.  The 
excision  of  a  V-shaped  piece  will  sometimes  prove  successful  in  diminishinp; 
the  prominence  of  an  abnormally  large  auricle,  but  I  know  of  no  means  of 
giving  firmness  to  a  drooping  auricle— one  which  lacks  a  properly  developed 
cartilagmous  framework— unless  it  be  by  causing  its  posterior  surface  to 
unite  with  the  adjacent  outer  surface  of  the  head. 

Frost-bite.— The  auricle,  by  reason  of  its  exposed  position,  is  very  apt  to 
suiter  trom  the  effects  of  extreme  cold.    At  first  the  cold  produces  contrac- 
tion of  the  bloodvessels  of  the  skin,  but  paralysis  of  their  muscular  elements 
soon  follows,  and  the  ear  then  presents  a  red  or  even  purplish  appearance, 
and  IS  likely  to  be  somewhat  swollen.   If  actual  freezing  takes  place,  the  ear 
assumes  a  whitish  appearance,  and  may  even,  under  the  influence  of  pro- 
longed cold,  become  brittle.     Under  favorable  circumstances  the  frozen 
auricle  (usually  only  its  upper  portion)  may  gradually  resume  its  natural  con- 
dition, though  very  commonly  a  certain  degree  of  paresis  of  the  bloodvessels 
remains,  causing  permanent  redness  of  the  affected  part.    The  best  method 
of  thawing  out  a  frozen  ear  is  to  rub  it  with  snow  at  first,  and  then  afterward 
with  cold  water.    This  must  be  done  gently,  as  there  is  danj^er  of  breaking; 
the  frozen  organ.    When  the  circulation  seems  to  have  been  re-establishecf 
tepid  water  may  be  used  instead  of  cold.     These  procedures  must  be  carried 
on  either  out-of-doors  or  in  a  cold  room,  the  aim.  being  to  restore  the  frozen 
part  very  gradually  to  its  proper  temperature.     In  unfavorable  cases— those, 
tor  example,  m  which  the  ear  has  been  allowed  to  remain  for  too  Ions:  a 
time  in  a  frozen  condition,  or  in  which  no  precautions  have  been  taken  to 
secure  its  gradual  restoration  to  a  normal  temperature— inflammation  sets  in 
and,  according  to  its  severity,  we  may  have  as  a  final  result  either  ^ano-rene 
and  sloughing  away  of  the  part  afiected,  or  a  perichondritis,  presentinS  the 
picture  of  a  well-marked  othsematoraa.     The  treatment  required  for  the  first 
of  these  conditions  is  amputation  of  the  gangrenous  portion  :  that  required 
tor  the  perichondritis  has  been  already  set  forth  on  a  precedino-  pag-e 

As  one  of  the  sequelae  requiring  surgical  interference,  I  may  mintion  the 
persistence  of  small,  deeply  excavated,  sluggish  ulcers,  covered  with  hard 
dry  crusts.  The  favorite  seat  of  these  ulcers  is  on  the  upper  part  of  the 
helix  or  occasionally  on  the  antihelix  (see  Fig.  950).  It  is  not  an  easy  matter 
to  eflect  a  genuine  healing  of  these  sores.  The  plan  which  I  have  found  the 
most  successful  IS  this  After  removing  the  crust,  pare  away  with  small! 
curved  scissors,  the  bluish,  undermined  skin  which  surrounds  the  ulcer  Then 
either  scrape  the  fibrous  or  cartilaginous  floor  of  the  ulcer  with  the  point  of 
the  knife,  or  touch  it  lightly  with  nitric  acid,  ^ext  fill  the  excavation  with 
a  pledget  of  cotton  saturated  with  the  compound  tincture  of  iodine  Finallv 
as  a  means  of  holding  the  pledget  in  place,  and  of  excluding  the  air,  spread 
a  few  fibres  of  cotton  like  a  network  o.>er  the  ulcerated  a?ea,  and  aturate 
the  whole  with  collodion.  Three  or  four  days  afterward,  when  Xe  dressTnS 
are  found  to  be  loose,  remove  them,  and  re-apply  cotton  saturated  with  the 
compound  tincture  of  iodine.  By  this  mode  of  procedure,  IW  in  ^ 
frostbUr'  permanently  healing  the  chronic  ulcers  resulting  from 

Burns.— Severe  burns  of  the  auricle  present  either  the  picture  of  a  decided 
perichondritis,  or  that  of  a  localized  death  or  gangrene,  ind  nothtg  further 


g92  INJURIES  AND  DISEASES  OF  THE  EAR. 

need  be  said  on  the  subject  in  this  place.  In  the  milder  cases,  Pain  and 
soreness  inav  be  greatly  mitigated  by  the  local  app  ication  of  carbola  ed  oil 
glj  of  carbolic  acid  to  giij  of  olive  oil)  or  carbolated  vaseline.  Cooling 
applications  also  afford  relief. 

Diseases  and  Injuries  op  the  External  Auditory  Canai. 

Impacted  CERUMEN.-Of  all  the  affections  of  the  external  auditory  canal, 
impaction  of  cerumen  is  by  far  the  most  common.  This  condition  is  apt  to  be 
developed  without  any  special  symptoms.  The  accumu  ation  of  cerumen  takes 
place  so  gradually  that  the  patient  rarely  suspects  what  is  occurring,  until 
he  suddenly  becomes  more  or  less  deaf  in  the  affected  ear,  and  experiences  a 
sense  of  fulness  on  that  side  of  the  head.  Sudden  alternations  between  good 
and  defective  hearing  are  among  the  most  marked  symptoms  of  this  condition 
When  the  affected  ear  is  examined  with  the  speculum  and  reflected  light, 
a  black  or  dark  brown  mass  will  be  found  filling  the  canal,  and  obstructing 
the  view  of  the  deeper  parts  of  the  ear._  As  impacted  cerumen  is  very  apt 
to  be  associated  with  catarrhal  inflammation  of  the  middle  ear  it  will  be  ound 
desirable  not  to  express  an  opinion,  either  with  regard  to  the  na  ure  of  the 
ailment  or  with  regard  to  the  prognosis,  until  the  auditory  canal  has  been 
cleared  of  all  obstructions.  .    „    •  ,    ^i  i- 

The  question  of  treatment  resolves  itself  practically  into  the_  question, 
how  can  the  obstructing  mass  be  removed  most  thoroughly,  quickly,  and 
pleasantly  ?  In  my  opinion,  the  instrumental  method  of  removing  impacted 
cerumen  Is,  in  the  ma  ority  of  cases,  the  most  effecti  ve  and  at  the  same  time 
^e  pleasai  test  way,  both  for  the  patient  and  for  the  physician  of  accom- 
S'sMng  the  desired  object.  I  must  confess,  however,  that  a  certain  degree 
of  manual  dexterity  is  absolutely  essential  to  the  proper  perlormance  of  the 
operation.  It  is  also  probably  true  that,  among  the  great  body  o  medical 
practitioners,  only  a  small  minority  possesses  the  requisite  skill  m  the 
handling  of  delicate  instruments.  While  therefore  the  removal  of  impacted 
ceTumen  by  means  of  the  syringe  may  seem  to  be  a  clumsy  and  oftentimes 
inXtual  method  of  attaining  tlie  object  desired,  no  better  method,  adapted 
to  o-eneral  use,  has  yet  been  devised. 

6ne  of  the  chief  reasons  why  syringing  so  often  fails  to  wash  out  the  mass 
of  impacted  cerumen,  is  this :  the  force  of  the  current  is  SP^"*  v^P""  f  ^..^^"'^^ 
surface  of  the  outer  end  of  the  plug,  and  tends  therefore  rather  to  diive  it 
farther  inward.  The  most  effective  plan  is  to  direct  the  stream  against  one 
edge  (preferably  the  upper  edge)  of  the  mass,  in  the  hope  of  ^ashi^F 
chfnnel  between  the  mkn  body  of  the  plug  and  .the  «pper  wall  of  the  raea^ 
tus.  As  soon  as  this  has  been  accomplished,  it  will  be  found  that  the  current 
begins  to  exert  a  vis  a  tergo  upon  a  portion  of  the  mass,  and  soon  brings 
away  fragments  of  considerable  size. 

If  simple  syringing  with  lukewarm  water  fails,  we  may  employ  some 
chemic™  reagJnt  f!r  the  purpose  of  softening  the  cerumen  and  loosening  its 
aSments  f  o  the  walls  ^of  the  canal.  Bicarbonate  of  .^^dmm  for  example 
may  be  used  to  advantage  as  a  solvent.  A  few  drops  of  a  strong  solut  on  ot 
this  salt  should  be  dropped  into  the  meatus  (the  patient's  head  ^mg  tunied 
well  over  toward  the  opposite  side  ,  and  should  be  allowed  to  .emain  there 
for  at  least  twenty  minutes.  If  syringing  then  fails  to  bring  away  the  ceru- 
minous  mass,  the  soda  solution  should  be  introduced  a  second  time,  and  even 

"  \?tt"instrureSal  method  of  removing  impacted  cerumen  tJ;e  ahn  is  to 
loosen  the  attachments  of  the  impacted  mass  by  means  of  suitable  instruments. 


•     DISEASES  AND  INJURIES  OF  THE  EXTERNAL  AUDITORY  CANAL.  693 

These  may  either  be  introduced  directly  into  the  substance  of  the  mass,  for 
the  purpose  of  breaking  it  into  fragments,  or  they  may  be  passed  flatwise 
between  it  and  the  walls  of  the  meatus,  with  the  view  of  dissectino-  it  out 
as  a  whole,  or  in  larger  pieces.  For  this  latter  purpose,  the  curette^will  be 
found  a  most  excellent  instrument.  Angular  forceps,  of  delicate  construction, 
can  also  scarcely  be  dispensed  with  in'removing  the  loosened  mass  or  its' 
component  parts.  As  we  approach  the  membrana  tympani,  in  our  mining 
operations,  the  slender  silver  probe  will  be  found  to  be  of  great  service,  as  it 
may,  with  care,  be  employed  in  loosening  the  inner  end  of  the  ceruminous 
mass  from  its  attachments  to  the  drurn-membrane,  or  to  the  anterior  inferior 
cul-de-sac  of  the  meatus.  In  conclusion,  let  me  remind  the  reader  that 
manipulations  of  this  kind  should  not  be  indulged  in,  unless  the  operator 
possess  delicacy  of  touch,  a  thorough  knowledge  of  the  topographical 
anatomy  of  the  auditory  canal,  and  properly  constructed  instruments. 

It  sometimes  happens,  in  these  cases  of  impacted  cerumen,  that  a  furuncle 
develops  in  the  obstructed  meatus,  or  that  an  acute  inflammation  is  set  up  in 
the  adjacent  middle  ear.  In  the  presence  of  such  a  complication,  the  question 
arises,  shall  we  allow  the  intercurrent  inflammation  to  run  its  course,  before 
we  make  the  attempt  to  remove  the  impacted  cerumen,  or  shall  we  undertake 
the  latter  operation  without  further  delay  ?  The  pain  attending  either  of  the 
two  combinations  mentioned,  is  apt  to  be  very  severe,  and  the  inflammation 
is  generally  more  extensive  and  of  a  more  serious  character  than  when  the 
auditory  canal  is  free  from  obstructions.  If,  therefore,  we  can,  by  any  means 
at  our  command,  remove  these  obstructions  at  once,  it  is  clear  that  this  is  the 
proper  course  to  pursue.  If  the  orifice  of  the  canal  is  closed,  through 
cedematous  swelling  of  the  soft  parts,  it  will  be  found  comparatively  easy  to 
dilate  It  gradually  by  means  of  Wilde's  specula,  or  by  the  aid  of  conical  mops 
of  cotton,  wound  firmly  around  the  end  of  a  probe  or.  cotton-holder,  and 
smeared  with  vaseline.  As  soon  as  the  ceruminous  mass  has  been  exposed 
to  view,  we  should  proceed  in  precisely  the  same  manner  as  if  the  case  were 
one  of  a  simple  nature. 

Furuncles,  or  Boils.— The  external  auditory  canal  seems  'to  possess  a 
special  predisposition  to  furuncular  inflammation.  Our  knowledge  of  the 
causes  which  give  rise  to  the  disease  is  very  scanty.  An  irritating  discharge 
from  the  middle  ear,  or  from  the  deeper  parts  of  the  meatus  (as,  for  example, 
in  eczema),  very  often  leads  to  the  formation  of  furuncles  in  the  outer  or  car- 
tilaginous portion  of  the  canal.  It  has  also  been  observed  that  the  disease  is 
often  encountered  in  persons  whose  general  health  is  not  quite  up  to  the 
proper  standard. 

Furuncles  usually  develop  gradually.  The  patient  first  notices  a  little  pain 
in  the  region  of  the  ear,  and,  on  pressing  with  his  finger  upon  the  parts,  finds 
that  they  are  slightly  tender.  Gradually  the  pain  increases  in  severity,  and 
the  ear  feels  full  and  heavy.  Deafness  is  not  observed  until  the  tumor 
reaches  such  a  size  as  to  close  the  meatus  at  the  point  involved.  The  motions 
of  the  jaw  are  apt  to  cause  pain,  and  in  some  cases  there  is  well-marked 
oedema  m  the  neighborhood  of  the  aftected  ear.  Eupture  of  the  abscess  may 
take  place  spontaneously  as  early  as  on  the  second  day,  but  as  a  rule  we  must 
not  look  for  this  event  before  the  third  or  fourth  day. 

The  prognosis  is  decidedly  favorable.  The  disease  shows  no  tendency  to 
extend  inward,  in  the  direction  of  the  middle  ear,  and  it  is  only  in  quite  rare 
cases  that  the  abscess,  instead  of  breaking  into  the  external  auditorv  canal, 
burrows  downward  and  forward  in  the  direction  of  the  parotid  gland,  or 
backward  and  downward  in  the  direction  of  the  soft  parts  lying  below  the 
mastoid  process. 


694  INJURIES  AND  DISEASES  OF  THE  EAR. 

Treatment  —If  it  be  admitted  that  neither  the  patient's  life  nor  his  hearing 
power  is  threatened,  the  chief  indication  will  clearly  be  to  relieve  his^  sut- 
ferincr     It  is  a  disputed  point  how  this  may  best  be  accomplished,  borne 
of  th?  his-hest  authorities  unhesitatingly  advise  the  early  employment  ot  the 
knife     My  own  experience,  however,  leads  me  to  adopt  the  rule  laid  down 
bv  Wilde  •  "As  soon  as  we  believe  matter  has  formed  and  come  some  way  to 
the  surface,  but  not  till  then,  we  should  make  an  incision."   I  prefer,  as  a  rule, 
to  wait  and  let  the  abscess  open  by  natural  processes ;  and,  as  a  means  ot 
hasteniiip;  these,  and  also  for  the  purpose  of  mitigating  the  patient  s  suftermg 
in  the  mean  time,  I  am  in  the  habit  of  prescribing  hot  poultices.  These 
should  be  of  sufficient  size  to  cover  the  entire  region  of  the  ear  (say  5  or  b 
inches  square),  and  they  should  be  renewed  at  frequent  intervals.   While  the 
flaxseed-meal  poultice  is  perhaps  the  best  that  can  be  used  for  this  purpose, 
there  are  various  substitutes  which  will  be  found  to  answer  almost  equa  ly 
well-  for  example,  a  rubber-bag  filled  with  hot  water,  a  tlannel  or  muslin 
pillow  filled  with  dried  hops  and  heated  in  the  oven  or  m  trout  ot  a  Hot 
open-grate  fire,  hot  bran  bags,  a  large  sponge  or  several  thicknesses  ot  fiannel 
wruna:  out  of  hot  water,  and  so  on.  -,    i     •  .  4.- 

I  have  very  little  faith  in  the  local  use  of  anodynes,  and  the  introduction 
of  slvcerine,  sweet-oil,  or  almond-oil,  commends  itself  still  less  to  my  judg- 
ment Glycerine  is  by  no  means  a  bland  and  soothing  fluid,  and  the  oils  may 
furnish  a  nidus  for  the  subsequent  development  of  the  penicilium  glaiicum  or 
some  other  variety  of  fungous  growth,  which  the  surgeon  may  find  it  diffi- 
cult to  dislodge.    Vaseline,  on  the  other  hand,  may  be  used  with  impunity 

^^^Local^blood-letting  by  means  of  leeches  is  very  apt  to  fail  in  this  form  of 
disease,  and  I  do  not  often  resort  to  its  use  if  I  am  sure  of  my  diagnosis.  In 
acute  affections  of  the  middle  ear  it  is  a  much  more  valuable  remedy.  ^ 

If  the  knife  be  employed,  the  best  pattern  for  this  special  purpose  is  a 
curved,  sharp-pointed  bistoury.  If  the  swelling  is  well  defined  the  mcision 
should  be  made  through  the  centre  of  it,  the  point  of  the  knife  being  carried 
from  within  outward.^ The  operation  should  be  performed  under  illumination 
from  the  forehead-mirror,  and  the  incision  should  be  made  of  such  a  length 
and  depth  as  will  afford  a  free  exit  to  the  pus.    If  the  swelling  we  11 

defined  my  plan  is  to  introduce  a  cotton-holder,  well  protected  with  cotton, 
into  the  swollen  canal,  and  then  to  exert  pressure  in  different  directions.  The 
region  of  greatest  tenderness  is  that  into  which  I  make  the  incision.  It  is 
well  to  have  at  hand  a  large  sponge  and  a  basin  filled  with  hot  water  Imme- 
diately  after  the  incision  has  been  made,  the  hot  and  moist  sponge  should  be 
held  against  the  ear,  for  the  purpose  of  quieting  the^  pam  which  for  a  few 
minutes  is  generally  very  acute.  When  the  pam  subsides,  dry  warmth  may 
be  substituted  for  the  hot  and  moist  application.  The  only  objection  to  the 
prolono-ed  use  of  moist  heat  under  these  circumstances  is,  that  it  favors  tne 
development  of  granulation-tissue  in  the  wound,  and  is  also  apt  to  set  up  a 
painful  inflammation  of  the  auricle. 

Diffuse  Inflammation.— Under  the  head  of  "diffuse  inflammation  of  the 
external  auditory  canal,"  may  be  grouped  the  different  pathological  condi- 
tions to  which  the  names  "  otitis  externa  diffusa,'  "periostitis  "eczema, 
"desquamative  inflammation,"  and  "otomycosis,"  or  "parasitic  disease  of  the 
external  auditory  canal,"  are  commonly  applied.  It  is  not  always  easy  to 
separate  these  dift'erent  conditions,  and  to  apply  to  them  their  proper  distin- 
ffuishing:  terms.  In  fact,  it  is  only  in  a  few  typical  cases  that  a  distinct  ine  ot 
separation  can  be  drawn.    Furthermore,  no  great  scientific  or  practical  gam 


DISEASES  AND  INJURIES  OF  THE  EXTERNAL  AUDITORY  CANAL. 


605 


18  effected  by  the  establishment  of  these  subdivisions,  and  I  may  therefore  be 
allowed  to  include  all  under  the  single  head  of  diffuse  inflammation. 

A  simple  diffuse  inflammation  of  the  osseous  portion  of  the  meatus  exter- 
nus,  may  be  set  up  by  the  presence  of  some  irritating  substance  or  fluid  in 
the  canal.  For  example,  salt  water  may  produce  such  an  inflammation  ;  and 
so  may  the  irritating  discharge  from  an  inflamed  middle  ear.  Among  the 
internal  or  constitutional  causes  may  be  mentioned  a  predisposition  to  eczema 
(rheumatic  ?  gouty  ?).  An  inHanmiation  of  the  medullary  spaces  or  of  the 
air-cells  of  the  surrounding  bone,  may  give  rise  secondarily  to  a  diffuse  otitis 
externa.    Direct  violence  is  also  not  a  rare  cause  of  this  form  of  disease. 

The  physical  characteristics  of  a  diffuse  inflammation  of  the  external  audi- 
tory canal  are,  at  first,  a  general  redness  and  swelling  of  the  osseous  portion. 
The  membrana  tympani  almost  invariably  participates  in  the  inflanmiation, 
though  sometimes  only  to  a  very  slight  degree.  At  a  later  stage  of  the  affec- 
tion, an  exudation  of  a  thin,  serous  fluid  will  be  found  to  have  taken  place 
from  these  red  and  sw^ollen  surfaces,  and  at  a  still  later  j)eriod  the  discharge 
will  be  found  to  contain  small  white  flakes,  or  even  large  white  sheets,  repre- 
senting the  cast-off,  uppermost  layers  of  epithelium.  Eventually,  ulceration 
may  take  place. 

In  those  cases  in  which  a  vegetable  parasitic  growth  develops  in  the  in- 
flamed meatus,  this  phenomenon,  it  seems  to  me,  should  not  be  considered  in 
the  light  of  a  primary  and  independent  disease,  but  rather  as  an  accidental 
complication.  The  moisture  supplied  by  the  inflammatory  exudation,  the 
absence  of  a  current  which  might  wash  away  the  germs,  the  presence  of 
decomposing  organic  matters  in  the  secretion,  and  probably  also  the  dark- 
ness, furnish  conditions  which  are  favorable  to  the  further  development  and 
multiplication  of  the  vegetable  germs  .which  at  all  times  fill  the  air,  and 
w^hich  must  therefore  at  all  times  be  in  the  cavity  of  the  external  auditory 
canal.  The  appearance  presented  to  the  eye,  in  a  typical  case,  is  that  of  a 
meatus  thinly  or  thickly  covered  with  a  fuzzy,  white  material  which  looks 
very  much  like  cotton-wool.  Black  specks  {aspergillus  nigi^kans)  are  often 
scattered  over  the  white  ground,  and  sometimes  this  variety  of  the  fungus 
predominates  over  the  white  or  yellow  variety. 

The  subjective  symptoms  of  an  otitis  externa  diffusa  are,  first,  a  sense  of 
fulness  in  the  affected  ear,  rarely  amounting  to  actual  pain ;  second,  more  or 
less  diminution  of  the  power  of  hearing ;  and,  third,  an  itching  sensation  in 
the  canal.  In  those  cases  which  seem  to  be  distinctively  eczematous  in  char- 
acter, this  last  symptom  is  sometimes  exti'emely  distressing. 

The  red,  swollen,  and  perhaps  moist  condition  of  the  parts,  enables  the 
observer  to  say  positively  that  a  diffuse  inflammation  of  the  external  audi- 
tory canal  exists,  but  it  is  not  so  easy  a  matter  to  determine  whether  this 
inflammation  is  primary  in  its  nature,  or  merely  secondary  to  an  afiec- 
tion  of  the  middle  ear.  We  must  test  the  hearing,  examine  the  condition  of 
the  naso-pharyngeal  mucous  membrane,  and  ascertain,  by  auscultation  during 
the  act  of  inflation,  the  condition  of  the  middle  ear  and  Eustachian  tube. 
If  there  is  comparatively  little  disturbance  of  the  hearing,  if  there  is  no  evi- 
dence of  an  acute  naso-pharyngeal  catarrh,  and  if  the  air  enters  the  tympanic 
cavity  freely  and  without  rales  or  crackling  sounds,  we  are  fairly  justified  in 
pronouncing  the  disease  an  acute,  primary,  diffuse  inflammation  of  the  exter- 
nal auditory  canal. 

The  presence  of  aspergillus  can  only  be  determined  positively  by  placing 
some  of  the  suspected  products  under  the  microscope,  and  demonstrating  the 
presence  of  the  stalks,  and  perhaps  also  of  the  fruit,  of  the  parasitic  plant. 

The  different  forms  of  diftuse  inflammation  of  the  auditory  canal  have 
very  little  tendency  to  damage  the  hearing,  and  apparently  none  whatever  to 


696  INJURIES  AND  DISEASES  OF  THE  EAE. 

spread  toward  the  middle  ear  or  mastoid  cells.  By  direct  extension,  they  may 
excite  a  subacute  mastoid  periostitis.  They  are  very  apt  also  to  occasion  or  to 
be  associated  with,  furuncles  of  the  cartilaginous  portion  of  the  canal.  In  the 
acute  cases,  the  prospects  of  an  early  and  complete  cure  are  good  -  in  the 
chronic  ones,  our  prognosis  must  he  guarded,  as  the  disease  is.  at  times 
exceedingly  stubborn,  and  relapses  are  very  common.  v.-  i, 

TT^eltment  musl  vary  according  to  the  stage  or  condition  ,n  which  the 
disease  happens  to  be.    If  the  parts  are  simply  red  and  swollen,  and  have 
nSTetbegmi  to  secrete,  a  small  blister  over  the  mastoid  process  maybe 
found  sufRment  to  check  the  further  progress  of  the  disease.    If  the  walls  of 
the  c.anal  are  already  moistened  by  secretion,  nitrate  of  silver  m  solution  is 
ffbe  eZloyed.    Before  the  solution  is  instilled  into  the  meat™,  it  is  very 
important  to  clean  the  inflamed  parts  thoroughly,  so  that  they  may  be 
exposed  to  the  full  action  of  the  remedy.    The  physician  should  therefore 
cam  out  this  part  of  the  treatment  himself.    Before  the  solution  is  intro- 
duced into  the  canal,  the  syringe  and  a  vessel  of  warm  water  should  be 
placed  within  easy  reach.    After  the  solution  has  been  dropped  mto  the 
canal,  the  physician  should  wait  until  the  patient  experiences  a  distinct  sen- 
sa  foi   of  warmth,  pain,  or  throbbing  in  the  ear.    I  always  request  the 
patot  beforehand  to  direct  his  attention  to  the  ear  and  to  >"^<?rm  "^e  as 
soon  as  he  perceives  either  of  the  sensations  just  mentioned.    With  a  solu- 
tion of  from  forty  to  sixty  grains  to  the  ounce,  the  sensation  of  warmth  will 
generally  not  be  felt  by  thi  patient  until  after  the  lapse  of  three  or  four 
mhiutes;  with  a  solution  of  double  that  strength,  the  sensation  is  usually 
rxperie^iced  much  sooner.    As  soon  as  decided  warmth  throbbing  or  pain 
iffelt  by  the  patient,  the  remedy  should  be  washed  out  of  the  canal  by  means 
of  the  syringe^and  tepid  water.'  The  walls  of  the  meatus  must  then  be  dried 
carefully  by  means  of  the  cotton-holder  armed  with_  absorbent  cotton,  ai  d 
w^en  properly  dried  they  should  be  anointed  with  simple  vaseline,  or  with 
vaseUne  to  which  a  little  oil  of  cade  has  been  added.    Very  often  a  single 
Inch  slight  cauterization  of  the  canal  suflices  to  arrest  the  disease.    In  other 
cases  two  or  three  repetitions  will  be  found  necessary.    These  should  he 
made  aUntervals  of  two  or  three  days,  and  if  the  discharge  rom  the  ear  is 
Sve!  he  patient  should  be  instructed  to  wash  out  the  canal  w i  h  the  jnnge 
or  doJche  once  or  twice  a  day.    Otherwise  the  ear  may  be  left  alone  from 

'"Life  moSitively  desquaBiative  c^ses,  the  treatmeiit  rnuBt  be  ^i^^^^^ 
modified  In  the  first  place,  a  thorough  removal  of  tlie  fiimly  attached 
kmin«  of  dead  skin  can  scarcely  be  eftected  without  the  aid  of  the  curette. 
THs  h^strument  inserted  flatwise  between  the  dead  and  the  living  skm,  may 
J^usr  veTeffect  vely  in  dissecting  ofl'  the  former.  The  forceps  then  comes 
into  Xv  or  if  it  be  preferred,  the  syringe  may  be  used  for  the  purpose  of 
remov  ng  the  fragments  or  sheks  of  dead'skin  that  have  been  separated  from 
™:tfachmenti  Lately  l  have  occasionally  Huid  potassa^ 
freeing  the  canal  from  these  masses,  and  have  found  it  very  efficacious. 
'X,f  the  wX  of  the  canal  have  thus  been  carefiilly  .J'- i/^Xe 
matters  and,  as  it  were,  laid  bare,  we  may  proceed  to_  the  instil  ation  ot  tbe 
Xer  solution.  Furthermore,  in  this  class  of  cases,  it  is  important  that^the 
padent  hould  keep  the  auditory  canal,  throughout  its  entire _  length,  we  1 
andnted  with  the  oil  of  cade  and  vaseline  mixture  or  with  simple  '  cuti- 
cura  At  least  twice  a  day  he  should  make  these  applications  to  the 
canal. 


DISEASES  AND  INJURIES  OF  THE  EXTERNAL  AUDITORY  CANAL. 


697 


Ulcers,  Polypoid  Growths,  and  Bone-Caries. — In  the  great  majority  of 
cases,  the  pathological  conditions  enumerated  in  the  above  title  are  encoun- 
tered only  as  secondary  phenomena,  dependent  upon  a  primary  inflammation 
of  the  middle  ear.  In  a  few  cases,  however,  they  present  all  the  appearances 
of  being  purely  independent  affections.  If  the  true  history  were  known  in 
each  such  instance,  it  would  probably  be  found  that  the  primary  afl^ection 
had  healed,  leaving  the  secondary  pathological  process  as  the  only  evidence 
of  active  disease. 

Cases  of  this  kind  are  by  no  means  common.  They  are  interestino-  as 
pathological  curiosities ;  but,  as  they  do  not  differ,  in  any  important  respect, 
from  the  same  lesions  of  a  clearly  secondary  nature,  I  may  be  allowed  to 
omit  any  further  mention  of  them  in  this  place. 

Syphilitic  Ulcers  and  Condylomata.— Well-marked  syphilific  lesions, 
such  as  ulcers,  giimmy  spots  or  tumors,  and  papillary  growths,  are  rarely 
seen  in  the  external  auditory  canal.  They  are  to  be  treated  in  preciselv  the 
same  manner  as  these  lesions  in  other  parts  of  the  body  are  usually  treated, 
viz.,  by  the  internal  administration  of  some  mercurial  preparation,  or  iodide  of 
potassium,  and  locally  by  cauterization  or  excision. 

Foreign  Bodies  in  the  Auditory  Meatus.— Under  this  heading  are 
included  all  ^  objects,  or  living  organisms,  which  find  an  entrance  into  the 
external  auditory  canal  from  without,  and  not  those  which  have  developed 
in  that  cavity,  or  originally  formed  a  part  of  its  walls.  They  consist  usually 
of  such  articles  as  a  child  is  in  the  habit  of  playing  with ;  as,  for  example, 
glass  beads,  small  pebbles,  bits  of  slate  pencil,  peas,  beans  of  different  varie- 
ties, cherry  and  prune  pits,  etc.  Insects  and  bugs  of  various  kinds  also 
sometimes  fi.nd  their  way  into  the  meatus. 

As  a  rule,  the  foreign  body  causes  very  little,  if  any,  discomfort,  and  the 
patient  is  usually  brought  to  the  physician's  office,  more  on  account  of  the 
fear,  on  the  part  of  the  parents,  that  damage  may  be  done  to  the  ear  if  the 
foreign  body  be  allowed  to  remain,  than  on  account  of  pain  or  any  marked 
impairment  of  the  hearing  observable  at  the  time.  When  pain  is  a  noticeable 
feature  of  the  case,  it  will  usually  be  found,  on  inquiry,  that  unskilled 
attempts  have  been  made — in  some  instances  by  friends,  in  others,  I  regret 
to  say,  by  medical  men— to  extract  the  foreign  body.  Cases  have  even  been 
known  in  which  persistent  and  violent  attempts  were  made  to  extract  a  foreio-n 
body  whose  presence  in  the  ear  was  purely  imaginary.  ^ 

It  is,  therefore,  the  physician's  first  duty,  when  consulted  about  a  case  of 
foreign  body  in  the  ear,  to  ascertain  by  direct  inspection  whether  the  object  in 
question  really  is,  or  is  not,  present  in  the  external  auditory  canal.  When 
he  has  seen  the  foreign  body,  he  should  proceed  to  ascertain,  by  careful 
exploration  with  the  curette  or  the  slender  middle-ear  probe,  whether  it  lies 
loosely,  or  is  firmly  impacted  in  the  canal.  The  anterior  cul-de-sac,  which  is 
situated  between  the  membrana  tympani  and  the  anterior  inferior  wall  of  the 
meatus,  is  sometimes  quite  a  deep  recess,  and  may  then  readily  harbor  a 
small  foreign  body  so  perfectly  that  simple  inspection  will  fail  to  discover 
the  fact  of  its  presence  in  the  canal.    If  we  have  reason,  therefore,  to  believe 

solid,  ointment-like  consistence  at  the  ordinary  temperature  of  the  human  body,  whereas  vase- 
line at  the  same  temperature  speedily  becomes  almost  as  fluid  as  water.  The  composition  of 
outicura  IS  unknown  to  me,  but  I  have  now  used  it  for  more  than  a  year  in  cases  of  inflammation 
(eczematous  or  otherwise)  of  the  external  auditory  canal,  and  can  speak  with  confidence  of  its 
peneticial  efl^ects.  I  do  not  believe  that  its  curative  powers  reside  in  anvthin-  that  is  peculiar  to 
tlie  preparation  as  a  drug  or  chemical  compound  ;  they  are  due  entirely,  I  believe,  to  the  pro- 
longed protection  which  it  is  capable  of  afi-ording  against  the  injurious  efl^ects  of  exposure  to 
1116  air. 


698 


INJURIES  AND  DISEASES  OF  THE  EAR. 


that  the  foreign  body  may  be  concealed  in  this  pocket,  we  must  bend  the  end 
of  the  middle-ear  probe  slightly,  pass  it  gently  down  to  the  inner  end  of  the 
canal,  and  then  sweep  the  tip  of  the  instrument  cautiously  along  the  bottom 
of  the  cul-de-sac,  in  order  to  bring  the  foreign  body  into  view,  if  it  be 
lodged  in  that  locality.    Again,  I  suppose  I  must  repeat  the  caution,  that 
only  those  who  who  are  able  to  see  the  membrana  tympani  distinctly,  and 
who  at  the  same  time  possess  the  requisite  degree  of  delicacy  in  their  manipu- 
lations, have  any  right  to  attempt  the  removal  of  such  a  foreign  body  by 
means  of  probes  or  hooks.    All  others  should  rest  satisfied  with  the  compara- 
tively safe  method  of  syringing  the  ear  which  is  believed  to  harbor  the 
foreign  body.    In  this  connection  I  desire  to  make  the  remark,  that  a  failure 
to  bring  to  light  an  object  that  is  supposed  to  be  lodged  in  the  external 
auditory  canal,  by  means  of  syringing,  affords  but  a  very  poor  guarantee 
that  the  canal  is  free  from  the  presence  of  any  such  foreign  body.  Further- 
more, there  are  occasions  when  the  employment  of  the  syringe  may  do 
positive  harm  ;  as  for  instance,  when  the  foreign  body  is  a  dried  bean  or  pea, 
which,  under  the  influence  of  moisture,  may  swell  up  to  twice  the  size  which 
it  possessed  in  the  dry  state.    In  the  case  of  larger  foreign  bodies,  which  are 
actually  impacted  in  the  meatus,  instrumental  interference,  by  means  of  long 
and  slender  hooks  of  different  sizes,  becomes  almost  a  necessity.    Under  such 
circumstances  syringing  is  reasonably  sure  to  fail,  and,  if  such  proves  to  be 
the  case,  the  physician  should  frankly  confess  his  inability  to  extract  the 
foreign  body,  and  should  obtain  the  assistance  of  an  expert.    If  the  patient 
is  free  from  pain,  and  there  are  good  reasons  for  believing  that  the  foreign 
body  is  not  exciting  inflammation  of  the  surrounding  parts,  it  will  be 
perfectly  proper  to  postpone  surgical  interference  for  several  days,  or  even 
weeks,  if  necessary.    The  reasons  why  the  foreign  body  should  be  removed, 
are  these.    It  may  change  its  position  and  assume  one  in  which  it  will  press 
against  the  membrana  tympani  ;  in  the  event  of  an  acute  inflammation  of  the 
middle  ear,  it  may  prevent  the  free  escape  of  the  discharge  from  the  drum- 
cavity,  and  thus  favor  the  development  of  serious  intracranial  disease  (abscess 
or  simple  meningitis) ;  and,  finally,  its  presence  in  the  auditory  canal  is 
almost  invariably  a  source  of  great  anxiety  to  the  parents,  and  its  removi.l 
is  therefore  likely  to  produce  correspondingly  great  satisfaction. 

In  removing  a  loosely-fitting  foreign  body  from  the  auditory  canal,  no 
difiSculty  will  be  experienced  in  passing  a  bent  slender  prolbe,  or  a  slender 
steel  hook,  by  the  side  of  the  object,  between  it  and  the  wall  of  the  meatus, 
and  then  turning  the  instrument  on  its  long  axis  in  such  a  manner  as  to  bring 
the  bent  part  of  the  hook  directly  behind  the  body.  By  cautiously  pulling 
upon  the  instrument  we  may  then  readily  extract  the  foreign  substance.  In 
the  case  of  a  tightly  fitting  object,  we  should  proceed  in  precisely  the  same 
manner.  The  task,  however,  will  be  found  far  more  difiicult,  and  we  may 
find  it  necessary  to  re-adjust  the  hook  several  times,  before  we  finally  succeed 
in  dislodging  the  foreign  body.  All  these  manipulations,  it  must  be  clearly 
understood,  are  to  be  made  only  when  the  auditory  canal  is  perfectly  illumi- 
nated, and  while  the  operator  is  observing  as  closely  as  he  can  the  direction 
in  which  his  instrument  is  travelling,  and  the  depth  to  which  he  has  made 
it  penetrate. 

The  after-treatment  in  the  more  serious  cases  should  be  essentially  the 
same  as  that  which  is  required  in  cases  of  acute  inflammation  of  the  external 
auditory  canal  or  middle  ear.  In  the  simpler  cases  no  after-treatment  is 
necessary. 

Wounds  of  the  Auditory  Meatus. — Wounds  involving  only  the  external 
auditory  canal  are  in  my  experience  quite  rare.    They  usually  result  from 


METHODS  OP  EXAMINING  THE  MIDDLE  EAR. 


699 


the  introduction,  into  the  meatus,  of  some  sharp-pointed  object  against  which 
a  blow  is  received.  These  lacerated  wounds  of  the  auditory  canal,  or  rather 
of  the  cartilaginous  portion  of  the  canal,  present  only  one  feature  of  special 
interest:  I  i*efer  to  the  persistent  bleeding  which  so  frequently  characterizes 
them.  This  symptom  is  undoubtedly  to  be  attributed  to  the  fact  that  those 
bloodvessels  which  pierce  the  cartilaginous  framework,  as  many  of  them  do, 
are  not  capable  of  contracting  and  retracting  beyond  a  very  limited  extent ; 
their  physical  relations  being  essentially  the  same  as  those  of  the  blood- 
vessels which  traverse  bony  structures. 

The  question  of  treatment  calls  for  no  special  remark. 

l^EW  Growths.— The  commonest  form  of  new  growth  in  the  external  audi- 
tory^  canal  is  the  osteoma.  It  is  encountered  both  in  the  form  of  an  exostosis 
and  in  that  of  a  more  ditfuse  hyperostosis.  The  latter  variety  is  more  frequent 
than  the  former.  In  many  cases,  the  development  of  new  bone  is  clearly  depen- 
dent upon  inflammatory  disturbances  in  the  skin  of  the  osseous  portion  of  the 
canal,  which  is  at  the  same  time  a  periosteum,  but  in  others  no  satisfactory  ex- 
planation of  the  cause  can  be  given.  On  an  examination  of  the  meatus  with  the 
speculum  and  reflected  light,  the  picture  presented  to  the  eye  of  the  observer 
is  either  that  of  a  smooth,  but  very  much  contracted  canal,  or  of  one  from 
some  portion  of  which  a  hemispherical,  broad-based,  and  very  smooth  mass,  or 
one  with  a  more  or  less  well-defined  neck,  projects.  The  necessity  to  operate 
upon  an  exostosis  may  arise,  as  it  appears  to  me,  only  under  two  conditions 
—VIZ.,  when,  by  its  encroachment  upon  the  calibre  of  the  meatus,  the  tumor 
seriously  diminishes  the  power  of  hearing  (the  other  ear  being,  at  the  same 
time,  either  totally  or  markedly  deaf),  or  when,  by  its  damming  up  a  discharge 
from  the  middle  ear,  it  threatens  to  superinduce  serious  disease  of  the  brain 
or  other  adjacent  organs.  In  the  latter  event,  the  establishment  of  a  counter- 
opening  in  the  mastoid  process  may  be  found  an  easier,  and  yet  equally  effec- 
tive, means  of  afi:brding  an  outlet  for  the  pent-up  matter. 

Primary  carcinoma  of  the  external  auditory  canal  is  exceedingly  rare,  and 
furthermore,  in  the  few  published  records  of  cases,  it  is  not  made  wholly  clear 
that  the  tumor  did  not  develop  primarily  in  some  neighboring  region. 

Sarcoma  \^  also  very  rare  as  a  primary  growth  in  this  region  of  the  ear. 

Cysts,  with  fluid  or  semi-solid  contents,  are  occasionally  encountered  in  the 
auditory  canal.  Those  with  fluid  contents  in  the  vicinity  of  the  drum-mem- 
brane are,  I  might  almost  say,  always  secondary  to  some  aftection  of  the 
middle  ear.  In  some  instances,  however,  the  primary  disease  recedes  so  com- 
pletely, that  the  cyst-like  formation  in  the  meatus  gains  proportionally  in 
individuality,  and  may  even  be  taken  for  a  tumor  of  primary  development. 
As  the  description  of  these  secondary  cysts  belongs  more  properly  under  the 
heading  of  diseases  of  the  middle  ear,  I  will  say  nothing  further  on  the  subject 
in  the  present  section. 


Methods  of  Examining  the  Middle  Ear. 

^  The  cavity  of  the  middle  ear  is  open  to  direct  inspection  only  when,  through 
disease,  a  large  portion  of  the  drum-membrane  has  been  destroyed.  Uncler 
other  circumstances,  we  are  obliged  to  infer  what  the  condition  of  this  cavity 
IS,  from  a  variety  of  data,  such  as  the  degree  of  acuteness  of  the  hearing  the 
appearances  presented  by  the  drum-membrane,  both  before  and  after  air  has 
been  forced  into  the  tympanum,  the  character  of  the  sounds  heard  through 
an  auscultation  tube  during  the  performance  of  this  operation,  the  condition  of 
the  integuments  covering  the  mastoid  process,  the  state  of  the  naso-pharyngeal 


700 


INJURIES  AND  DISEASES  OF  THE  EAR. 


mucous  membrane,  the  results  obtained  with  the  tuning-fork  test,  the  subjec 
tive  symptoms  as  described  by  the  patient,  etc.    Of  all  these  data,  the  most 
valuable  is  unquestionably  the  appearance  presented  by  the  membrana  tym- 
pani.    A  perfectly  normal  condition  of  the  tympanic  mucous  membrane,  and 
a  perfect  condition  of  the  function  of  hearing,  are  scarcely  possible,  unless  the 
membrana  tympani  is  subjected  to  the  same  degree  of  atmospheric  pressure 
on  both  sides.    To  maintain  such  a  condition  of  equilibrium  between  the 
inner  and  the  outer  atmospheric  pressure,  Nature  has   constructed  the 
Eustachian  tube,  or  the  channel  of  communication  between  the  middle  ear 
and  the  throat,  in  such  a  way  that  the  air  can  readily  pass  through  it,  to  and 
from  the  cavity  of  the  tympanum.    When  this  channel  becomes  obstructed 
by  mucus,  or  closed  through  the  swollen  state  of  its  walls,  the  condition  of 
equilibrium  ceases  to  exist ;  for  the  air  confined  in  the  middle  ear  rapidly 
becomes  rarefied  through  absorption,  and,  as  a  result,  the  greater  pressure 
upon  the  outer  surface  of  the  drum-membrane  forces  it  inward  beyond  the- 
position  which  it  occupied  when  pressure  and  counter-pressure  were  exactly 
equal.    The  degree  of  patency  of  the  Eustachian  tube  may  therefore  be  esti^ 
mated  with  considerable  accuracy  by  a  careful  inspection  of  the  drum-mem- 
brane.   A  slight  diminution  in  the  perviousness  of  the  tube  to  air,  will  show 
itself  in  a  shortening  of  the  triangular  "  bright  spot,"  w^hich  should  extend 
from  the  immediate  neighborhood  of  the  "umbo,"  or  tip-end  of  the  handle  of 
the  hammer,  nearly  to  the  periphery  of  the  membrane  ;  in  a  change  in  the 
outer  surface  of  the  membrane,  which,  instead  of  the  form  of  a  shallow  cone, 
assumes  that  of  a  saucer,  or  segment  of  a  hollow  sphere ;  and,  finally,  in  some 
cases,  in  an  increased  transparency  of  the  membrane.   Only  a  practised  eye  can 
note  changes  of  such  a  very  slight  degree.    In  the  more  marked  cases  of  tubal 
obstruction,  the  "  bright  spot"  will  be  found  indeed  to  be  a  mere  spot  in  the 
central  part  of  the  membrane,  in  front  of  the  "umbo ;"  the  unnatural  concavity 
of  the  membrane  will  be  readily  recognized  by  even  an  unpractised  eye ;  and 
its  transparency  may  be  so  great  as  to  delude  even  an  expert  into  the  belief 
that  he  is  looking  directly  in'to  a  middle  ear  which  has  been  deprived  of  its 
membrana  tympani.    This  peculiar  transparency  of  the  membrane  may  be 
lacking :  and  in  that  event  our  attention  will  probably  be  attracted  by  other 
equally  striking  changes  in  the  relations  of  the  parts.    I  refer  to  the  marked 
prominence  of  the  short  process  of  the  hammer,  to  the  sunken  condition 
of  the  soft  parts  {membrana  flaccida)  immediately  surrounding  this  bony 
prominence,  to  the  sharply-defined  outlines  of  the  posterior  fold,  to  the  fore- 
shortening of  the  handle  of  the  hammer,  and  to  its  apparent  nearness  to  and 
parallelism  with  the  posterior  margin  of  the  membrana  tympani. 

Inspection  of  the  membrana  tympani,  when  illuminated  by  reflected  light, 
reveals  to  us  still  other  conditions  of  this  membrane  and  of  the  adjacent  tym- 
panic cavity.  Thus,  for  example,  we  may  learn  the  degree  of^  vascularity 
and  oedematous  infiltration  of  these  parts,  the  amount  of  free  fluid  contained 
within  the  tympanum,  the  presence  of  an  excessive  quantity  of  air  in  the 
middle  ear,  and  many  other  less  important  changes  in  the  condition  of  nutri- 
tion of  these  parts.  The  value  of  inspection  may  be  greatly  enhanced,  m 
many  cases,  by  the  employment  of  certain  collateral  procedures,  such  as 
inflation  of  the  middle  ear  by  either  Valsalva's  or  Politzer's  method,  the 
inclination  of  the  patient's  head  either  backward  or  forward,  the  careful  ma- 
nipulation or  exploration  of  the  parts  with  a  slender  probe  or  curette,  and 
the  exhaustion  of  the  air  in  the  external  auditory  canal.  This  latter  proce- 
dure  is  carried  out  by  means  of  -what  is  known  as  Siegle's  pneumatic  specu- 
lum. This  instrument  consists  of  a  central  cylindrical  chamber,  of  either 
metal  or  hard  rubber,  to  which  is  attached  a  flexible  rubber  tube  about  a 
foot  in  length.    To  one  end  of  the  chamber,  which  is  a  little  over  three  cen- 


METHODS  OF  EXAMINING  THE  MIDDLE  EAR. 


701 


timetres  in  diameter,  a  conical  speculum  is  fitted  ;  tne  opposite  end  is  closed 
by  a  glass  window  placed  at  such  an  inclination  to  the  axis  of  the  cylinder, 
that  the  rays  of  light  used  for  illuminating  the  drum-membrane  may  readily 
pass  through  it  without  any  portion  of  them  behig  reflected  back  to  the  eye 
of  the  observer.  The  free  end  of  the  speculum  is  sheathed  with  rubber 
tubing,  and  may  therefore  be  made  to  fit  air-tight  into  the  auditory  canal. 
When  the  instrument  is  in  actual  use,  the  observer,  by  holding  the  free  end 
of  the  rubber  tube  in  his  mouth,  has  it  in  his  power  to  condense  or  rarefy 
the  air  in  the  auditory  canal,  and,  while  doing  so,  to  watch  the  efiects  of 
these  procedures  upon  the  drum-membrane  and  handle  of  the  hammer. 

The  remaining  methods  of  studying  the  condition  of  the  middle  ear,  derive 
their  value  chiefly  from  the  facts  which  may  be  learned  by  auscultation 
combined  with  the  forcible  introduction  of  air  into  this  part,  by  way  of  the 
Eustachian  tube.  There  are  three  such  methods,  viz.,  Valsalva's,  Politzer's, 
and  that  by  means  of  the  Eustachian  catheter. 

In  inflating  the  middle  ear  by  Valsalva's  method,  the  patient  closes  both 
nostrils^  by  grasping  the  nose  with  the  thumb  and  forefinger  of  one  hand, 
shuts  his  mouth  firmly,  and  then  makes  a  strong  expiratory  eftbrt.  In  this 
way  he  compresses  the  air  in  the  pharyngeal  and  nasal  cavities  to  such  an 
extent  that  it  seeks  an  outlet  through  the  Eustachian  tubes.  If  the  effort  is 
successful,  the  surgeon,  who  has  previously  established  a  communication 
between  his  own  ear  and  that  of  the  patient,  by  means  of  a  flexible  ausculta- 
tion-tube, will  hear  a  slight  puff'  or  thud,  as  the  air  enters  the  middle  ear 
and  distends  the  drum-membrane.  Of  the  three  methods  at  our  command, 
this  is  the  most  unsatisfactory  for  the  purposes  of  auscultation,  but  decidedly 
the  best  when  we  desire  to  watch  the  changes  that  may  take  place  in  the 
drum-membrane  while  air  is  being  forced  into  the  middle  ear.  For  thera- 
peutic purposes,  on  the  other  hand,  it  is  decidedly  inferior  to  either  of  the 
other  two,  chiefly  because  it  is  associated  with  an  undesirable,  if  not  danger- 
ous, degree  of  venous  congestion  about  the  head  and  neck.  In  Valsalva's 
method  the  introduction  of  air  into  the  middle  ears  is  not  facilitated  by  the 
act  of  swallowing,  which  is  an  essential  feature  of  Politzer's  plan. 

Politzer's  method  of  inflating  the  middle  ear  is  very  little  better,  for  auscul- 
tatory purposes,  than  that  of  Valsalva,  unless  the  surgeon  can  avail  himself 
of  the  services  of  an  assistant.  If  he  attempt  to  inflate  and  auscultate  at 
the  same  time,  he  will  find  the  task  an  extremely  diflacult  one,  at  least  in 
adult  patients.  In  children,  so  little  force  is  required  to  inflate  the  middle 
ear,  that  one  can  often  perform  both  acts  at  the  same  time  in  a  very  satisfac- 
tory manner. 

The  apparatus  which  is  usually  employed  in  carrying  out  Politzer's  method 
consists  of  a  rubber  bag,  provided  at  one  end  with  a  hard-rubber  nozzle  ;  of  a 
short  piece  of  soft-rubber  tubing,  of  rather  small  calibre,  but  of  comparatively 
thick  and  unyielding  walls  ;  and  lastly,  of  either  a  curved,  cylindrical,  or  a 
bulbous,  hard-rubber  nose-piece.  In  adults,  the  curved,  hard-rubber  nose- 
piece,  like  that  represented  in  the  accompanying  cut  (Fig.  952),  will  be  found 
entirely  satisfactory  in  the  majority  of  cases.  In  children  under  four  or  five 
years  of  age,  in  whom  the  nasal  orifice  is  quite  small  and  tender,  a  nose-piece 
consistmg  of  a  spherical  or  cone-shaped  hard-rubber,  or,  still  better,  glass 
bulb,  will  usually  be  found  preferable  to  the  cylindrical  one. 

The  mode  of  procedure,  in  Politzer's  method,  is  as  follows  :  The  patient 
should  take  a  little  water— a  few  drops  will  suffice— into  the  mouth,  and 
then,  when  the  proper  signal  is  given,  he  should  swallow  the  water,  while 
keepmg  his  lips  closed.  The  physician,  on  his  part,  should  hold  the  rubber 
bag  m  his  right  hand,  and,  when  the  patient  has  taken  the  water  into  his 
mouth,  he  should  introduce  the  nose-piece  a  distance  of  about  half  an  inch 


702 


INJURIES  AND  DISEASES  OF  THE  EAR. 


into  his  left  nasal  orifice,  using,  if  necessary-,  his  left  hand  to  aid  him  in 
placino-  the  instrument  in  its  proper  position  on  the  floor  of  the  nasal  passage. 
^  As  soon  as  he  has  accomplished  this,  he 

Fig.  951.  Fig.  952.        should   at  once  compress   the  nostrils' 

firndy  over  the  rubber  nose-piece,  and 
give  the  patient  the  signal  to  swallow 
the  water.    The  act  of  compressing  the 
bag  and  forcing  air  into  the  nasal  cavi- 
ties should  follow  the  signal  almost  in- 
stantly. With  very  deaf  persons,  a  nod  of 
the  head  or  a  nudge  with  the  knee  will 
serve  as  a  signal ;  but  in  the  majority  of 
cases  it  is  customary  to  give  the  command, 
Swallow  I   With  children,  it  is  often  suffi- 
cient to  simply  instruct  the  child  to  keep 
the  mouth  tightl}^  closed,  or  to  inflate  the 
cheeks,  at  the  moment  w^hen  we  are  ready 
to  compress  the  rubber  bag.    These  de- 
vices, however,  and  some  others  which 
lack  of  space  will  not  permit  me  to  de- 
scribe, are  inferior  to  the  original  Polit- 
[     zer's  method  in  one  important  particular, 
viz.,  they  do  not  take  advantage  of  the 
great  assistance  afforded  by  the  act  of 
Qg  in  separating  the  lips  of  the  tubal  oriflces, 
rendering  the  tubes  themselves  more  easily 
to  air,  at  least  for  the  brief  moment  of  time 
1  by  this  act. 

\  connection  I  should  call  attention  to  the  fact 
m  may  sometimes  be  done  to  the  ear  by  the 
)r  injudicious  use  of  Politzer's  method  of  in- 
The  operation  should  never  be  resorted  to 
:r  both  drum-membranes  have  been  examined. 
The  conditions  which  contraindicate  sudden  and  forci- 
Poiitzer's  apparatus.        blc  inflation  of  the  middle  ears,  are  these:  a  highly 
sunken  drum-membrane,  which  may  possibly  also  be 
adherent  to  some  of  the  deeper  parts  of  the  middle  ear ;  a  decidedly  atro- 
phied drum-membrane,  or  one  in  which  a  very  thin  cicatrix  exists ;  and, 
finally,  an  acutely  inflamed  drum-membrane.    In  all  of  these  conditions  it 
is  best  to  employ  inflation,  at  first,  in  a  cautious  manner,  or  even — as,  for 
instance,  when  there  is  active  inflammation  of  the  middle  ear — to  abstain 
entirely  from  using  it. 

The  third  method  of  inflating  the  middle  ear  is  that  by  means  of  the 
Eustachian  catheter.  When  this  instrument  is  used,  the  air  passes  through 
the  Eustachian  tube  into  the  middle  ear  in  a  continuous  current  of  one  or 
two  seconds'  duration.  This  steadiness  and  long  duration  of  the  current 
afford  the  physician  ample  opportunity  to  listen  deliberately  to  the  character 
of  the  sounds  which  it  produces.  For  purposes  of  diagnosis,  therefore,  this 
method  possesses  a  decided  superiority  over  the  other  two.^ 

The  instruments  required  for  the  operation  of  catheterizing  the  Eustachian 
tube,  are  a  suitable  catheter,  either  of  hard  rubber  or  of  metal,  an  ausculta- 
tion-tube, and  a  soft-rubber  bag  with  a  nozzle  that  can  be  applied  to  the 
mouth  of  the  catheter  in  such  a  manner  as  to  close  it.  A  well-made  hard- 
rubber  catheter  is  an  excellent  instrument,  and  leaves  very  little  to  be  desired. 
It  is  a  very  difficult  matter,  however,  to  obtain  such  a  well-made  catheter. 


Hard-rubbe 
curved  nos€ 
piece.  Ful 
size. 


1 


swallow 
and  thus 
pervious 
consume^ 
In  this 
that  bar 
careless  ( 
flation. 
until  aft( 


METHODS  OF  EXAMINING  THE  MIDDLE  EAB.  703 

The  calibre  of  the  instrument  is  rarely  as  large  as  it  should  be,  or  else,  if  the 
calibre  is  sufficiently  large,  the  total  diameter  of  the  instrument  is  so  ^reat 
that  It  can  be  used  only  m  exceptional  cases.  A  good,  serviceable  Eustachian 
catheter  should  have  a  calibre  of  about  two  and  one-fourth,  or  two  and  one- 
half  millimetres,  and  a  total  diameter  of  not  more  than  three  and  one-half 
niillimetres._  This  proportion  of  calibre  to  total  diameter  is  scarcely  attain- 
able m  an  instrument  made  of  hard  rubber.  The  largest  rubber  catheter 
that  can  ordinarily  be  bought  in  the  shops,  measures  nearly  four  and  one- 
half  millimetres  m  its  total  diameter,  while  its  calibre  measures  only  two 
rai  limetres.  For  the  majority  of  nasal  passages  this  insti-ument  is  too  laro-e 
and  yet  its  calibre  is  barely  large  enough  to  allow  a  current  of  air  to  he 
driven  through  the  instrument  into  the  Eustachian  tube  with  the  requisite 
degree  of  force.  On  the  whole,  therefore,  the  silver  catheter,  if  made  of 
coin  metal  and  properly  proportioned,  will  be  found  to  give  the  greatest  satis 
tac  ion.  A  the  same  time,  it  must  not  be  forgotten  tfat  many'of  the  sHver 
catheters  sold  m  the  shops  are  even  less  serviceable  than  those  made  of  hard 
rubber.  The  calibre  is  not  one  whit  larger,  in  proportion  to  the  total  dia- 
meter, tha.i  that  of  the  average  hard-rubber  oathete/-;  and,  furthermM-e  he 
edges  of  the  beak  ot  the  instrument  are  often  so  sharp  as  to  cause  the  r  atie  ? 

7"CSZ^^r^''  ^'^'•^"^"'^  '"^^         -  -""'^  -  the^mouth 


With  regard  to  tlie  curve  which  a  good  Eustachian  catheter  should  have 
I  may  say  that  the  one  represented  in  the  accompanying  cut  is  that  which  I 


Fig.  953. 


Eustachian  caiheter,  of  silver;  fall  size. 

jiave  found  suited  to  the  great  majority  of  adult  patients.  Some  of  my  cc  - 
leagues  use  a  straighter  instrument,  and  others,  one  of  even  greater  curvature  • 
from  which  it  is  proper  to  draw  the  conclusion  that  the  middle  ear  mav  be 
successfully  inflated  by  variously  curved  catheters.  To  secure  the  most 
eftective  inflation,  however,  we  should  give  the  catheter  such  a  curve  that 
when  It  IS  m  position  and  air  is  forced  through  it,  the  direction  of  the  escap- 
ing current  may  be  the  same  as  that  of  the  Eustachian  tube  itself.  The  com- 
mon error,  as  far  as  my  observation  goes,  is  to  give  the  instrument  a  curve  of 
too  short  a  radius,  which  causes  a  large  part  of  the  force  of  the  current  of  air 
to  spend  itself  upon  the  upper  wall  of  the  Eustachian  tube.  In  children 
trom  Ave  to  about  twelve  years  of  age,  it  will  be  found  better  to  use  a  cathe- 
ter that  IS  even  less  curved  than  that  represented  in  the  cut;  or  one  at  all 
events,  in  which  the  curve  begins  at  a  point  considerably  nearer  the  free  end 
than  it  does  in  this  instrument. 

In  my  work  on  Diseases  of  the  Ear,  I  have  given  a  detailed  description  of 
the  different  steps  of  the  procedure  of  introducing  the  Eustachian  catheter 
and  I  wnl  essentially  reproduce  it  here.  The  surgeon  should  sit  directlv 
facing  the  patient  and  at  his  right  hand,  within  easy  reach,  should  be  his 
rubber  bag,  auscultation-tube,  and  a  bowl  or  goblet  partially  filled  with 
water  and  containing  five  or  six  catheters  of  different  sizes  and  decrees  of 
curvature.  He  should  have  his  forehead-mirror  in  position,  ready  for  use 
as  he  may  at  the  very  beginning  find  it  desirable  to  examine,  under  illumina- 


Y04  *         INJURIES  AND  DISEASES  OF  THE  EAR. 

tion  by  reflected  light,  the  patient's  anterior  nares.    Everything  being  in 
readiness,  and  the  water  having  been  shaken  or  blown  out  of  the  catheter, 
the  operator  should  place  the  fingers  of  his  left  hand  firmly  upon  the  patient's 
forehead,  and,  with  the  end  of  his  thumb,  he  should  elevate  as  much  as  pos- 
sible the' end  of  the  patient's  nose— the  object  of  the  latter  procedure  being 
to  straighten  the  entrance  to  the  nasal  passage,  and  in  so  far  to  facilitate  the 
introduction  of  the  catheter.    This  instrument  should  be  held  lightly  by  the 
suro-eon,  between  the  thumb  and  forefinger  of  his  right  hand,  and  at  no 
time  should  force  be  used  in  overcoming  any  obstacles  that  may  be  encoun- 
tered.   Just  within  the  nasal  orifice,  the  floor  of  the  nasal  passage  rises  up 
in  the  form  of  a  ridge,  the  inner  or  deeper  side  of  which  is  more  abrupt  than 
the  outer  one.    When  the  catheter  is  first  introduced  into  the  nasal  orifice, 
its  outer  end  should  be  at  a  somewhat  lower  level,  though  in  some  cases  we 
may  begin  at  once  with  the  histrument  in  a  nearly  horizontal  position.  To 
pass  it  beyond  the  ridge,  and  engage  it  in  the  lower  nasal  passage,  the  sur- 
geon must  elevate  the  ring  end  of  the  instrument  until  it  occupies  a  nearly 
horizontal  position.    It  is  at  this  stage  of  the  operation  that  the  beginner  is 
very  apt  to  make  a  mistake.    Instead  of  passing  the  catheter  along  the  floor 
of  the  nasal  canal,  he  slips  it  over  the  upper  surface  of  the  inferior  turbinated 
bone,  and,  on  reaching  the  naso-pharyngeal  space,  Avonders  why  his  eftorts  to 
turn  the  instrument  into  the  mouth  of  the  Eustachian  tube  cause  the  patient 
such  great  distress.    A  glance  at  the  illustrations  of  this  region,  in  some 
good  treatise  on  anatomy,  will  show  how  easy  it  is  to  make  this  mistake.  It 
IS  only  necessary  to  push  the  beak  of  the  instrument  a  short  distance  beyond 
the  summit  of  the  ridge,  and  we  shall  find  it  slipping  only  too  easily  along 
the  wrong  channel.    When  the  catheter  has  been  pushed  beyond  the  ridge, 
and  is  actually  resting  upon  the  inferior  turbinated  bone,  the  elevation  of  the 
ring  end  of  the  instrument  will  not  correct  the  error  unless  the  catheter  be 
withdrawn  a  certain  distance.    In  the  first  stage  of  the  operation,  therefore, 
it  is  important  to  hug  the  floor  of  the  nasal  passage  with  the  beak  of  the 
catheter,  at  least  until  the  instrument  has  passed  beneath  the  inferior  turbi- 
nated bone,  and  is  well  engaged  in  the  lower  channel.    As  already  stated,  it 
is  better,  from  this  point  onward,  to  let  the  instrument  find  its  own  way. 
By  this  i  mean  that  if  the  catheter  encounters  some  obstacle,  we  should  aban- 
don the  attempt  to  push  it  onward  in  a  certain  fixed  manner— that  is,  with. 
the  beak  always  pointing  downward  and  backward — and  should  rotate  the 
instrument  slowly,  while  keeping  up  a  gentle  pressure  from  behind,  until  w^e 
find  a  position  in  which  it  no  longer  encounters  opposition,  but  yields  to  the 
pressure  which  tends  to  drive  it  farther  inward  toward  the  naso-pharynx. 

As  we  wish  the  instrument,  on  first  reaching  the  cavity,  to  lie  with  its  beak 
turned  directly  downw^ard,  we  should  begin  at  once,  after  passing  the  obstacle 
referred  to,  to  rotate  the  catheter  back  tow^ard  the  desired  position.  If  w^e 
fail  in  our  efforts  to  overcome  the  obstacle  encountered,  w^e  must  either  resort 
to  an  instrument  of  smaller  diameter,  or  try  to  reach  the  Eustachian  tube  by 
way  of  the  nasal  passage  of  the  opposite  side.  The  latter  course  will  usually 
be  found  the  preferable  one.  When  the  catheter  is  in  the  naso-pharyngeal 
space,  with  its  beak  turned  directly  downward,  we  should  first  make  sure  of 
our  bearings  by  pushing  the  instrument  onward  until  we  feel  the  resistance 
ofiered  by  the  posterior  pharyngeal  wall.  When  the  catheter  is  in  this  posi 
tion,  we  know  that  if  we  rotate  it  far  enough  Ave  shall  carry  the  beak  into  what  is 
known  as  Rosenmiiller's  fossa,  a  slight  depression  located  just  behind  the 
mouth  of  the  Eustachian  tube.  Hence,  if  we  wish  to  introduce  the  instrument 
into  the  latter  cavity,  we  must  draw  it  out  a  distance  of  a  quarter  or  three- 
eighths  of  an  inch,  and  then  rotate  it  through  an  arc  of  about  one  hundred 
and  thirty-five  degrees,  or  until  a  line  drawn  through  the  plane  of  the  ring 


METHODS  OF  EXAMINING  THE  MIDDLE  EAR.  705 

attached  to  the  catheter  passes  through  the  outer  aiii^-le  of  the  patient'.^ 
eye.    If  we  rotate  the  beak  of  the  catheter  first  into  Roseinniiller's  fossa 
and  then  draw  it  out  a  short  distance,  we  can  often  feel  the  end  of  the  instru- 
ment pass  over  the  rounded  eminence  which  constitutes  the  inner  lip  of  the 
mouth  of  the  Eustachian  tube.    As  the  distance  of  the  tubal  orifice  from 
the  posterior  pharyngeal  wall  varies  in  different  individuals,  the  method 
last  described,  of  guiding  our  movements  by  aid  of  the  sense  of  touch 
rather  than  by  rough  estimates  of  distance,  is  the  one  to  which  most  aurists' 
I  think,  give  the  preference.    In  some  individuals,  the  landmark  which  I 
have  just  described  is  so  feebly  developed,  or  the  surrounding  parts  are  so 
swollen,  that  the  operator  feels  doubtful  whether  he  has  reached  the  mouth 
of  the  tube  or  not.    In  such  cases  the  Giampetro-Lowenberg  method  will  be 
found  useful.     According  to  this  method,  the  catheter  is  to  be  rotated 
toward  the  Eustachian  tube  of  the  opposite  side,  and  when  its  beak  occupies 
a  horizontal  position,  as  indicated  by  the  metal  ring,  the  instrument  is  to  be 
drawn  out  until  the  resistance  of  the  posterior  edge  of  the  nasal  septum  i« 
encountered.    The  catheter  is  then  to  be  rotated  in  the  opposite  direction 
through  an  arc  of  at  least  one  hundred  and  eighty  degrees,  into  the  nK.uth  of 
the  Eustachian  tube  which  it  is  desired  to  reach.    In  all  three  methods  but 
especially  in  the  one  last  described,  the  surgeon  will  do  well  to  grasp  the 
body  of  the  catheter  with  the  thumb  and  forefinger  of  his  left  hand  before 
he  performs  the  act  of  rotation  with  his  right  hand.    In  any  event  he  will 
have  to  grasp  it  m  this  manner  after  the  instrument  finally  reaches  its  proper 
position,  as  the  right  hand  will  be  required  for  other  purposes.    The  support 
thus  aftorded  to  the  catheter  is  a  very  firm  one,  as  the  last  three  finc^ers  of 
the  left  hand  find  a  strong  resting-place  on  the  bridge  of  the  patient's^  nose, 
or  on  the  lower  part  of  his  forehead.    As  long  as  the  operator's  fino-ers 
press  firmly  against  the  patient's  skull,  he  need  have  very  little  fear  of  "the 
disturbing  mfiuence  of  a  sudden  motion  of  the-patient's  head  upon  the  position 
oi  the  catheter.  ^ 

When  the  surgeon  believes  that  the  beak  of  the  instrument  is  lyina:  in 
the  mouth  of  the  Eustachian  tube,  he  should  give  the  patient  one  end  of  the 
auscultation-tube  to  place  m  the  meatus  of  the  corresponding  ear,  and  should 
w-.ul^  ^'^^V'^-^  I''        ^'"^'^  auditory  canal,  preferably  the  left  one. 

With  his  right  hand  he  should  then  grasp  the  rubber  bag  (the  ordinary  Pol- 
itzer  s  bag  will  answer  well  for  this  purpose)  and  apply  the  hard-nibber 
nozzle  of  the  mstruraent  to  the  mouth  of  the  Eustachian  catheter.  If  the 
latter  instrument  is  in  the  right  position,  and  the  Eustachian  tube  is  not  un- 
naturally  contracted,  he  will  hear  the  air  streaming  as  it  were  into  his  own 
ear  It  the  catheter,  however,  occupies  a  wrong  position,  he  will  probably 
still  hear  the  air  streaming  out  of  the  end  of  the  instrument,  but  it  will  no 
longer  seem  to  be  escaping  into  his  own  ear;  the  sound  will  appear  to  be 
more  distant  and  less  distinct. 

In  withdrawing  the  catheter  from  the  nasal  cavities,  no  special  precautions 
are  necessary.  The  instrument  is  first  to  be  rotated  back  to  its  original 
position,  with  the  beak  pointing  downward,  and  then  it  is  to  be  drawn  out 
gently  from  the  nose. 

Great  stress  is  laid,  in  some  treatises  on  practical  otology,  on  the  dan«-ei 

of  causing  emphysema  of  the  cellular  tissue  in  various  part/^f  the  neck,  but 

particularly  in  the  region  surrounding  the  entrance  to  the  air-passac.es  in  the 

ZZlw  into  the  middle  ear  by  means  of  the 

thlt^r  f '^''r    \  T^^'''  ^  ^^^^^  ^^^^^^^  ^^^^^^  instance  of 

this  accident,  nor  have  I  heard  of  its  occurrence  in  the  practice  of  any  of  my 

eSir,  W       ^iT  ^  "-^i:  '^''^y  understa^l,  however,  tliat  the 

employment  of  a  catheter  with  a  sharp-edged  beak,  or  the  use  of  loo  much 
VOL.  IV. — 45 


706 


INJURIES  AND  DISEASES  OF  THE  EAR. 


force  in  getting  the  instrument  into  its  proper  position,  might  lacerate  the 
mucous  membrane  at  the  mouth  of  the  tube,  and  so  open  the  way  for  the 
production  of  an  emphysema  of  even  wide  extent. 


Diseases  of  the  Middle  Ear. 


I^ON-siJPPURATiVE  INFLAMMATION  OR  SiMPLE  Catarrh.  —  By  the  term 
catarrh  of  the  middle  ear,"  as  used  in  this  article,  and  very  generally  by 
American  surgeons,  is  meant  a  type  of  inflammati,on  of  the  mucous  membrane 
of  the  Eustachian  tube,  tympanum,  and  communicating  pneumatic  spaces, 
which  is  characterized  by  redness,  swelling,  and  increased  secretion  of  the 
parts,  and  which  stops  short  of  ulceration  and  perforation  of  the  membrana 
tympani.  When  the  affection  is  of  recent  date,  and  subsides  in  the  course  of 
a  few  days  or  weeks,  we  speak  of  it  as  an  acute  catarrh  of  the  middle  ear" 
(otitis  media  catarrhalis  acuta).  When  the  history  given  by  the  patient  shows 
that  the  pathological  process  has  been  going  on  for  months,  and  perhaps 
even  years,  we  may  properly  designate  the  affection  as  a  chronic  catarrh  of 
the  middle  ear"  (otitis  media  catarrhalis  chronica). 

An  acute  catarrh  of  the  middle  ear  may  manifest  itself  under  different  forms. 
For  example,  the  inflammation  may  restrict  itself  almost  entirely  to  the 
Eustachian  tube,  and  the  expression  "  Eustachian  catarrh"  is  then  very  often 
employed.  In  comparatively  rare  instances,  the  inflammation  displays  a  mild 
character  in  its  course  along  the  Eustachian  and  tympanic  portions  of  the 
mucous  membrane,  and  then  spends  its  greatest  force  upon  the  ^mastoid 
portions  ;  or  the  upper  portions  of  the  tympanic  cavity  may  show  evidences  of 
an  active  inflammation  of  the  mucous  membrane,  while  the  lower  portions 
remain  in  almost  a  normal  state.  In  fact,  many  cases  of  severe  purulent 
inflammation  of  the  middle  ear  begin,  as  far  as  I  have  been  able  to  judge  from 
simple  inspection  of  the  membrana  tympani  with  reflected  light,  as  a 
localized  inflammation  of  the  upper  portions  of  the  tympanic  cavity.  I  he 
prevailing  type  of  an  acute  catarrh  of  the  middle  ear,  however,  is  charac- 
terized by  a  more  uniformly  distributed  congestion  and  swelling  of  the  drum- 
membrane,  and  by  more  or  less  marked  closure  of  the  Eustachian  tube. 
Sometimes  both  ears  are  equally  affected,  but  as  a  rule  the  inflammation  is 
much  more  active  on  one  side  than  on  the  other. 

An  inflammation  of  the  naso-pharyngeal  mucous  membrane  almost  mvari- 
bly  precedes  this  variety  of  aural  disease,  and  the  naso-pharyngeal  inflam- 
mation in  its  turn  owes  its  origin  to  exposure  to  cold,  or  to  the  specific 
influence  of  the  poison  of  smallpox,  scarlet  fever,  or  measles.  In  a  few  cases 
the  ear  disease  owes  its  origin  directly  to  the  entrance  of  an  irritating  fluid 
into  the  tympanic  cavity,  by  way  of  the  Eustachian  tube,  or  to  the  irritation 
caused  by  the  presence  of  too  hot  or  too  cold  fluid  m  the  external  auditory 

^^The  symptoms  are  various,  and  all  are  not  always  present  in  one  and  the 
same  case,  or  in  one  and  the  same  ear.  Pain  in  the  affected  region  is  the  most 
prominent  symptom.  It  is  rarely  severe,  and  in  many  cases  is  entirely 
absent.  Pulsation  is  not  often  felt  by  the  patient.  If  present,  it  usually 
indicates  that  an  exudation  of  fluid  has  taken  place  m  the  tympamc  cavity, 
or  that  the  Eustachian  tube  is  impervious  to  air.  Subjective  noises  of  vary- 
incr  intensity  and  character,  and  resonance  of  one's  own  voice  in  speaking, 
are  common  symptoms.  More  or  less  marked  diminution  of  the  hearing  is 
always  present.  A  sensation  of  fulness  or  weight  m  the  affected  ear  is 
sometimes  mentioned  as  a  prominent  symptom.    Numbness  of  the  aftected 


DISEASES  OF  THE  MIDDLE  EAR.  'JQ'J 

side  of  the  head  is  not  a  rare  accompaniment  of  the  disease,  and  I  have  known 
It  to  persist  tor  a  long  time  In  exceptional  cases,  deep  pressnre  in  front  of 
the  tragus  causes  pain,  and  the  glands  on  the  side  of  the  neck,  below  the  ear 
are  very  apt  to  be  tender  and  perceptibly  swollen.  The  act  of  swallowin^^ 
IS  at  times  accompanied  by  pain,  or  by  a  sense  of  soreness  in  the  region  of  the 
Jiust-achian  tube.  In  some  cases  the  patient  complains  that  lo^ud  sounds 
produce  a  pamtul  sensation,  not  so  much  in  the  ear  proper  as  in  the  sensorium 
Certain  musical  tones,  especially  those  of  a  comparatively  hi^h  pitch  may 
also  produce  a  peculiar  fluttering  or  jarring  sensation,  which  "is  felt  di'rectlv 
in  the  ear,  and  which  is  very  distressing.  Double  hearing  even  is  observed 
m  rare  instances  1  mally,  in  a  certain  proportion  of  the  cases,  free  serum 
or  mucus  accumulates  m  the  tympanic  cavity,  and  its  presence  may  then  eive 
rise  to  sorne  very  characteristic  symptoms,  such  as  a  sense  of  sometlino- 
moving  m  the  deeper  parts  of  the  ear  when  the  head  is  moved,  a  cracklinS 
sound  when  the  nose  is  blown,  and  a  marked  increase  in  the  acuteness  of  th% 
neariug  when  the  head  is  held  in  a  certain  position-as  a  rule,  that  main- 
taini?d  by  a  person  m  the  recumbent  posture. 

The  physical  examination  follows  next  in  order.    Some  impairment  of  the 
hearing  ot  one  or  both  ears  will  always  be  found,  but  it  may  be  of  very  sli-ht 
degree    The  vibrations  of  the  tuning-fork  which  rests  upon  the  centre  of 
the  patient  s  forehead,  will  almost  invariably  be  heard  loudest  in  the  ear  most 
attectecl.    i  have,  m  a  few  instances,  met  with  the  reversed  state  of  things 
anci  have  been  puzzled  to  find  a  plausible  explanation  of  the  phenomenon 
That  given  on  page  682  is  the  only  one  that  I  can  offer.    We  must  remem- 
ber, however,  that  whi  e  a  temporary  participation  of  the  labyrinthine 
vessels  in  the  inflammation,  leading  to  diminished  perceptive  power  of  the 
some  o7tr'"'  °^  t'^«.«''lf,^ffected,  will  perhaps  serve  as  an  explanation  for 
ZZuf.^T  °^'^V      ''^"■f'        1"'*"  Voss'^^e  that  the  phenomenon  may 
be  due  to  the  existence,  in  the  apparently  well  ear,  of  some  changes  in  the 
struc  ure  or  tension  ot  the  apparatus  of  hearing,  of  so  slight  a  degree  that 
we  are  unable  to  measure  them,  but  yet  sufliciently  markid  to  produce  the 
discrepancy  referred  to  above,  viz.,  that  of  referring  the  so  nd  of  he 
vibrating  tuning-fork  to  the  good  ear.    As  a  matter  ot^^ourse,  the  presence 
ot  a  mass  of  cerumen  or  of  a  plug  of  cotton  in  the  presumably  well  ear, 
will  destroy  the  value  of  the  tuning-fork  test  j       i  eai, 

The  drum-membrane  of  an  earNvhich  is  the  seat  of  an  acute  catarrhal 
mflammation  of  the  middle  ear,  may  be  expected  to  show,  in  the  earlier 
n.X  the  disease  evidences  of  congestion.  The  long  process  of  the 
malleus,  and  the  circular  periphery  of  the  membrane,  are  the  regions  in  which 

rednel""*    'if ^"'^"^  ^1°°''-    Sonietim^s  the  area  of 

occnTnn.i  '"""l''"  "^tervening  parts  of  the  drum-membrane,  and 
of™  °t     \       *  cutaneous  walls  of  the  canal  will  show  evidences 

m.Zf+rf  "  .1  '  inflammation  The  polished  appearance,  which  is  a 
L  ,P  «n!fl     '  f  membrana  tympani;  is  soon  succeeded  by  a 

2 Tvn,nb.i''r^n  "f '  «f  f^lf  t^*''  ^""butable  to  an  exudation  of  serum 
fi  d  *     b  oodvessels.    In  another  class  of  cases,  we  shall, 

tnd  tlie  lower  part  ot  the  drum-membrane  fairly  normal  in  appearance 
nn  wil  P'^'-t' and  particularly  the  thicker  tissues  constituting  the 

bitl  «  evidences  of  active  inflammation,  "in  a 

third  class,  finally,  the  membrane,  while  retaining  its  polished  surface, 
membranT.  ""S^!"'  I^^^e  different  from  that  observed  in  the  normal  drum: 
rd^b^^ll'  •  ''f  .«on>Posing  It  look  as  if  they  had  been  soaked  in  oil, 
bSa  d  ,?k  ™^  "°  'n'  ^'^^      slate-color  of  the  normal  membrane 

find  tb^f  V    P        f  ■  ®"  0"  closer  inspection,  we  shal 

Had  that  we  are  looking  at  a  very  much  sunken  membrane,  and  that  the 


YQg  IiqjURIES  AND  DISEASES  OF  THE  EAR. 

peculiar  color  is  due  to  the  reflection  of  light  from  the  very  red  mucous 
membrane  of  the  promontory.  If  air  still  remain  in  the  drum  cavity,  the 
tint  reflected  will  be  reddish  or  purple,  but  if  a  yellowish,  translucent  serum 
be  present  in  the  cavity,  it  will  be  likely  to  impart  a  greenish  hue  to  the  color. 
In  these  cases,  we  may  confidently  assume  that  the  Eustachian  tube  partici- 
TDates  very  decidedly  in  the  pathological  changes,  and  that  its  permeability 
to  air  is  for  the  time,  suspended.  If  the  tympanum  contains  partly  air  and 
partly  fluid,  we  may  see  the  outlines  of  bubbles  through  the  membrana 
tympani,  ov  a  delicate  line  corresponding  to  the  boundary  of  the  fluid 

Our  attention  should  next  be  directed  to  the  condition  of  the  naso-pharyn- 
creal  res-ion  From  the  patient's  own  statements,  we  shall  probably  already 
have  learned  that  the  aural  symptoms  developed  during  an  attack  of  ^"  cold 
in  the  head,"  and  on  direct  examination  of  the  pharyngeal  mucous  memorane, 
we  shall  be  likely  still  to  find  evidences  of  the  disease  in  this  locality,  viz., 
redness,  swelling,  and  perhaps  increased  secretion.  If  such  evidences,  how- 
ever are  lacking,  we  must  not  allow  ourselves  to  draw  the  inference  that  the 
rescion  which  is  situated  higher  up,  and  which  we  cannot  see  unless  we 
employ  a  rhinoscopic  mirror,  is  likewise  free  from  all  inflammatory  irritation. 
In  fact,  we  may  with  great  positiveness  assume  the  very  reverse  ot  this  and 
that  too,  oftentimes,  despite  the  patient's  assurance  that  all  sympt5)ms  ot  the 
"  cold  in  the  head"  have  entirely  disappeared.  This  a  point  on  which  1  desire 
to  lay  particular  stress,  for  it  is  one  that  is  very  often  overlooked,  and  yet  it 
is  the  very  one  upon  which  the  successful  treatment  of  this  class  of  cases 

I^well-marked  cases,  the  course  of  the  disease  will  cover  a  period  of  from 
two  to  five  or  six  weeks.  Under  unfavorable  conditions  the  irritation  may 
persist  for  months,  and  may  resist  our  best  eflTorts  to  get  the  mastery  over  it. 
A  complete  or  apparently  complete  return  of  the  middle  ear  to  a  normal 
condition,  may  confidently  be  looked  for  in  the  great  majority  of  cases.  It 
is  only  in  a  few  of  them  that  the  acute  attack  proves  to  be  the  beginning  ot 
the  chronic  form  of  the  disease,  with  its  attendant  symptoms— permanent 
diminution  of  the  power  of  hearing  and  distressing  subjective  noises.  _ 

Treatment— A&  1  have  already  said,  the  most  important  feature,  m  tho 
treatment  of  this  disease,  is  to  try  and  restore  the  naso-pharyngeal  mucous 
membrane  to  a  healthy  condition.    In  my  hands,  nitrate  of  silver  has  proved 
to  be  the  remedy  by  far  the  most  efleective  in  accomplishing  this  object.  It 
.  is  certainly  a  disagreeable  remedy,  even  when  properly  managed ;  and  when 
applied  in  a  careless  manner,  it  is  quite  sure  to  produce  nausea  or  headache, 
or  at  least  a  great  increase,  for  a  short  time,  in  the  amount  of  mucus  secreted 
by  the  p-lands  of  the  naso-pharyngeal  region.    If  we  are  careful,  however,  to 
employ  only  as  much  of  the  solution  as  will  sufiice  to  thoroughly  moisten  the 
"  mucous  membrane  to  which  it  is  applied,  we  shall  rarely  meet  with  any  ot 
the  disagreeable  symptoms  mentioned.   If  we  are  careless  about  taking  these 
precautions,  and  introduce  too  large  a  quantity  of  the  solution,  the  excess 
will  find  its  way  into  the  larynx,  into  the  nasal  passages,  or  down  upon  the 
upper  surface  of  the  roof  of  the  tongue,  and  thus  give  rise  to  a  great  deal  ot 
unnecessary  discomfort,  if  not  to  symptoms  of  a  decidedly  alarming  character 
such  as  spasm  of  the  glottis.    A  rod,  probe,  or  wire,  bent  near  one  end  at 
a  right  ande,  and  armed  with  a  mop  of  absorbent  cotton,  will  be  found  a 
mos^  useful  instrument  for  the  purpose  of  applying  the  remedial  solution  to 
the  naso-pharyngeal  cavity.    The  strength  of  the  solution  must  vary  accord- 
ing to  the  ao;e  of  the  patient,  the  activity  of  the  catarrhal  inflammation,  and 
other  minor  circumstances.    In  a  young  child  I  usually  begin  with  a  ten- 
e:rain  solution,  and  soon  increase  to  one  containing  twenty,  thirty,  or  even 
forty  grains  of  nitrate  of  silver,  in  a  fluidounce  of  water.    In  an  adult  1 


DISEASES  OF  THE  MIDDLE  EAR. 


709 


always  begin  with  a  twenty-grain  solution,  and  increase,  if  necessary,  to  one 
of  double  or  treble  that  strength.  In  the  majority  of  cases  it  is  not  necessary 
to  use  habitually  anything  stronger  than  a  thirty -grain  solution.  I  am  not 
in  the  habit  of  making  the  applications  oftener  than  once  every  other  day, 
or  three  times  a  week ;  and  if,  hy  the  end  of  the  third  or  fourth  week,  I  have 
not  succeeded  in  allaying  the  major  part  of  the  naso-pharjaigeal  irritation,  I 
advise  the  patient  to  take  a  rest  of  one,  two,  or  three  weeks,  befor<5  I  resume 
the  applications  to  the  affected  region.  If  no  improvement  whatever  results 
from  the  first  series  of  applications,  it  is  not  at  all  likely  that  a  continuance 
of  the  same  treatment  will  prove  any  more  successful.  It  is  more  than  likely, 
in  such  a  case,  that  adenoid  vegetations  are  present,  or  that  some  similar 
condition  of  the  vault  of  the  pharynx  exists. 

In  addition  to  these  direct  remedial  applications,  we  must  see  to  it  that  the 
patient  is  not  indulging  the  habit  of  smoking  to  excess,  or  of  imbibing  fre- 
quently the  stronger  (undiluted)  alcoholic  drinks.  Both  of  these  habits  tend 
nnmistakably  to  promote  congestion  of  the  naso-pharyngeal  mucous  mem- 
brane. 

The  practice  of  injecting  weak  remedial  solutions  through  the  catheter  into 
the  middle  ear — or  at  least  into  the  Eustachian  tube — is  one  which  I  have 
long  ago  abandoned,  though  I  believe  that  it  is  still  very  commonly  followed 
by  European  specialists.  The  good  effects  produced  by  the  application  of 
remedies  to  the  naso-pharyngeal  cavity  are  not  by  any  means  confined  to  that 
particular  region  ;  they  extend  promptly  to  the  neighboring  Eustachian  tube, 
and  even  to  the  middle  ear  proper,  and  we  may  place  sufficient  confidence  in 
this  extension  of  a  beneficial  therapeutic  influence,  to  justify  us  in  abstaining 
from  all^  direct  interference  with  the  deeper  regions.  I  know  that  European 
authorities  are  all  against  me  in  this  opinion,  but  my  own  experience,  and 
that  of  at  least  some  of  my  brother  specialists,  warrant  me  in  maintaining  it 
strongly. 

While  the  treatment  of  the  naso-pharyngeal  disease  often  succeeds  in  re- 
storing the  middle  ear  to  a  normal  condition  without  the  aid  of  any  other 
measures,  it  is  better,  as  a  rule,  to  employ  systematically  inflations  by  Polit- 
zer's  method,  in  addition  to  the  naso-pharyngeal  treatment,  just  as  soon  as 
the  ear  has  been  free  from  pain  for  a  period  of  two  or  three  consecutive  days. 
The  beneficial  effects  of  this  procedure  are  to  be  attributed  in  part  to  pressure 
upon  the  swollen  mucous  membrane  of  the  Eustachian  tube  and  middle  ear, 
in  part  to  the  restoration  of  that  condition  of  equilibrium  to  which  I  have 
already  made  reference,  in  part  to  the  actual  expulsion  of  some  of  the  mucus 
or  muco-pus  contained  in  the  middle  ear,  and  perhaps  also  in  part  to  the 
breaking  up  of  any  fresh  adhesions  that  may  have  formed  between  difterent 
parts  of  the  membrana  tympani,  or  chain  of  ossicles,  and  the  neighboring 
walls  of  the  cavity.  Experience  has  shown  that  excellent  results  are  obtained 
by  resorting  to  Politzer's  inflations  only  on  alternate  days ;  and  it  has  been 
found,  furthermore,  that  three  or  four  successful  inflations,  at  each  visit  or 
sitting,  suffice.  In  a  few  cases  we  shall  find  it  necessary  to  employ  the 
catheter,  in  order  to  gain  an  entrance  for  the  air  into  the  middle  ear ;  but  in 
the  great  majority  of  instances  we  shall  find  no  need  of  subjecting  the  patient 
to  this  very  unpleasant  operation. 

In  persons  who  are  somewhat  depressed  in  health,  especially  if  they  have 
passed  the  age  of  fifty,  it  is  not  an  unusual  experience  to  fail  in  our  eflforts  to 
restore  the  aftected  ear  to  its  normal  condition,  either  in  appearance  or  in 
function.  The  naso-pharyngeal  mucous  membrane  seems  to  respond  well 
enough  to  treatment,  but  the  Eustachian  tube  and  middle  ear  lag  behind,  and 
display  very  little  recuperative  power.  Under  these  circumsta^ices,  I  perse- 
vere in  the  treatment  for  three,  four,  or  perhaps  five  weeks,  usins;  as  adjuncts 


710 


INJURIES  AND  DISEASES  OF  THE  EAR. 


counter-irritation  behind  the  ear  (tincture  of  iodine  every  night,  or  cantharidal 
collodion  every  lifth  or  sixth  day),  and  even  sometimes  local  blood-letting 
(one  or  two  leeches  in  front  of  the  tragus).  If  the  affection  still  remains 
stubborn,  and  if  the  patient  can  afford  to  take  such  a  trip,  I  urge  the  advan- 
tages of  a  decided  change  in  climate,  scene,  and  diet,  for  a  period  of  a  few 
weeks.  This  pleasant  prescription  has,  in  my  experience,  repeatedly  accom- 
plished what  my  local  measures  have  been  powerless  to  effect.  The  dryness 
afforded  by  a  decidedly  sandy  soil,  and  the  protection  from  strong  winds 
conferred  by  pine  forests,  are  two  important  features  to  be  sought  after  in  the 
selection  of  such  a  temporary  place  of  residence.  But  if  these  peculiarities 
of  soil  and  surroundings  can  only  be  obtained  at  the  cost  of  considerable 
personal  discomfort,  such  as  is  caused  by  a  poor  diet,  uncomfortable  living 
quarters,  and  an  uncongenial  social  atmosphere,  I  think  that  a  mere  pleasure 
trip,  in  which  the  exhilarating  effects  of  travel  constitute  the  chief  curative 
factor,  should  be  given  the  preference. 

This  is  the  proper  point  at  which  to  consider  the  question,  how  far  our 
treatment  should  be  modified  when  we  find  the  middle  ear  filled  with  a  serous 
or  mucoid  exudation.  This  state  of  things,  which  is  commonly  termed  otitis 
media  serosa^  or  otitis  media  mucosa^  naturally  suggests  the  propriety  of  incis- 
ing the  membrana  tympani,  and  evacuating  the  fluid  contents  of  the  middle 
ear  through  the  artificial  opening  thus  established.  The  operation  is  not 
usually  a  difficult  one,  and  the  immediate  results  of  evacuating  the  fluid  are 
often  brilliant,  but,  unfortunately,  they  are  very  apt  to  be  of  only  short  duration. 
The  fluid  returns ;  a  fresh  impetus  is  given  by  the  incision  to  the  tympanic 
irritation ;  and  we  find,  after  the  lapse  of  a  few  days,  that  the  patient  is  in 
precisely  the  same  condition  as  that  in  which  he  was  at  the  time  when  the 
operation  was  performed.  At  the  present  time  I  very  rarely  resort  to  para- 
centesis of  the  membrana  tympani  for  the  relief  of  the  condition  now  under 
consideration ;  and  my  impression  is,  that  the  best  authorities,  at  least  in  the 
United  States,  hold  very  nearly  the  same  views  that  I  do  with  regard  to  the 
efiicacy  of  this  procedure.  The  presence  of  serum  or  mucus  in  the  drum- 
cavity  is  one  of  the  legitimate  phenomena  of  an  acute,  catarrhal  inflammation 
of  the  middle  ear,  and  calls  for  no  material  modification  of  the  treatment 
commonly  adopted  in  cases  of  that  affection. 

The  operation  of  paracentesis  of  the  membrana  tympani  will  be  described 
hereafter,  under  the  head  of  Acute  Purulent  Inflammation  of  the^ Middle  Ear. 

The  term  chronic  catarrh  of  the  middle  ear  is  very  commonly  applied  to  a 
variety  of  conditions,  which  are  probably  quite  distinct  from  each  other  in  their 
mode  of  origin  and  nature,  but  which  are  characterized  by  the  same  train  of 
symptoms,  viz.,  progressive  deafness,  subjective  noises  in  the  ears,  and  an  intact 
drum-membrane.  For  purposes  of  convenience,  we  may  roughly  divide  these 
cases  into  three  groups.  In  the  first,  we  may  place  those  cases  which  are  cha- 
racterized by  evidences  of  congestion  and  infiltration  of  the  mucous  membrane 
of  the  middle  ear,  associated  w^ith  a  similar  condition  of  the  naso-pharyngeal 
mucous  membrane.  Chronic^  hypertrophic^  catarrhal  rnjiamm-ation  of  the 
middle  ear  would  be  a  proper  expression  to  employ  in  designating  these  cases. 
The  characteristic  features  of  the  second  group  of  cases  are  these :  a  very 
transparent  membrana  tympani,  revealing  quite  clearly  the  lower  end  of  the 
long  process  of  the  anvil,  the  dark  niche  of  the  fenestra  rotunda,  and  the 
intervening  whitish  region  of  the  promontory  ;  an  apparently  unobstructed 
Eustachian  tube;  and,  finally,  a  perfectly  smooth,  or  slightly  ridged,  pale, 
thin  pharyngeal  mucous  membrane,  traversed  perhaps  by  two  or  three  dilated^ 
superficial  veins.  A  process  of  atrophy  and  sclerosis  will  explain  all  of  these 
apfjearances,  and  we  may  therefore  designate  the  cases  belonging  to  this 


DISEASES  OF  THE  MIDDLE  EAR. 


711 


second  group  by  the  term  sclerosis  of  the  laucous  membrane  of  the  middle 
ear.  Finally,  we  may  place  in  the  third  group  all  those  cases  in  which  ^^'e 
are*  unable  to  discover  any  lesions  of  sufficient  gravity  to  account  for  the 
marked  impairment  of  the  hearing.  To  explain  the  deafness  in  such  cases, 
we  are  obliged  to  resort  to  mere  guessing :  there  may  be  an  anchylosis  of  the 
stapedio-vestibular  joint,  brought  about  by  a  rheumatic  or  other  inflarnmation 
of  the  annular  ligament,  or  of  the  tendon  and  sheath  of  the  stapedius  mus- 
cl3;  calcareous  material  may  have  been  deposited  in  these  structures,  or  in 
the'secondary  tympanic  membrane  at  the  round  window,  and  thus  an  anchy- 
losis may  have  been  produced ;  an  exostosis,  or  a  more  diffuse  hyperostosis, 
may  hamper  the  stirrup  in  its  action,  or  may  limit  the  excursions  of  the 
membrane  at  the  round  window ;  and,  finally,  the  lesion  may  be  located  at 
some  point  in  the  course  of  the  auditory  nerve.  All  of  these  lesions  have 
been  found  after  death,  but  with  our  present  knowledge  we  can  only  conjec- 
ture their  existence  during  a  patient's  lifetime. 

The  prognosis,  in  chronic  catarrh  of  the  middle  ear,  is  decidedly  unfavor- 
able. In  the  cases  which  belong  to  the  first  group,  the  patient  is  very  apt  to 
hear  better  at  one  time  than  at  another,  and  by  appropriate  treatment  we  can 
sometimes  improve  the  condition  of  the  hearing  to  an  appreciable  degree. 
In  cases  belongino;  to  the  other  two  groups,  however,  and  also  in  very  many, 
perhaps  the  majority,  of  those  belonging  to  the  first,  we  cannot  encourage 
the  patient  to  hope  for  any  improvement.  On  the  other  hand,  we  may  make 
the  statement  that,  in  very  many  cases,  the  progressive  quality  of  the  disease 
is  lacking :  a  certain  degree  of  impairment  of  the  hearing  is  reached,  and 
then  for  years,  perhaps  for  the  remainder  of  one's  life,  no  further  diminution 
takes  place. 

If  a  more  or  less  active  naso-pharyngeal  catarrh  exists,  with  some  conges- 
tion of  the  middle  ear,  the  treatment  appropriate  for  this  condition  must  be 
adopted.^  Some  patients  are  much  more  anxious  to  be  relieved  of  tlie  dis- 
tressing tinnitus  that  often  accompanies  this  affection,  than  of  the  deafness. 
If  there  are  sufficient  grounds  for  the  belief  that  a  sluggish  gastric  digestion 
is  promoting  the  naso-pharyngeal  irritation,  and  secondarily  the  tinnitus,  we 
may  sometimes  materially  diminish  the  severity  of  this  distressing  symptom 
by  prescribing  dilute  nitro-muriatic  acid,  in  doses  (three  times  a  day,  ini me- 
diately after  meals)  of  from  three  to  ten  drops,  to  be  taken  in  a  sufficient 
quantity  of  water.  In  a  few  cases,  the  bromides  afford  some  relief,  and  the 
same  is  true  of  counter-irritation  behind  the  ear.  Active  out-door  exercise 
will  also  be  found  beneficial  in  some  cases.  Chronic  tinnitus  is,  in  the  main, 
about  as  incurable  as  cirrhosis  of  the  liver. 

Acute  Purulent  Inflammation  of  the  Middle  Ear.—  This  form  of  inflam- 
mation of  the  middle  ear,  like  the  catarrhal  vanety,  usually  ow^es  its  origin 
to  an  extension  of  the  inflammation  from  the  naso-pharyngeal  space  to  the 
tympanic  cavity,  by  w^ay  of  the  Eustachian  tube.  In  scarlet  fever,  smallpox, 
syphilis,  diphtheria,  and  perhaps  typhoid  fever  and  measles,  the  inflammation 
peculiar  to  these  diseases  may  develop  primarily  in  the  middle  ear,  in  the 
same  manner  as  it  does  in  the  pharynx  and  naso-pharyngeal  space.  Exposure 
to  cold  is  also  a  very  common  cause  of  the  inflammation,  and  not  a  few  cases 
owe  their  origin  to  bathing  in  salt  water,  some  of  which  penetrates  into  the 
middle  ear  by  way  of  the  Eustachian  tube.  The  nasal  douche  and  the  pos- 
terior nasal  syringe  sometimes  act  in  the  same  way.  The  inflammation  of 
the  middle  ear  observed  in  cerebro-spinal  meningitis  may  be  due  in  some  in- 
stances, possibly  in  all,  to  an  extension  of  the  disease  from  the  cranial  cavity 


1  See  page  708. 


712 


INJURIES  AND  DISEASES  OF  THE  EAR. 


to  that  of  the  middle  ear.  The  same  remark  is  probably  true  of  those  rare 
cases  ill  which  an  otitis  media  acuta  develops  in  consequence  of  an  attack  of 
sunstroke  or  heat-prostration.  Finally,  direct  violence  may  be  the  exciting 
cause  of  the  disease. 

Symptoms. — In  its  early  stages,  an  acute  purulent  inflammation  of  the  mid- 
dle ear  is  not  distinguishable,  in  its  subjective  and  objective  phenomena,  from 
the  acute  catarrhal  variety.  The  pain,  it  is  true,  is  apt  to  be  more  severe, 
and  a  point  is  soon  reached  at  which  the  objective  appearances  show  clearly 
that  the  disease  is  to  be  of  the  purulent  variety.  The  drum-membrane 
either  presents  a  dry,  red,  and  tense  appearance,  or  else  all  the  tissues  at  the 
inner  end  of  the  external  auditory  canal  appear  to  be  soaked,  and  a  small 
quantity  of  free  exudation  may  be  found  on  the  lower  wall  of  the  canal. 
Beneath  this  white  coating  of  soaked  and  loosened  epithelium,  which  can 
generally  be  removed  without  difficulty,  there  will  be  found  the  red  and 
swollen  tissues  of  the  inflamed  drum-membrane.  If  the  swelling  is  moderate 
in  degree,  the  posterior  half  will  probably  be  found  in  a  bulging  condition, 
but  when  the  swelling  is  more  marked  we  must  not  expect  to  And  any  recog- 
nizable bulging  of  the  membrana  tympani.  If  at  this  time  a  vent  is  not 
established  artificially  in  the  membrane,  the  continued  pressure  upon  its  inner 
surface  will  sooner  or  later  cause  one  to  form,  and  thus  aflbrd  an  outlet  for 
the  pent-up  secretions ;  for  the  swelling  of  the  parts  around  the  tympanic 
orifice  of  the  Eustachian  tube  prevents  all  escape  of  fluids  by  way  of  this 
channel.  In  such  diseases  as  scarlet  fever,  diphtheria,  and  smallpox,  it  is 
probable  that  a  certain  local  lack  of  vitality,  or  ulcerative  tendency,  co-operates 
with  the  pressure  in  producing  the  perforation.  Every  part  of  the  drum- 
membrane  is  liable  to  become  the  site  of  such  a  spontaneously  formed  open- 
ing, but  in  a  majority  of  instances  the  anterior  inferior  quadrant  seems  to  be 
the  favorite  locality.  As  soon  as  a  vent  has  been  established,  the  pain  usually 
begins  to  abate.  The  discharge  continues  for  a  variable  length  of  time, 
generally  from  one  to  three  weeks,  and  finally  ceases.  This  occurrence 
usually  takes  place  simultaneously  wdth  the  healing  of  the  perforation.  The 
swelling  and  redness  then  disappear,  and  the  hearing  returns  to  its  normal 
state. 

While  the  simple  course  which  I  have  just  described,  is  that  of  the  majority 
of  cases  of  acute  purulent  inflammation  of  the  middle  ear,  in  not  a  few 
instances  the  disease  runs  a  more  complicated  course,  or  even  assumes  a  fata^ 
form.  The  more  important  of  these  complications  will  be  considered  in  the 
sections'  devoted  to  fractures  of  the  temporal  bone,  chronic  purulent  inflam- 
mation of  the  middle  ear,  and  diseases  of  the  mastoid  process.  The  partici- 
pation of  the  cervical  and  post-auricular  glands  in  the  inflammatory  process 
is  a  noticeable  feature  in  quite  a  large  proportion  of  cases  of  acute  purulent 
inflammation  of  the  middle  ear.  This  sympathetic  inflammation  of  the 
glands  rarely  calls  for  special  attention. 

In  the  simpler  forms  of  acute  purulent  inflammation  of  the  middle  ear  - 

and  they  constitute  the  great  majority  of  cases— the  prognosis  is  favorable, 
both  as  regards  recovery  of  the  sense  of  hearing,  and  as  regards  the  efifects  of 
the  disease  upon  the  general  health.  There  is  a  widespread  belief  among 
non-professional  persons,  that  a  perforation  in  the  drum-membrane,  no  matter 
how  established,  means  the  destruction  of  the  powder  of  hearing.  This  is, 
happily,  an  error,  and  we  may  assure  our  patients  with  the  greatest  confidence 
that  the  mere  establishment  of  a  perforation  in  the  membrana  tympani, 
whether  produced  directly  by  disease  or  by  the  cutting  edge  of  the  knife, 
exerts  little  or  no  influence  prejudicial  to  the  hearing,  "in  the  vast  majority 
of  instances  the  perforation  heals  as  soon  as  the  discharge  from  the  middle 
ear  ceases.    In  fact,  it  often  heals  too  soon,  that  is,  before  the  swollen  condi- 


DISEASES  OF  THE  MIDDLE  EAR. 


713 


tion  of  the  walls  of  the  Eustachian  tube  has  sufficiently  subsided  to  permit 
the  fluid  secretions  of  the  middle  ear  to  find  an  outlet  by  this  channel ;  and 
under  these  circumstances  the  membrana  tympani  is  very  likely  to  be  sub- 
jected to  considerable  tension,  from  the  pressure  of  these  accumulating 
secretions. 

The  duration  of  a  visible  discharge  from  the  ear  is  very  variable,  it  often 
lasts  only  a  few  days,  and  then  again  it  may  continue  for  a  period  of  several 
weeks.  If  the  case  pass  into  a  chronic  condition,  the  discharge  may  continue 
for  years. 

Inasmuch  as  the  membrana  tympani  forms,  anatomically,  a  part  ot  the 
external  auditory  canal  as  well  as  of  the  middle  ear,  it  may  participate  in 
the  inflammation  of  either  of  these  regions.  Under  certain  circumstances, 
therefore,  it  may  be  difficult  or  even  impossible  to  determine,  by  mere  inspec- 
tion, whether  the  appearances  presented  by  the  membrana  tympani  indicate 
a  primary  inflammation  of  the  middle  ear,  or  merely  an  extension  of  one  that 
developed  originally  in  the  external  meatus,  and  spread  thence  not  only  to 
the  membrana  tympani  but  also  to  the  cutaneous  wall  of  the  osseous  portion 
of  the  meatus.  In  the  great  majority  of  instances  in  vvhich  the  true  signifi- 
cance of  this  combined  myringitis  and  otitis  externa  diftusa  cannot  be  leariied 
by  mere  inspection  of  the  parts,  we  may  easily  arrive  at  a  correct  conclusion 
by  testing  the  hearing  of  the  affected  ear,  and  by  ascertaining  how  much  pain 
the  patieiit  has  experienced.  If  he  can  hear  the  ticking  of  a  watch  at  a 
distance  of  several  inches  from  the  aftected  ear,  and  if  he  has  had  very  little 

pain  possibly  none  at  all— we  may  be  confident  that  we  are  dealing  with  a 

case  of  primary  inflammation  of  the  external  auditory  canal,  involving  the 
dermoid  portion  of  the  drum-membrane.  On  the  other  hand,  a  priniary 
inflammation  of  the  middle  ear,  of  sufficient  severity  to  involve  the  coverings 
of  the  osseous"  position  of  the  external  auditory  canal,  could  scarcely  run  its 
course  so  far  without  producing  severe  pain. 

Treatment. — The  most  urgent  indication,  in  the  treatment  of  an  acute 
inflammation  of  the  middle  ear,  is  to  afford  relief  from  the  pain,  which^  is 
sometimes  severe.  In  young  children,  it  is  often  an  easy  matter  to  accomplish 
this  by  simply  applying  heat  and  moisture  in  close  proximity  to  the  inflamed 
parts.  In  carrying  out  this  procedure,  however,  it  is  important  to  pay 
considerable  attention  to  details.  The  child  should  lie  upon  the  side  corres- 
ponding to  the  well  ear,  and  water  at  a  temperature  of  about  100°  F.  should 
be  poured  into  the  outer  canal  of  the  inflamed  ear  until  it  seems  to  be  full. 
Then  a  hot,  flaxseed-meal  poultice,  or  a  pad  composed  of  several  thicknesses 
of  flannel  wrung  out  of  hot  water,  should  immediately  be  placed  over  the 
ear  and  surrounding  region.  As  an  outside  covering,  and  also  as  a  means 
of  holding  the  poultice'properly  in  its  place,  a  flannel  cap  with  strings  that 
can  be  tied  under  the  chin,  may  be  adjusted.  As  soon  as  the  poultice  or  the 
hot  cloths  seem  to  have  lost  their  heat,  fresh  ones  should  be  ready  at  hand  to 
supply  their  places.  By  this  procedure,  which  brings  the  heat  and  moisture 
in  close  proximity  to  the  inflamed  parts,  we  shall  rarely  fail^  in  children  to 
arrest  an  acute  inflammation  of  the  middle  ear,  provided  that  it  be  not  due  to 
some  specific  poison  like  that  of  scarlet  fever  or  diphtheria,  and  provided  that 
the  disease  be  not  of  too  long  standing.  In  adults,  also,  this  plan  of  treatment 
is  sometimes  successful,  but'it  is  rare'that  a  full-grown  person  will  consent  to 
submit  to  treatment  of  any  kind,  until  the  time  has  gone  by  when  such 
simple,  home-made  measures  are  competent  to  arrest  the  progress  of  the 
inflammation.  Still  it  is  often  possible,  even  at  this  late  stage,  to  quiet  the 
pain  and  arrest  the  further  progress  of  the  inflammation  by  the^  measures 
which  I  have  described,  and  it  is  therefore  well  to  give  them  a  trial.  Xow 
and  then  we  shall  encounter  a  patient  to  whom  some  form  of  dry  heat  affords 


714 


INJURIES  AND  DISEASES  OF  THE  EAR. 


greater  relief  than  does  the  poultice  or  the  hot  douche.  A  soft,  flannel  bag 
filled  with  dried  hops,  and  heated  thoroughly  before  an  open  fire  or  in  the 
oven,  will  be  found  to  serve  an  excellent  purpose  in  such  cases.  Bran, 
oatmeal,  or  coarse  salt  may  be  used  in  the  place  of  the  hops.  A  rubber-bag 
filled  with  hot  water,  and  covered  with  flannel,  is  also  a  good  substitute  for 
the  hop  pillow\  A  still  more  perfect  method  of  applying" heat  and  moisture 
to  the  inflamed  drum-membrane,  is  by  means  of  a  gravity  douche,  provided 
with  a  pronged,  hard-rubber  nozzle,  such  as  will  be  described  hereafter.  By 
refilling  the  tin  reservoir  ("  Clark's  douche")  or  the  rubber  bag  as  often  as 
may  be  required,  a  stream  of  warm  water  may  be  kept  playing  upon  the 
inflamed  parts  as  long  a  time  as  may  be  wished. 

If  these  simpler  measures  fail,  we  may,  according  to  the  a2:e,  sex,  and 
strength  of  the  patient,  apply  from  one  to  four  leeches  either  Tm mediately 
behind,  or  immediately  in  front  of,  the  auricle,  as  close  as  possible  to  the 
tragus.  ^  As  a  rule,  however,  it  will  be  found  that  the  cases  in  which  warm 
applications  and  rest  in  bed  fail  to  alleviate  the  pain,  are  characterized  either 
by  a  bulging  condition  of  the  posterior  half  of  the  drum-menjbrane,  or  by  an 
intense  inflammation  of  all  the  soft  parts  bordering  upon  the  upper  part  of 
the  membrane,  without  any  recognizable  bulging.  The  pain  is  due  to  the 
pressure  of  accumulated  secretions  upon  an  inflamed,  and  therefore  highly 
sensitive,  mucous  membrane,  and  the  most  rational  and  conservative  pro- 
cedure is  to  remove  the  pressure  by  establishing  an  artificial  opening  in  the 
membrana  tympani,  through  which  the  secretions  may  find  an  easy  escape.  I 
will  quote  here  briefly  from  my  work  on  ear  diseases,  already  referred  to,  all  that 
I  think  it  necessary  to  say  with  regard  to  this  operation  :  If  performed  with  a 
reasonable  degree  of  care  by  a  physician  who  knows'something  about  the  ana- 
tomy of  the  middle  ear,  it  .may  be  considered  as  a  perfectly  safe  operation. 
There  is  but  one  real  danger,  and  that  is  this :  the  operator  may,  with  the  point 
of  his  knife,  injure  the  delicate  attachments  of  the  anvil,  or  drive  the  stirrup 
into  the  vestibule  with  such  force  as  to  rupture  the  annular  ligament,  or  injure 
some  of  the  delicate  labyrinthine  structures.  However,  the  attachments  of 
the  stirrup  to  the  oval  window  are  quite  strong,  and  this  ossicle  can  unques- 
tionably be  handled  rather  roughly  without  serious  injury  being  caused  to 
the  organ  of  hearing.  The  attachments  of  the  hammer  are  also  very  power- 
ful. On  the  other  hand,  those  of  the  anvil  are  very  feeble.  This  ossicle  is, 
as  it  were,  suspended  between  the  hammer  and  the  posterior  w^all  of  the 
tympanum.  The  bands  which  attach  it  to  the  hammer  are  extremely  deli- 
cate. From  these  the  anvil  derives  little  or  no  stability ;  but  from  the  peculiar 
interlocking  of  the  articular  surfaces  it  derives  probably  its  chief  strength. 
At  best,  however,  this  ossicle  possesses  very  feeble  supports,  and  may  easily 
be  disconnected  from  the  hammer  by  the  manipulations  of  an  ignorant  or 
careless  operator.  In  incising  the  membrana  tympani,  therefore,  we  should  so 
guide  the  end  of  the  slender,  spear-pointed  knife  that  it  shall  not  strike  the  end 
of  the  long  process  of  the  anvil,  or  the  attached  head  of  the  stirrup.  All 
these  parts  which  are  to  be  avoided,  occupy,  fortunately,  a  comparatively 
small  portion  of  the  area  within  which  the  knife  can  be  used.  This  dangerous 
region  occupies  about  half  (the  upper  half)  of  the  posterior  superior  quadrant. 
Henc'e  we  may,  without  the  slightest  fear  of  injuring  the  ossicles,  begin  our 
incision  a  little  above  the  dividing-line,  between  the  upper  and  lower  posterior 
quadrants,  and  midway  between  the  handle  of  the  hammer  and  the  periphery 
of  the  membrane,  and  carry  it  down  nearly  to  the  lower  limit  of  the  latter. 
The  membrana  tympani  secundaria  need  give  no  anxiety,  as  it  lies  safely 
concealed  in  its  niche  of  bone,  quite  out  of  reach  of  any  straight  instrument 
that  may  be  introduced  through  the  outer  meatus.  Furthermore,  if  the 
point  of  the  blade  be  carried  too  far  inward,  the  only  result  will  be  an  incised 


DISEASES  OF  THE  MIDDLE  EAR. 


715 


or  punctured  wound  of  the  mucous  membrane  covering  the  inner  bony  wall 
of  the  tympanum,  a  result  that  has  no  significance  in  the  pathological  condi- 
tions now  under  consideration. 

It  is  by  no  means  an  indifferent  matter  what  sort  of  a  cutting  instrument 
is  used  in  making  an  opening  in  the  membrana  tympani.  In  a  general 
way,  it  may  be  said  that  a  spear-pointed,  two-edged  blade  is  the  best 
adapted  to  this  purpose.  In  the  construction  of  such  a  knife — or  myrin- 
gotome^ as  it  is  often  called — regard  must  be  had  to  the  relations  of  the 
drum-membrane  to  the  inner  wall  of  the  tympanum.  Thus,  for  example, 
it  is  safe  to  assume  that  we  shall  never  be  called  upon  to  incise  a  mem- 
brane whose  posterior  half  occupies  a  position  less  than  tw^o  millimetres 
distant  from  the  inner  wall  of  the  tympanum.  We  may  also  take  it  for 
granted  that  we  shall  never  find  it  necessary  to  incise  a  membrane  so  dis- 
tended that  it  occupies  a  position  more  than  five  millimetres  distant  from  the 
inner  wall  of  the  tympanum.  It  is  therefore  unnecessarj^  to  have  the  cutting 
edges  of  the  spear-[)ointed  knife  of  greater  length  than  five  millimetres.  The 
myringotomes  which  I  use  have  cutting  edges  only  three  and  a  half  milli- 
metres in  length,  and  I  find  them  amply  long.  In  the  next  place,  it  is 
desirable  that  the  spear-headed  blade  should  be  quite  broad  at  its  base;  the 
breadth  in  this  case  being  measured  from  cutting  edge  to  cutting  edge.  In 
children  and  sensitive  people,  a  single  stab  is  often  all  that  we  can  obtain, 
unless  we  resort  to  the  use  of  an  anesthetic.  Under  such  circumstances  the 
broader  the  blade  of  our  knife,  the  greater  will  be  the  length  of  our  incision 
in  the  drum-membrane.  In  my  instruments  the  greatest  breadth  is  barely 
three  millimetres.  Possibly  a  breadth  of  three  and  a  half  millimetres  would 
be  found  better  adapted  to  all  the  purposes  for  which  a  mj^ringotome  is  used; 
but  we  must  not  forget  that  we  are  often  called  upon  to  operate  in  a  canal  of 
very  small  calibre,  and  that  even  a  slight  increase  in  the  size  of  the  knife  may 
be  sufficient  to  greatly  increase  the  difficulty  of  the  task  of  operating  success- 
fully. It  is  largely  a  matter  of  individual  preference  whether  a  straight  or  a 
slightly  bent  myringotome  shall  be  employed.  After  using  both  kinds,  I 
have  gradually  fallen  into  the  habit  of  using  only  the  straight  instrument.  It 
seems  to  me  that  I  can  control  such  a  straight  myringotome  more  perfectly 
than  I  can  a  bent  one.  Those  which  I  use  are  made  from  a  single  piece  of 
steel,  sixteen  centimetres  long ;  the  slender  shank,  together  with  the  blade, 
measures  seven  centimetres,  while  the  eight-sided,  roughened  handle  measures 
nine  centimetres. 

After  an  opening  has  been  made  in  the  drum-membrane,  the  hot  applica- 
tions described  above  should  be  continued  until  the  pain  has  been  relieved 
and  until  a  free  discharge  has  been  established.  Then  heat  is  no  longer  re- 
quired. The  chief  care  from  this  time  forward  must  be  to  secure  the  most 
perfect  cleansing  possible  of  the  external  auditory  canal  and  outer  surface  of 
the  drum-membrane,  as  long,  at  least,  as  the  discharge  continues.  At  first 
thought,  one  would  be  disposed  to  consider  this  part  of  his  therapeutic  task 
as  very  easy  to  accomplish.  The  fact  is,  this  most  important  part  of  the 
treatment  of  purulent  aft'ections  of  the  middle  ear  is  rarely  carried  out 
properly.  Two  or  three  serious  difficulties  usually  stand  in  the  way.  Of 
the  numerous  ear-syringes  sold  in  the  shops,  both  here  and  abroad,  man}^  are 
utterly  worthless  for  the  purpose;  and  of  the  remainder,  scarcely  one  is  fit 
for  anybody  but  an  expert  to  use.  The  syringing  of  the  ear,  however,  must 
as  a  rule  be  carried  out  by  a  nurse  or  by  some  member  of  the  family,  or  pos- 
sibly even  by  the  patient.  The  fear  of  injuring  the  ear  by  introducing  the 
nozzle  of  the  syringe  too  far  into  the  auditory  canal,  is  almost  universal,  and 
as  a  result  the  pus  and  masses  of  cast-oft'  epidermis  lying  next  to  the  mem- 
brana tympani  remain  undisturbed  by  the  current  of  water  ejected  from  the 


716 


INJURIES  AND  DISEASES  OF  THE  EAR. 


syringe.  They  soon  become  putrid,  and  so  increase  the  existing  inflamma- 
tion. If  instructions  are  given  to  pull  the  auricle  upward  and  backward 
during  the  operation  of  syringing,  a  more  perfect  cleansing  of  the  parts  is 
often  obtained.  But  if  the  canal  is  s woollen  and  tender,  as  is  very  apt  to  be 
the  case,  even  this  procedure  will  aid  very  little  in  rendering  the  syringing 
successful  in  its  results.  Several  years  ago  I  devised  an  instrument  which 
has  been  sold  under  the  name  of  "Eeynders's  douche,"  and  which  has  been 
tried  now  for  so  long  a  time  and  so  extensively  that  I  feel  no  hesitation  in 
recommending  it  as  a  very  useful  ear-syringe  or  douche.  It  consists  of  a  soft- 
rub  ber^  bulb  or  reservoir,  from  one  pole  of  which  a  short,  flexible,  rubber 
tube,  eight  or  ten  inches  in  length,  leads  to  a  hard-rubber  tip  or  nozzle, 

Fig.  954. 


Ear-douche. 

armed  with  lateral  prongs  that  prevent  the  instrument  from  being  pushed 
too  far  into  the  auditory  canal. ^  This  pronged  nozzle,  which  constitutes  the 
important  part  of  the  apparatus,  is  represented  correctly  in  the  accompany- 
ing illustration  (Fig.  955).    Instead  of  simple  water  I  am  in  the  habit  of 


Fig.  955. 


Hard-rubber,  pronged  ear-nozzle  ;  full  size. 


using,  by  preference,  a  saturated  solution  of  boracic  acid — two  teaspoonfuls  of 
the  coarse  crystals,  or  of  the  powdered  acid,  to  the  pint,  or  one  tablespoonful 
to  a  litre  of  water.  As  boracic  acid  does  not  dissolve  readily  in  tepid  water, 
it  is  better  to  employ  water  that  is  decidedly  hot,  and  then  allow  it  to  cool 
down  to  the  proper  temperature  (about  100°-105°  Fahr.)  before  it  is  injected 
into  the  ear.  For  cleansing  purposes,  it  will  be  sufficient  to  douche  the  ear 
three  or  four  times  a  day  at  first,  and  then,  as  the  discharge  becomes  less 
active,  we  may  resort  to  this  procedure  less  and  less  frequently.  When  the 
discharge  has  apparently  ceased,  and  when  the  water  that  escapes  from  the 
ear  during  the  douching  procedure  seems  to  be  quite  clear,  we  may  venture 
to  dispense  with  the  instrument  altogether. 

This  is  perhaps  the  proper  place  at  which  to  call  attention  to  a  remedial 

•  At  the  present  time,  the  best  modification  of  this  douche,  for  sale  in  New  York,  is  that  manu- 
factured by  T.  Angelo,  of  Thirty-first  Street  and  Fourth  Avenue.  The  bulb  contains  a  decidedly 
larger  amount  of  water  than  did  that  first  manufactured,  and  soft,  black  rubber  is  now  used  in 
place  of  the  coarse,  white  variety,  for  the  tube  which  connects  the  nozzle  with  the  reservoir. 
These  modifications  have  materially  increased  the  efficacy  of  the  instrument. 


DISEASES  OF  THE  MIDDLE  EAR. 


717 


procedure  which  is  very  commonly  employed,  but  which  is,  as  I  believe, 
objectionable.  I  refer  to  the  instillation  of  warm  laudanum  and  sweet  oil 
into  the  external  auditory  canal,  a  remedy  which  is  widely  recommended  by 
physicians  in  all  cases  of  pain  in  the  ear.  This  procedure  does  mdeed,  in 
some  instances,  diminish  the  pain,  but  it  accomplishes  this  in  an  illegitimate 
manner,  if  I  may  so  express  myself.  It  deadens  the  nervous  sensibility  of 
the  inflamed  parts,  but  it  does  not  arrest  or  diminish  the  inflammation.  On 
the  contrary,  both  the  oil  and  the  alcohol  in  the  laudanum  tend  rather  to 
increase  the  inflammation :  the  former,  by  reason  of  the  numerous  germs  of 
vegetable  mould  which  it  contains,  and  which  may  quickly  take  root  m  the 
inflamed  tissues ;  the  latter,  by  reason  of  its  well-known  irritating  properties. 

In  the  majority  of  cases  of  acute  inflammation  of- the  middle  ear,  no  other 
measures  beside  those  which  I  have  described  will  be  found  necessary  for  the 
restoration  of  the  afl:ected  region  to  a  condition  of  health.    In  a  few  cases, 
however,  we  find  it  desirable  to  resort  to  other  expedients  and  remedies. 
Thus,  for  example,  the  discharge  may  show  little  or  no  tendency  to  diminish, 
although  a  period  of  two  or  three  weeks  may  have  elapsed  since  it  first 
made  ite  appearance,  and  although  the  most  careful  douching  may  have  been 
practised.    Perhaps  the  most  common  cause  of  this  persistent  discharge  is 
what  I  might  term  a  relaxed  condition  of  the  mucous  membrane  of  the  mid- 
dle ear ;  its  bloodvessels  being  dilated  and  paralyzed,  and  the  surrounding 
tissues  being  infiltrated  with  seram  and  lymphoid  cells.    Such  a  mucous 
membrane  needs  the  stimulating  eflects  of  nitrate  of  silver,  and  the  problem 
which  we  have  to  solve  is,  how  to  brins;  it  in  contact  with  the  diseased  parts 
eftectively  and  safely.    If  there  is  a  krge  opening  in  the  drum-mem brano, 
the  task'is  a  very  easy  one.    By  aid  of  the  douche  and  of  inflations  with  a 
Politzer  bag,  we  can  usually  remove  the  greater  part  of  the  secretions  accu- 
mulated in  the  drum-cavity.    A  few  drops  of  the  solution  are  next  to  be  in- 
stilled into  the  auditory  canal,  the  head  of  the  patient  being  turned  to  one 
side  in  such  a  manner  as  to  favor  the  descent  of  the  fluid  to  the  inner  end  of 
the  meatus  ;  and  then,  after  the  solution  has  become  warmed  by  the  heat  of  the 
surrounding  parts— that  is,  after  the  lapse  of  two  or  three  minutes— suflacient 
pressure  should  be  made  upon  the  orifice  of  the  canal  to  force  the  fluid  con- 
tained in  it  to  find  its  way  into  the  afiected  drum-cavity,  and  perhaps  also 
into  the  Eustachian  tube  and  other  outlying  parts.    While  the  pressure  is 
being  applied,  the  patient  should  be  requested  to  perform  the  act  of  swallow- 
ing three  or  four  times  in  succession,  as  the  entrance  of  the  remedial  solution 
into  the  middle  ear  will  thereby  be  materially  facilitated.  In  cases  of  compara- 
tively recent  origin,  weak  solutions  of  nitrate  of  silver  will  usually  be' found 
suflticiently  eflfective.    If  the  perForation  is  as  large  as  one-half  of  a,  milli- 
metre in  diameter,  we  may  use,  with  perfect  safety,  solutions  of  from  five  to 
thirty  grains  to  the  ounce  of  w^ater.    I  have  rarely  found  it  desirable  to  use 
a  strono;er  solution  than  one  containing  five  grains  to  the  ounce.^   If  the  per- 
foration is  quite  small,  perhaps  no  larger  than  a  small  pin-hole,  it  is  better  to 
use  a  still  weaker  solution — one,  for  instance,  that  contains  only  two  or  three 
grains  to  the  ounce.    On  the  other  hand,  in  cases  in  which  the  perforation 
measures  as  much  as  three  millimetres  in  diameter,  and  the  mucous  mem- 
brane of  the  inner  wall  of  the  tympanum  appears  to  be  much  swollen  and 
congested,  I  frequently  introduce  a  slender  probe,  upon  whose  knobbed  end 
a  bead  of  pure  nitrate  of  silver  has  been  fused,  .and  pass  it  lightly  over  all 
the  mucous  membrane  that  is  within  reach.    A  single  such  application  will 
sometimes  arrest  the  discharge  as  if  by  magic,  and  the  swelling  and  con- 
gestion then  disappear  gradually  w^ithout  any  further  therapeutic  interference. 
If  the  perforation  is  very  small,  it  is  not  an  easy  matter  to  bring  our  reme- 


718 


INJURIES  AND  DISEASES  OF  THE  EAR. 


dies  in  contact  with  the  tympanic  mucous  membrane,  at  least  bv  any  of  thf^ 
methods  which  I  have  thus  far  described. 

Injections  by  means  of  the  Eustachian  catheter,  are,  under  these  circum- 
stances, preferred  by  many  authorities.  This  plan  of  treatment,  however  is 
open  to  the  objection  that  it  gives  the  patient  unnecessary  discomfort,  and  often 
tails  to  introduce  the  remedial  solution  into  the  middle  ear.  A  far  more  direct 
and  perfect  method  is  by  means  of  slender  glass  or  metal  tubes,  which  can 
easily  be  passed  through  the  smallest  perforation.  As  it  is  necessary  to  intro- 
duce only  a  few  drops  of  the  remedial  solution,  it  will  be  found  convenient 
to  attach  to  the  tube  an  elastic  cap,  by  means  of  which  we  may  both  dY^^y 
up  mto  It  the  remedy,  and  at  the  proper  moment  discharge  it  through  the 
perforation  into  the  drum-cavity.  The  accompanying  cut  is  a  faithful  repre- 
sentation of  such  a  glass  tube  with  its  elastic  rubber  attachment.  Such  a 
middle-ear  pipette"  is  very  likely  to  inject  only  air  into  the  middle  ear 
unless  we  take  care  to  elevate  the  reservoir  end  a  little  above  the  level  of  the 

Fig.  956. 


Middle-ear  pipette  ;  full  size. 


perforation.  I  need  scarcely  remind  the  reader  that  this  apparently  simple 
operation  is  not  to  be  undertaken  by  everybody.  Like  very  nearly  all  the 
manipulations  necessary  in  either  the  examinatioxi  or  the  treatment  of  the 
ear,  this  procedure  requires  skill  in  keeping  the  drum-membrane  steadily 
illuminated,  delicacy  m  the  manipulation  of  the  instrument,  and  a  perfect 
knowledge  of  the  whereabouts  of  the  tip  of  the  pipette  in  the  middle  ear. 

Two  or  three  questions  still  remain  to  be  answered.  In  the  first  place  we 
must  consider  how  frequently  these  remedial  applications  to  the  mucous 
membrane  of  the  middle  ear  should  be  made.  It  is  possible  that  the  patient 
will  make  more  rapid  progress  toward  recovery  if  we  apply  our  remedies  to 
the  affected  part  every  day,  than  if  we  make  the  applications  only  three  times 
a  week.  I  have  not  tested  this  point  thoroughly,  and  cannot  therefore 
answer  the  question  in  a  positive  manner.  I  get  excellent  results  from  appli- 
cations made  only  on  alternate  days,  and  I  have  sometimes  found  that  I  could, 
with  apparent  advantage,  make  the  intervals  even  longer.  I  have  therefore 
adopted  the  rule  not  to  see  patients  who  are  affected  with  a  purulent  inflam^ 
mation  of  the  middle  ear,  oftener  than  three  times  a  week.  As  a  matter  of 
course,  we  must  see  them  oftener  during  the  acute  stajje  of  the  attack  ;  but  the 
rule  which  I  have  given  applies  only  to  the  later  stages.  If  the  weaker  solu- 
tions do  not  seem  to  diminish  the  discharge,  I  employ  the  stronger  ones,  and 
w^hen  these  seem  to  increase  the  inflammation  and  the  amount  of  the  dis- 
charge, I  return  to  the  weaker  solutions,  or  I  abstain  from  all  active  inter- 
ference for  a  few  days,  or  I  employ  some  other  remedy.  In  this  disease,  how- 
ever, I  rarely  find  it  necessary  to  resort  to  any  other  remedy,  and  the  only 
articles  that  I  use  under  such  circumstances,  are  finely  pow^dered  iodoform, 
burnt  alum,  and  boracic  acid.  As  the  condition  of  the  ear  improves  under 
the  use  of  nitrate  of  silver,  there  comes  a  time  when  nothino;  remains  but  a 
thin,  scanty  discharge,  and  there  is  no  longer  any  visible  evidence  of  active 


DISEASES  OF  THE  MIDDLE.  EAR. 


719 


iiillamniation.  This  is  the  time  when  a  minute  quantity  of  finely  pulverized 
burnt  alum,  or  of  alum  and  iodoform  mixed  in  equal  parts,  or  of  iodoform 
alone,  if  judiciously  pushed  through  the  perforation  into  the  tympanum,  will 
tio-hten  up  the  relaxed  tissues,  and  virtually  put  an  end  to  the  disease.  As 
tar  as  my  experience  goes,  boracic  acid  is  far  inferior  to  iodoform  in  its  cura- 
tive powers,  and  furthermore  it  occasionally  seems  to  act  as  an  irritant. 
Burnt  alum  is  an  exceedingly  valuable  remedy,  hut  it  is  only  after  long  expe- 
rience that  one  can  use  it  satisfactorily.  It  sometimes  sets  up  a  pathological 
disturbance  which  it  is  hard  to  control.  While  I  should  probably  fail  if 
r  were  to  attempt  to  lay  down  any  accurate  indication  for  its  employment,  I 
may  say,  in  a  general  way,  that  it  should  always  be  introduced  in  very  small 
quantities,  and  never  when  any  trace  remains  of  active  iuilammation.  ^  In 
particularly  stubborn  cases,  we  may  find  it  necessary  to  administer  cod-liver 
oil  internally,  or  to  send  the  patient  away  from  home  for  a  period  of  two 
or  three  weeks.  Such  a  change  of  air  and  scene  will  often  effect  what  the 
most  painstaking  and  skilful  treatment  has  failed  to  accomplish. 

Chronic  Purulent  Inflammation  of  the  Middle  Ear.— A  chronic  puru- 
lent inflammation  of  the  middle  ear  may  almost  invariably  be  traced  back  to 
an  acute  attack  that  had  its  origin  in  a  ''cold,"  or  in  scarlet  fever,  measles, 
or  some  other  infective  disease.  In  a  few  cases  the  affection  begins  in  an 
insidious  manner,  without  pain,  and  apparently  without  any  exciting  cause. 
These  comparatively  rare  instances  are  observed  in  scrofulous  or  consumptive 
individuals^  and  the  middle-ear  disease  may  then  be  set  down  as  being  of  a 
distinctively  tubercular  or  scrofulous  nature.  The  salient  feature  of  all  these 
cases  of  chronic  purulent  inflammation  of  the  middle  ear,  is  the  constant  or 
frequently  recurring  discharge  of  pus  from  the  affected  region.  With  regard 
to  all  the  other  symptoms— the  degree  of  the  diminution  in  the  hearing 
power,  the  presence  or  absence  of  pain,  tinnitus,  etc.,  and  the  lesions  observ- 
able by  the  aid  of  the  speculum  and  reflected  light— the  cases  differ  to  such 
an  extent  that  a  general  description  would  fit  only  a  comparatively  small 
number.  Furthermore,  if  we  look  at  this  question  from  a  practical  point  of 
view,  from  the  standpoint  of  one  who  desires  to  effect  a  cure,  we  shall  appre- 
ciate the  folly  of  attempting  to  draw  anything  like  a  general  picture  of  the 
disease.  Each  case  must  be  a  study  by  itself,  and  when  the  student  wishes 
to  make  a  diagnosis,  he  must  strive  to  render  an  account  to  himself  of  the 
chano-es  that  are  going  on  in  all  the  different  parts  of  the  ear.  If  he  rests 
satisfied  with  the  mere  diagnosis  of  "  chronic  purulent  inflammation  of  the 
middle  ear,"  and  then  consults  some  text-book  for  the  purpose  of  ascertaining 
what  is  the  proper  treatment  for  the  disease  which  bears  this  name,  he  will 
often  fail  to  arrest  a  discharge  which  might  otherwise  be  easily  checked. 

As  the  space  alloted  to  this  article  is  limited,  I  will  make  no  attempt  to 
classify  the  different  types  of  chronic  purulent  inflammation  of  the  middle 
ear,  but  will  simply  describe  the  plan  which  I  usually  follow  when  I  am 
called  upon  to  ascertain  the  seat  and  the  extent  of  the  disease  in  a  case  of 
protracted  discharge  from  this  organ.  Every  observer  has  his  own  particular 
method  of  getting  at  the  truth,  and  yet  these  different  methods  all  lead  to 
the  same  result.  The  one  which  I  have  adopted,  is  probably,  in  all^  material 
respects,  the  same  as  that  employed  by  many  other  observers.  It  is,  briefly 
stated,  as  follows  :  I  obtain  from  the  patient,  or  from  the  parents  or  guardians, 
as  clear  an  account  as  possible  of  the  origin  and  progress  of  the  affection. 
It  is  important  to  learn  the  degree  of  activity  of  the  discharge,  whether 
constant  or  intermittent,  whether  fetid  in  character,  and  whether  pale  or 
tinned  with  hlood.  I  ascertain  also  whether  pain  has  been  an  accompaniment 
of  the  disease,  and  endeavor  to  find  out  the  precise  locality  to  which  the  pain 


720 


INJURIES  AND  DISEASES  OF  THE  EAR. 


has  been  referred.  The  value  of  the  previous  history  of  the  case  will  be 
appreciated  when  we  come  to  weigh  the  signilicance  of  certain  lesions  that 
may  be  discovered  in  the  course  of  an  actual  inspection  of  the  parts.  We 
must  also  not  forget  to  test  the  hearing  of  the  aifected  ear.  Then,  if  the 
case  under  consideration  be  one  of  a  somewhat  acute  nature,  our  next  step 
should  be  to  ascertain  the  body  temperature.  Otherwise,  we  may  proceed  at 
once  to  an  examination  of  the  ear  and  neighboring  parts.  Pressure  should 
be  made  with  the  finger  upon  the  soft  parts  immediately  surrounding  the 
ear,  and  particularly  upon  those  covering  the  mastoid  portion  of  the  temporal 
bone.  An  unnatural  redness  of  the  skin  in  this  region  is  a  valuable  indica- 
tion, and  its  presence  should  be  noted.  With  all  these  facts  in  our  possession 
— the  previous  history,  the  degree  of  diminution  in  the  hearing,  the  bod}^- 
temperature,  and  the  condition  of  the  skin  in  the  immediate  neighborhood 
of  the  ear — we  shall  be  able  to  interpret  correctly  the  pathological  changes 
which  we  may  see  in  the  deeper  parts  of  the  organ.  If  the  meatus  is  filled 
with  pus,  we  must  take  steps  to  remove  it,  not  simply  in  a  general  way,  but 
in  the  most  thorough  manner,  so  as  to  expose  to  view  every  nook  and  cranny. 

The  question  of  syringing  presents  itself  at  this  point.  Is  it  best  to 
remove  the  pus  and  other  debris  by  syringing,  or  not  ?  The  answer  to  this 
question  may  be  either  yes  or  no.  I  never  use  the  syrin2;e  under  these 
circumstances :  I  much  prefer  to  soak  up  the  pus  little  by  little,  with  a  mop 
of  absorbent  cotton  wound  around  the  end  of  a  slender,  malleable,  steel  cotton- 
holder,  and,  in  performing  this  operation,  I  keep  the  canal  well  illuminated 
and  w^atch  each  step  as  I  carry  my  mop  deeper  and  deeper  into  the  canal. 
If  I  were  to  syringe  the  meatus,  I  should  still  be  obliged,  afterward,  to 
resort  to  the  use  of  the  mop  ;  for  the  w^ater  that  clings  to  the  deeper  parts  of 
the  ear  and  to  all  the  irregular  places,  w^ill  be  found  to  mask  the  true  condi- 
tion of  the  parts  almost  as  efi:ectively  as  if  pus  and  not  water  covered  them. 
It  is  therefore  easier  and  better  to  omit  the  syringing,  and  to  trust  entirely 
to  the  mop.  On  the  other  hand,  an  unskilled  person  will  have  to  employ  the 
syringe,  and  he  will  have  to  interpret,  as  best  he  may,  the  ill-defined  picture 
which  he  finds  spread  out  before  him.  As  an  imperfect  or  an  erroneous 
diagnosis  leads,  in  very  many  of  these  cases,  to  equally  imperfect  treatment, 
it  will  be  seen  that  I  have  a  right  to  w^arn  the  reader  against  trusting  to  such 
an  imperfect  procedure  as  that  of  cleansing  the  ear  by  means  of  a  syringe. 
Oftentimes  we  shall  find  it  also  necessary  to  use  the  slender  middle-ear  probe, 
the  curette,  and  the  angular  forceps,  in  our  efforts  to  clear  away  the  obstacles 
that  obstruct  the  view.  These  usually  consist  of  scab-like  formations, 
-conglomerations  of  cheesy  pus,  and  masses  of  epithelium.  The  latter  often 
cling  quite  firmly  to  the  underlying  inflamed  tissues,  and  require  to  be  dis- 
sected off"  by  means  of  the  curette.  When  the  mass  has  been  detached,  we 
can  readily  extract  it  by  means  of  the  slender,  angular  forceps.  Irregularities 
of  the  surface  must  be  touched  and  handled,  if  I  may  use  the  expression, 
with  the  probe  or  curette.  In  this  way  we  often  discover  ulcerated  areas  or 
spots  of  granulation- tissue,  which,  under  simple  inspection,  had  seemed  to  be 
simple  unevennesses  of  the  surface.  Sometimes  the  orifice  of  a  sinus  gets 
filled  with  cheesy  pus  or  epithelial  debris^  and  then  presents  the  appearance 
of  a  mere  white  spot.  Careful  pressure  with  the  end  of  the  probe  will  at 
once  reveal  to  us  the  existence  of  such  a  sinus,  and  b}^  further  manipulations 
with  the  same  instrument  we  may  ascertain  its  depth,  the  direction  which  it 
t^kes,  and  the  presence,  at  some  point  in  its  course,  of  an  exposed,  bony  sur- 
face, or  of  a  loose  fragment  of  bone.  If  the  sinus  is  of  sufiicient  size,  we 
may  gain  a  more  accurate  knowledge  of  its  relations  to  neighboring  cavities 
by  the  employment  of  a  slender  canula,  of  either  metal  or  glass,  through 
which,  by  the  aid  of  an  attached  soft-rubber  bulb-syringe,  we  may  inject  a 


DISEASES  OF  THE  MIDDLE  EAR. 


721 


stream  of  tepid  water  into  the  mouth  of  the  sinus.  Every  mass  of  granula- 
tion-tissue that  springs  from  any  part  of  the  external  auditory  canal  should 
lead  us  to  search,  in  the  immediate  vicinity,  for  the  presence  of  a  sinus  or  of 
a  spot  of  carious  bone.  Sometimes  the  sinus  begins  at  the  very  edge  of 
such  a  granulation  growth.  Perhaps  equally  often  the  opening  will  be  found 
in  the  very  centre  of  the  mass. 

Our  attention  should  next  be  directed  to  the  drum-membrane.  Every  i)art 
of  it  should  be  laid  bare,  so  that  Ave  may  feel  sure  that  we  know,  from  actual 
inspection,  what  is  its  condition.  A  perforation  is  rarely  lacking.  If  it  be 
quite  small,  and  especially  if  the  membrana  tympani  at  this  point  be 
decidedly  thicker  than  normal,  we  may  fail  to  discover  the  existence  of  the 
perforation  by  simple  inspection.  We  must  then  take  advantage  of  Valsalva's 
experiment,  and  watch  the  eftects  of  it  upon  the  membrana  tympani.  As 
the  compressed  air  finds  a  way  of  escape  through  the  perforation  in  the  drum- 
membrane,  it  is  very  likely  to  force  out  into  the  meatus  a  certain  amount  of 
the  fluid  contents  of  the  typanum.  The  locality  occupied  by  the  perforation 
is  thus  quickly  revealed.  In  cases  of  this  kind,  we  can  only  infer  what  the 
condition  of  the  middle  ear  is  from  the  appearance  of  the  neighboring  })arts, 
and  from  a  consideration  of  the  data  previously  obtained.  In  cases  in  which 
the  perforation  is  larger,  we  may  obtain  a  direct  view  of  the  deeper  parts, 
and  if  the  perforation'is  quite  large,  we  may  be  able  to  form  a  fairly  accurate 
judgment  with  regard  to  the  condition  of  the  middle  ear.  Direct  inspection, 
however,  must  always  be  supplemented  by  exploration  with  the  probe.  In 
this  way  we  can  learn  the  thickness  and  consistency  of  the  tympanic  mucous 
membrane,  and  the  presence  or  absence  of  masses  of  epithelium  and  cheesy  pus 
(the  so-called  cholesteatomata),  especially  when  they  lie  concealed  from  view 
in  the  upper  and  posterior  portions  of  the  drum-cavity  or  in  the  antrum. 
In  this  way,  also,  polypoid  growths  are  discovered  at  points  which,  to  the 
unaided  eye,  seem  to  be  cove'red  only  with  a  smooth  though  perhaps  swollen 
mucous  membrane.  Bone  ulcers,  w^hich  are  by  no  means  rare  lesions  in  the 
middle  ear,  can  only  be  discovered  by  means  of  the  probe. 

The  examination  is  now  complete.  In  the  great  majority  of  cases,  we 
know  exactly  what  is  the  condition  of  the  external  auditory  canal  and  mem- 
brana tympani,  and  we  possess  sutficient  additional  data  to  enable  us  to  form 
a  fairly  accurate  opinion  with  regard  to  the  condition  of  the  middle  ear.  In 
a  few  cases,  the  auditory  canal  is  found  to  be  in  such  a  swollen  condition  that 
we  are  unable  to  gain  a  view  of  either  the  drum-membrane  or  the  inner  half 
of  the  meatus.  Under  these  circumstances,  w^e  must  carefully  weigh  the  other 
objective  phenomena,  and  the  degree  of  impairment  of  the  hearing  in  con- 
nection with  the  history  of  the  case.  The  beginner  may  find  it  a  very  difii- 
cult  task  to  clear  up  the  pathology  of  these  apparently  obscure  cases,  but  to 
the  expert  it  will  be  comparatively  easy  to  arrive  at  the  truth.  In  our  first 
attempt,  we  are  obliged  to  go  patiently  through  the  process  of  analyzing  each 
symptom,  or  lesion,  in  its  relations  to  the  others  and  to  the  history  of  the  case. 
With  each  new  case,  however,  this  analytical  process  of  reasoning  will  be 
found  to  consume  less  and  less  time,  until,  finally,  we  cease  to  be  conscious  of 
any  such  complicated  process  of  reasoning,  and  arrive,  as  it  were  intuitively, 
at  a  correct  judgment  with  regard  to  the  nature  of  the  malady.  As  I  cannot 
hope,  in  a  short  article  such  as  this,  to  clear  up  all  the  difiiculties  that  sur- 
round the  task  of  making  a  correct  diagnosis,  I  will  take  up,  in  turn,  the 
more  important  symptoms  and  lesions,  and  will  endeavor  to  show  the  signifi- 
cance of  each. 

When  pain  occurs  in  the  course  of  a  chronic  discharge  from  the  ear,  we 
may  look  for  its  source  in  a  variety  of  places.    It  may  be  due,  for  example, 
to  the  development  of  a  furuncle  in  the  walls  of  the  external  auditory  canal. 
VOL.  IV. — 46 


722  INJURIES  AND  DISEASES  OF  THE  EAR. 

All  irritating  discharge  from  the  ear  is  very  apt  to  induce  furuncular  iuflam- 
matioii.  The  condition  may  easily  be  recognized  upon  an  examination  with 
the  speculum  and  reflected  light.  The  escape  of  pus  from  the  middle  ear 
under  pressure,  such  as  exists  when  a  small  perforation  in  the  membrana 
tympani  becomes  blocked  in  any  way,  is  a  very  common  source  of  pain 
After  we  have  once  verified  the  existence  of  such  an  insufficient  or  obstructed 
outlet,  we  can,  by  the  aid  of  other  symptoms  and  lesions,  measure  the  extent 
of  the  harm  that  is  being  caused  by  the  obstruction.  Finallv,  decided  pain 
of  an  obstinate  character  may  be  a  very  prominent  symptom  in  chronic  puru- 
lent inflammation  of  the  middle  ear,  without  the  slightest  trace  of  a  condition 
of  obstruction,  or  of  active  inflammation,  of  the  visible  portions  of  the  middle 
ear.  The  pain,  under  these  circumstances,  is  probably  due  to  a  chronic 
hypertrophic  osteitis  of  the  mastoid  process.  Farther  on,  I  shall  consider  both 
of  these  classes  of  cases  more  fully. 

Tenderness  on  pressure  may  exist  in  the  auditory  canal,  or  at  any  point  in 
the  immediate  vicinity  of  the  ear.  Tenderness  in  the  meatus  signifies  either 
a  localized,  furuncular  inflammation,  or  a  dififuse  periostitis  of  the  canal  In 
the  case  of  this  latter  condition,  we  must  endeavor  to  distinguish  between  a 
mere  superficial  inflammation,  due  to  the  exposure  of  the  parts  to  a  constant 
flow  over  them  of  an  irritating  pus,  and  one  that  represents  a  direct  extension 
of  a  more  or  less  serious  inflammation  of  the  middle  ear.  Tenderness  behind 
and  above  the  ear,  if  developed  in  the  course  of  a  chronic  purulent  dischars-e 
from  the  meatus,  always  means  one  of  two  pathological  processes :  either  an 
inflammation  of  the  soft  parts  of  the  auditory  canal  has  travelled  outward 
along  the  canal  to  the  parts  behind  and  above  the  ear,  or  an  inflammation 
involving  the  antrum  and  cellular  structures  of  the  mastoid  process  has  spread 
along  the  mastoid  emissary  veins  to  the  outer  periosteum.  A  study  of  the 
condition  of  the  auditory  canal  will  usually  enable  us  to  deternnne  correctly 
which  of  these  two  processes  is  the  one  at  work  in  the  case  under  considera- 
tion. 


In  a  large  proportion  of  cases  of  chronic  discharge  from  the  ear,  we  may 
safely  take  it  for  granted  that  the  discharge  is  ke^Dt  up  by  a  limited  patch  of 
■hone-caries,  usually  superficial  in  character,  or  by  a  mass  or  masses  of  qranu- 
lation-tissue.    The  latter  condition  is  by  far  the  more  common  of  the  two 
though  the  former  is  by  no  means  rare.    There  is  undoubtedly  such  a  thing 
•as  a  persistent  and  fairly  active  discharge  without  either  of  the  above-named 
conditions,  but  I  am  convinced  that  such  a  state  of  things  is  comparativelv  un- 
common. Hence  the  necessity,  if  we  desire  to  arrest  the  discharge,  of  makino-  a 
most  thorough  and  minute  search  for  some  hidden  granulation-growth.  In 
more  than  one  case  of  obstinate  discharge  I  have  tried  in  vain  to  eflect  a  cure. 
The  perforation  in  the  membrana  tympani  being  small  (a  millimetre  or  a 
millimetre  and  a  half  in  diameter),  I  have  not  been  able  to  learn  much,  from 
actual  exploration,  about  the  condition  of  the  middle  ear.    In  a  few  of  these 
cases  I  have  had  the  good  fortune,  after  the  lapse  of  weeks  or  months,  to  dis- 
cover the  existence  of  a  small  polypoid  grow^th  in  the  tympanic  cavity.  At 
first  it  was  too  small  to  come  within  my  limited  range  of  vision,  but  as  the 
mass  increased  in  size  it  finally  encroached  upon  the  small  field  bordered  by 
the  edges  of  the  perforation.    The  case  then  became  quite  clear,  and  the 
removal  of  the  growth  with  the  wire  snare  promptly  put  an  end  to  the  dis- 
<^harge.    In  some  cases  I  have  succeeded,  by  aid  of  the  slender  middle-ear 
probe,  bent  at  a  right  angle  near  the  tip,  in  bringing  into  a  view  a  small 
polypoid  growth,  which  the  moment  before  had  been  completely  concealed 
from  view.    With  regard  to  bone-caries,  I  have  very  little  to  say  that  will 
be  of  practical  value.    My  impression  is,  that  I  have  found  these  patches  or 
areas  of  bone-canes  more  often  at  the  posterior  end  of  the  tympanum,  just  at 


DISEASES  OF  THE  MIDDLE  EAR. 


723 


the  edge  of  the  entrance  to  the  antrum,  than  at  any  other  part  of  that  cavity. 
The  floor  of  the  tympanum,  and  the  lower  part  of  the  inner  wall,  just  above 
the  floor,  are  also  localities  in  which  such  an  area  of  bone-caries  is  apt  to  be 
found.  Fistulous  tracks  in  the  region  immediately  above  the  membrana 
tympani  are  not  uncommon. 

The  prognosis^  in  all  cases  of  chronic  purulent  inflammation  of  the  middle 
ear,  must  be  guarded.  Our  knowledge  of  the  exact  nature,  location,  and 
extent  of  the  disease,  is  never  sufl&ciently  exact  to  justify  us  in  giving  a  posi- 
tively favorable  prognosis.  We  are  justified,  however,  in  making  the  state- 
ment that  judicious  treatment  succeeds,  in  the  majority  of  cases,  in  either 
arresting  the  discharge  entirely,  or  in  rendering  it  so  scanty  that  no  outward 
evidence  of  its  existence  can  be  discovered  by  the  ordinary  observer.  As  far 
as  danger  to  life  is  concerned,  w^e  may  give  a  decidedly  favorable  prognosis 
in  all  cases  in  which  the  perforation  in  the  membrana  tympani  is  of  good 
size,  and  the  external  auditory  canal  not  materially  narrowed  by  exostoses. 
The  cases  that  are  likely  to  assume  a  grave  aspect,  are  those  in  which  pus 
stagnates  in  the  deeper  recesses  of  the  middle  ear.  In  a  few  instances,  the 
removal  of  mechanical  obstacles  (pus,  masses  of  epidermis,  granulation- 
growths,  and  undue  swelling  of  the  mucous  membrane  in  the  neighborhood 
of  the  labyrinthine  windows  and  around  the  joints  of  the  ossicula)  decidedly 
improves  the  hearing,  but  in  a  large  proportion  of  cases  treatment  fails  to 
materially  benefit  the  patient's  condition  in  this  respect.  In  fact,  the  hear- 
ing is  sometimes  rendered  less  acute;  for,  upon  the  arrest  of  the  discharge, 
the  chronically  inflamed  tissues  become  contracted,  dry,  and  rigid,  and  the 
mobility  of  the  ossicular  apparatus  is  therelw  impaired. 

In  principle,  the  treatment  of  these  cases  of  chronic  purulent  inflammation  of 
the  middle  ear  is  very  simple.  As  stagnation  and  decomposition  of  the  secre- 
tions are  the  chief  source  of  all  the  inflammation,  ulceration,  and  growth  of 
granulation-tissue  in  the  middle  ear  and  external  auditory  canal,  so  our  thera- 
peutic eftbrts  must  be  directed  chiefly  to  the  frequent  and  thorough  removal 
of  these  secretions.  In  very  many  cases,  this  part  of  the  treatment  can  be 
carried  out  perfectly  well  by  the  patient  at  home.  According  to  the  activity 
and  the  degree  of  foulness  of  the  discharge,  the  ear  should  be  douched  or 
syringed  from  one  to  four  or  five  times  daily,  either  with  simple,  tepid  water 
or,  preferably,  with  a  warm,  saturated  solution  of  boracic  acid  (about  two 
drachms  to  the  pint).  If  a  sinus  in  the  bone  exists,  or  if  there  is  a  tendency 
to  the  accumulation  of  secretions  in  the  mastoid  antrum,  or  in  the  upper  half 
of  the  tympanic  cavity,  the  surgeon  will  have  to  wash  out  these  regions,  at 
least  tw^o  or  three  times  a  week,  by  the  aid  of  a  suitable  canula  attached  to 
a  gravity-douche,  or  to  a  bulb-syringe.  If  the  skin  of  the  auditory  canal,  or 
the  mucous  membrane  of  the  middle  ear,  be  ulcerated,  or  in  a  granulating 
condition,  at  any  point,  we  must  apply  pure  nitrate  of  silver  to  the  aftected 
spot.  A  bead  of  the  caustic  can  readily  be  fused  upon  the  end  of  a  probe  or 
cotton-holder,  and  by  means  of  such  an  instrument  we  may  readily  cauterize 
only  the  limited  area  that  requires  such  treatment.  A  separate  mass  of 
granulation-tissue,  no  matter  how  small,  can  best  be  gotten  rid  of  by  means 
of  a  wire  snare  or  loop,  such  as  can  be  prepared  in  a  few  moments  in  the 
admirable  instrument  known  as  "  Blake's  snare."  This  instrument,  which 
was  first  described  as  "  Blake's  modification  of  Wilde's  snare,"  is  so  difterent 
from,  and  so  decidedly  superior  to,  the  latter  instrument,  that  I  have  no 
hesitation  in  speaking  of  it  as  simply  Blake's  snare.  (Fig.  957.) 

In  the  case  of  the  smaller  polypoid  growths  of  granulation-tissue,  the  ope- 
ration of  passing  the  loop  of  wire  over  the  growth  is  so  comparatively  simple 
that  no  particular  description  of  it  need  be  given.  In  the  case  of  the  larger 
growths,  of  which  only  the  outer  portion  can  be  seen,  there  may  be  some 


724 


INJURIES  AND  DISEASES  OF  THE  EAR. 


doubt  as  to  what  is  the  best  course  to  pursue  in  removing  them.  If  the 
polypus  is  so  large  as  to  fill  the  outer  orifice,  it  may  be  removed  by  means  of 
an  ordinary  dressing-forceps,  or,  better  still,  by  means  of  a  Hinton's  polypus- 
forceps,  provided  that  the  growth  be  not  of  the  firm,  fibrous  variety.  The 

Fig.  957. 


Blake's  snare ;  somewhat  reduced  in  size. 


mass  should  be  firmly  grasped  between  the  blades  of  the  instrument,  and 
should  then  be  separated  from  its  deeper  attachments  by  a  combined  rotary 
and  pulling  motion,  or  simply  by  direct  traction.  If  the  growth  is  situated 
more  deeply  in  the  canal,  and  reflected  light  is  required  to  render  the  mass 


Fig.  958. 


Proper  method  of  holding  Blake's  snare. 

visible,  such  an  instrument  as  Hinton's  forceps  will  be  found  awkward  to 
manage,  and^  likely  to  produce  pain.  Blake's  snare,  armed  with  malleable 
steel  wire  (size  l^o.  37),  is  the  proper  instrument  to  use  under  these  circum- 
stances. By  aid  of  the  slender,  silver  probe,  the  surgeon  can  ascertain  whether 
the  mass  grows  from  the  cutaneous  walls  of  the  canal,  or  from  the  middle  ear 
or  mastoid  cells.  Where  the  growth  is  of  such  size  as  to  fill  the  canal,  it  is  not 
necessary  that  he  should  satisfy  himself  of  the  exact  situation  of  the  base-  of 
the  polypus  before  applying  the  loop  of  wire.  It  is  suificient  for  him  to 
ascertain  by  actual  probing  that  he  can  pass  his  snare  over  the  mass  to  a 
given  depth  (distance  from  the  orifice  of  the  meatus)  without  encountering 
any  obstacle.  The  loop  is  then  pushed  in  over  the  mass  to  this  depth,  and 
tightened  sufiiciently  to  hold  the  polypus  firmly  in  its  grasp.  If  the  growth- 
be  succulent  and  not  very  firm,  and  especially  if  it  can  easily  be  rotated  about 
its  long  axis,  steady  traction  should  be  made,  in  the  hope  of  pulling  out  the 
polypus,  peduncle  and  all.  In  not  a  few  cases  this  object  will  be  attained  ; 
but  even  if  the  effort  fail  to  remove  the  entire  growth,  at  least  as  much  of 
the  mass  will  be  torn  off  as  would  have  been  if  the  wire  had  been  made  to 
cut  through  the  polypus  instead  of  simply  grasping  it  firmly.  If  the  growth 
is  firm  in  texture,  and  not  easily  rotated,  it  is  better  to  use  the  loop  simply 
as  a  means  of  cutting  off  portions  of  the  growth.  Under  these  circumstances 
traction  should  not  be  employed.  As  soon  as  the  bleeding  has  ceased,  and 
the  portion  cut  off  by  the  wire  loop  has  been  removed  with  the  bent  forceps, 


DISEASES  OF  THE  MIDDLE  EAR.  725 

the  remainder  of  the  growth  is  to  be  treated  in  precisely  the  same  way  as  the 
first  portion.  The  wire  loop  is  to  be  applied  again  and  again  until  the  base 
of  the  growth  has  been  cut  away  to  the  level  of  the  surrounding  mucous 
membrane  or  skin.  If  the  polypoid  mass  springs  from  some  portion  of  the 
external  auditory  canal,  it  will  be  found  as  a  rule  decidedly  firmer  in  texture 
and  more  sensitive  than  one  of  middle-ear  origin.  It  will  also  not  possess 
the  same  degree  of  mobility  as  the  latter.  The  polypi  of  middle-ear  origin, 
we  shall  find,  spring  more" frequently  from  the  upper  and  posterior  portion 
of  the  tympanum  (entrance  to  the  antrum)  than  from  any  other  locality. 

It  is  a  good  rule  in  practice  not  to  resort  to  the  use  of  caustics  until  the 
base  or  peduncle  of  the  polypus  has  been  cut  away  with  the  snare  to  the 
level  of  the  surrounding  parts  (skin  or  mucous  membrane).  Furthermore, 
in  deciding  whether  the"  peduncle  has  been  cut  away  to  the  proper  level,  we 
are  not  to^trust  to  the  sense  of  sight  alone  ;  the  behavior  of  the  peduncle, 
when  circumscribed  by  the  end  of  the  probe,  furnishes  the  only  trustworthy 
guide  to  a  knowledge  of  the  exact  relations  which  this  peduncle  bears  to  the 
surrounding  parts.  When  the  mass  has  been  so  far  extirpated  that  we  can- 
not eiicb'cle'it  with  a  wire,  we  may,  with  benefit  to  the  patient,  resort  to  the 
use  of  caustics  and  astringents. 

In  a  few  cases,  after  the  removal  of  a  polypoid  growth  from  the  ear,  the 
hemorrhage  from  the  divided  vessels  is  quite  active.    This  occurrence,  how- 
ever, need°give  us  no  anxiety,  as  the  bleeding  very  rarely  proves  to  be  exces- 
sive. In  placing  the  loop  of  wire  over  granulation-growths  in  the  immediate 
neighborhood  of  the  middle  ear,  great  care  must  be  taken  not  include  one  of 
the^ossicles,  especially  the  handle  of  the  hammer,  in  the  loop.    After  we  have 
out  away  as  much  of  the  growth  as  w^e  can  with  the  wire  loop,  if  the  remain- 
ing stump  or  base  rise  iii'  the  slightest  degree  above  the  surrounding  level, 
we  should  apply  caustic  to  the  exposed  raw  surface.    Care,  however,  must 
be  taken  not  to  cauterize  the  part  too  deeply.    By  some  excellent  authorities 
chromic  acid  is  preferred  to  nitrate  of  silver  as  a  caustic.    While  I  feel  more 
at  home  in  the  use  of  nitrate  of  silver,  I  am  disposed  to  look  upon  chromic 
acid  as  a  most  useful  caustic.    The  only  objection  that  I  can  raise  against  it, 
is  this :  it  must  be  applied  to  the  afi'ected  part  with  decided  caution,  or  its 
destructive  action  will  extend  to  a  greater  depth  than  is  desirable.  The 
remedy  should  only  be  used  in  a  fluid  state  (after  deliquescence  has  taken 
place),  as  the  old  practice  of  depositing  a  minute  crystal  of  the  acid  upon 
the  part  to  be  cauterized,  often  leads  to  the  development  of  a  severe  and 
troublesome  inflammation.    Furthermore,  it  is  a  good  plan  not  to  make 
caustic  applications  oftener  than  on  every  other  day.    When  we  belieye  that 
we  have  accomplished  all  that  is  necessary  in  the  matter  of  levelling  the 
granulating  area,  we  should  abandon  the  caustic  ti-eatment,  and  apply 
powdered  burnt  alum  to  the  aftected  spot.    We  should  transport  the  alum, 
grain  by  grain,  on  the  moistened  end  of  a  slender  probe,  until  the  part  is 
well  covered  with  the  powder.    The  old  plan  of  blowing  the  powder  indis- 
criminately over  all  the  deeper  parts  of  the  ear,  is  open  to  decided  objections. 
Powdered  iodoform,  or  boracic  acid,  may  safely  be  blown,  in  a  thin  layer, 
over  all  these  parts,  but  it  is  not  good  practice  to  use  alum  in  this  unrestricted 
manner,  as  it  sometimes  greatly  aggravates  the  inflammation  which  we  are 
striving  so  hard  to  control.    Whei^we  find  that  the  ulcerative  process  has 
involved  the  underlying  bone,  we  must  not  be  surprised  if  our  therapeutic 
efforts  prove  only  partially  successful.     Various  plans  of  treatment  have 
been  tried  for  the  cure  of  bone-caries  in  the  outer  or  the  middle  ear,  but 
I  have  not  found  any  of  them  of  special  value.    In  cases  of  this  nature,  I 
carry  out  precisely  the  same  plan  of  treatment  as  that  which  I  have  just 
described.  As  soon  as  I  have  succeeded  in  clearing  the  cavities  of  granulation- 


726 


INJURIES  AND  DISEASES  OF  THE  EAR. 


growths,  I  dismiss  the  patient  with  careful  instructions  about  cleansing  the 
ear  once  or  twice  every  day.  Under  this  plan  of  systematic  cleansing,  the 
bone-disease  is  sometimes  arrested,  and  the  discharge  ceases.  Relapses,  how- 
ever, are  common. 

In  a  few  cases,  as  I  have  already  said,  there  is  no  discoverable  disease  of 
the  bone,  the  external  auditory  canal  appears  to  be  sound,  and  nothing  like 
granulation-tissue  can  be  found  in  the  middle  ear.  The  promptly  successful 
results  of  the  treatment  in  these  cases  warrant  the  conclusion  that  the  only 
pathological  lesion  upon  which  the  discharge  depends,  must  be  a  relaxed 
condition  of  the  mucous  membrane  of  the  middle  ear ;  a  condition  wdiich, 
as  I  have  already  said,  is  probably  characterized  by  paresis  of  the  walls 
of  the  bloodvessels,  and  by  the  consequent  infiltration  of  the  mucous  mem- 
brane with  lymphoid  cells  and  the  watery  elements  of  the  blood.  The 
application  of  a  solution  of  nitrate  of  silver  (from  two  to  five  grains  to  the 
ounce  of  water)  to  the  entire  lining  membrane  of  the  middle  ear,  either  by 
means  of  the  middle-ear  pipette  or  in  some  coarser  manner,  usually  brings 
the  relaxed  mucous  membrane  soon  back  to  a  quiet,  non-secreting  condition. 
In  these  cases,  as  a  matter  of  course,  the  diagnosis  can  only  be  made  after  a 
cure  has  been  effected. 

With  regard  to  the  employment  of  more  general  measures  in  the  treatment 
of  chronic  purulent  inflammation  of  the  middle  ear,  I  must  refer  the  reader 
to  the  remarks  on  acute  purulent  inflammation  of  this  region. 

Diseases  of  the  Mastoid  Process. 

It  has  been  the  custom  to  speak  of  diseases  of  the  mastoid  process  as  if 
they  were  separate  and  distinct  from  the  different  types  of  inflammation  of 
the  middle  ear.  While,  as  a  matter  of  fact,  the  two  groups  of  diseases  are  in- 
separably connected,  as  a  matter  of  expediency  it  is  better  that  this  custom  of 
separating  them  should  be  maintained.  The  mastoid  cells- 
ordinarily  participate  in  whatever  inflammatory  processes 
take  place  in  the  tympanic  cavity,  without  manifesting 
any  symptom  that  is  likely  to  attract  our  attention  to 
that  quarter.  In  some  cases,  however,  the  symptoms 
pointing  particularly  to  this  region  outweigh  the  others, 
and  under  such  circumstances  no  hesitation  need  be  felt 
in  grouping  these  cases  together  under  the  title  of  diseases 
of  the  mastoid  process.  Before  attempting  to  portray  this 
class  of  cases,  I  will  first  describe  briefly  some  of  the  more 
important  anatomical  features  of  the  mastoid  region,  as  it 
will  be  very  difficult,  without  such  knowledge,  to  under- 
stand the  varying  picture  of  mastoid  disease. 

At  birth,  the  mastoid  process  consists  of  a  small,  flat- 
tened tuberosity,  containing  but  one  cell  of  material  size — 
viz.,  the  antrum.  During  the  first  year  of  infancy  this 
cavity  usually  lies  so  near  the  outer  surface  of  the  process 
that  only  a  thin  wall  of  bone,  perhaps  only  a  millimetre 
ill  thickness,  separates  it  from  the  external  periosteum. 
Furthermore,  this  thin  partition  of  bone  is  often  perfo- 
rated b}^  quite  a  large  opening,  through  which  passes  at 
least  one  of  the  mastoid  emissary  veins.  It  is  important 
to  remember  these  relations  of  the  parts  as  they  exist  in 
infancy;  for  without  this  knowledge  we  might  experience  great  alarm  over 
phenomena  which,  indeed,  seem  to  point  to  serious  disease,  but  which  appear 


Fig.  959. 


Mastoid  process  of  a 
child  two  or  three  years 
old.  The  darkly  shaded 
region,  above  and  toward 
the  left,  represents  the 
antrum.  A  large  pneuma- 
tic cell,  whose  thin  outer 
■wall  of  bone  has  been 
broken  away,  may  be  seen 
a  little  above  the  tip  of 
the  process. 


DISEASES  OF  THE  MASTOID  PROCESS. 


727 


comparatively  harmless  when  interpreted  in  the  light  of  the  anatomical  rela- 
tions which  I  have  just  described.  The  phenomena  to  which  I  refer  are 
these :  A  large  swelling  develops  rather  rapidly  behind  the  ear  of  an  infant, 
who  has  been  fretful  and  feverish  for  a  few  days.  There  may  or  may  not 
have  been  a  slight  discharge  from  the  are;  but  if  there  have  been  a  dis- 
charge, it  will  have  ceased  before  the  swelling  makes  its  appearance.  From 
the  fluctuation,  which  is  readily  discoverable,  from  the  inflamed  appearance 
of  the  neighboring  skin,  and  from  the  elevation  of  the  body-temperature,  it 
becomes  reasonabl}^  certain  that  the  swelling  represents  an  abscess.  An  in- 
cision is  then  made,  and  the  correctness  of  the  diagnosis  is  established;  the 
recovery  that  follows  is  rapid  and  complete.  I  have  had  the  opportunity 
of  examining  the  ear  in  two  or  three  such  cases,  and  have  satisfied  myself 
that  the  pathology  of  these  abscesses  is  simply  this  :  The  resistance  offered  . 
to  the  pus  accumulating  in  the  cavities  of  the  middle  ear,  happens  to  be  less 
in  the  direction  of  the  mastoid  integuments  than  in  that  of  the  membrana 
tympani,  and  the  pus  accordingly  forces  a  way  for  itself  in  this  direction 
rather  than  through  the  tissues  of  the  drum-membrane.  The  abscess  is 
not,  as  in  adult  life,  an  indication  of  a  severe  and  unchecked  inflammation  of 
the  middle  ear,  but  simply  a  revelation  of  the  peculiarly  free  communication 
which  happens  to  exist  betw^een  the  antrum  and  the  outer  surface  of  the 
mastoid  bone.  The  absence  of  any  marked  swelling  of  the  walls  of  the  audi- 
tory canal  shows  clearly,  in  these  cases,  that  the  pus  has  not  travelled  out- 
ward— as  we  occasionally  see  it  travel  in  older  individuals— between  the 
bone  and  the  skin  of  the  external  meatus. 

The  anatomical  relations  of  the  antrum,  in  infantile  life,  have  other  impoi  - 
tant  bearings  of  a  practical  nature.  In  the  first  place,  the  outer  bony  wall 
of  this  cavity  is  quite  easily  broken,  at  this 
period  of  life,  by  moderately  firm  pressure 
with  some  hard  instrument.  It  is  therefore 
easy  to  penetrate  from  without  into  the  an- 
trum, Avhenever  the  condition  of  the  ear  seems 
to  call  for  such  a  procedure.  In  the  next 
place,  counter-irritation  behind  the  ear,  in 
quite  young  children,  often  produces  promptly 
beneficial  effects  upon  a  sluggish  inflammation 
of  the  middle  ear.  The  explanation  of  this 
fact  may  be  sought  for  in  this  peculiar  near- 
ness of  the  antrum  to  the  skin  covering  the 
mastoid  process,  and  in  the  intimate  vascular 
and  nervous  relations  that  exist  between  the 
two  regions. 

The  mastoid  process  of  a  child,  four  or  five 
years  of  age,  already  presents  all  the  essential 
features  of  that  belonging  to  a  full-grown  adult. 
It  is  smaller,  however,  and  the  bone  substance 
is  still  somewhat  less  dense  and  firm  than  it  is 
in  adult  life.  Even  in  its  fully  developed  state, 
the  mastoid  bone  will  be  found  to  vary  greatly 
in  size  in  different  individuals.  I  can  give  no 
exact  measurements,  as  the  limits  of  the  mas- 
toid portion  of  the  temporal  bone  are  not 
vsharply  defined.  I  have  a  specimen,  however, 
in  which  the  distance  between  the  upper  and 
lower  limits  of  the  mastoid  cells  measures  an  inch  and  three  quarters,  w^hile 
horizontally  the  extreme  limits  are  an  inch  and  a  quarter  apart.    This  speci- 


Fig.  960. 


Mastoid  process  of  adult.  Transverse, 
vertical  section. 


728  INJURIES  AND  DISEASES  OF  THE  EAR. 

men,  I  am  satisfied,  must  be  considered  as  an  unusually  large  one,  for  among 
a  number  of  temporal  bones  in  my  possession,  I  can  find  no  otber  in  which 
the  mastoid  cells  are  of  equally  great  extent.  Strictly  speaking,  the  term 
mastoid  process  refers  only  to  the  lower,  teat-like  projection  of  the  bone,  but 
in  this  article,  and  in  fact  in  medical  parlance  generally,  the  expression  is 
intended  to  refer  to  all  that  portion  of  the  temporal  bone  which  contains  the 
honeycombed  structure  usually  found  in  the  mastoid  process.  This  peculiar 
structure  consists  of  a  number  of  small  cavities  or  cells,  which  vary  greatly 
in  size  and  shape,  not  only  in  the  same  temporal  bone,  but  also  in  those  be^ 
longing  to  difierent  individuals.  Many  of  these  cells,  probably  the  great  ma- 
jority of  them,  are  lined  with  an  extension  of  the  mucous  membrane  of  the 
tympanum,  and  communicate  one  with  another.  Under  normal  conditions 
they  contain  air,  and  are  therefore  spoken  of  as  the  pneumatic  cells.  The 
remaining  cavities  are  filled  with  a  fatty  tissue  resembling  that  which  is  found 
in  the  diploe  of  fresh  bones.  Zuckerkandl,  who  examined  one  hundred  mas- 
toid processes  in  the  fresh  state,  and  one  hundred  and  fifty  macerated  tempo- 
ral bones,  foand  that  air-cavities  were  wholly  lacking  in  twenty  per  cent,  of  the 
specimens,  and  that  perfectly  pneumatic  mastoid  processes,  without  any  dip- 
loetic  spaces,  represented  only  38.6  per  cent,  of  the  entire  number.  Further- 
more, he  ascertained  the  fact  that  in  some  individuals  only  the  lower  half  of 
the  process  was  diploetic,  while  the  upper  half  was  entirely  pneumatic.  These 
comparatively  recent  researches  throw  a  great  deal  of  light  upon  the  pathology 
of  acute  and  chronic  purulent  affections  of  the  middle  ear.  They  make^it 
easy  to  comprehend  how  in  one  individual,  whose  mastoid  cells  are  quite 
large  and  communicate  freely  one  with  another,  an  inflammation  of  the  mid- 
dle ear  may,  almost  at  the  very  onset  of  the  attack,  involve  the  mastoid 
region,  while  in  another  the  same  disease,  in  perhaps  a  far  more  severe  form, 
will  leave  this  region  wholly  unaffected.  Unfortunately,  Zuckerkandl's 
researches  do-not  show  whether  we  are  permitted  to  consider  the  absence  of 
pneumatic  cells,  in  the  specimens  examined  by  him,  as  a  perfectly  natural 
peculiarity  of  construction,  or  whether  these  spaces  may  not  have  been  oblite- 
rated by  an  unnatural  hypertrophy  of  the  bone,  the  result  of  disease. 

We  must  next  consider  the  mastoid  cells  in  their  relations  to  neighboring 
parts.  Superiorly,  they  may  extend  as  high  as  to  within  half  an  inch  of  the 
temporo-parietal  suture.  In  this  comparatively  thin  part  of  the  temporal 
bone,  they  are  separated  on  the  outer  side  from  the  periosteum,  and  on  the 
inner  side  from  the  dura  mater,  by  a  dense  layer  of  bone,  which  varies  from 
one  to  three  millimetres  in  thickness.  Anteriorly,  the  pneumatic  cells  extend 
forward  over  the  external  auditory  canal.  Posteriorly,  they  cease  somewhat 
abruptly,  that  is,  without  any  material  diminution  in  size,  in  the  immediate 
vicinity  of  the  temporo-occipital  suture.  Hyrtl,  according  to  the  authority 
of  Schwartze,  found  three  skulls  (among  six  hundred  which  he  examined  for 
this  purpose)  in  which  the  pneumatic  cells  extended  even  into  the  occipital 
bone.  I  once,  in  trephining  the  skull,  found  pus  between  the  outer  and  inner 
tables  of  the  occipital  bone,  a  short  distance  back  of  the  temporo-occipital 
suture,  and  thought,  at  the  time,  tliat  it  had  travelled  along  the  diploetic 
spaces  from  a  large  abscess  which  existed  in  the  body  of  the  mastoid  process. 
In  the  light  of  Ilyrtl's  discovery,  it  now  seems  to  me  at  least  equally  probable 
that  the  pus  found  at  this  remote  spot  was  really  lying  in  pneumatic  spaces 
which  stood  in  direct  communication  "with  those  immediately  surrounding 
the  abscess.  The  lateral  sinus  occupies  a  groove  in  the  bone  in  the  immediate 
vicinity  of  the  posterior  limits  of  the  mastoid  cells.  J^ot  far  from  the  centre 
of  the  irregularly  shaped  mass  of  mastoid  cells,  but  much  nearer  to  their  inner 
than  to  their  outer  limit,  lies  a  single  cavity,  known  by  the  name  of  the 
"antrum,"  or  "horizontal  portion  of  the  mastoid  cells,"  as  it  is  termed  by 


DISEASES  OF  THE  MASTOID  PROCESS. 


729 


Toynbee.  It  opens  anteriorly,  by  a  comparatively  large  mouth,  into  the 
tympanum  proper.  Its  floor  usually  lies  at  a  higher  level  than  that  of  the 
tympanum.  Its  walls  present  a  honeycombed  appearance,  which  is  due  to 
the  presence  of  numerous  openings  leading  into  the  surrounding  pneumatic 

Fig.  961. 


Extensive  distribution  of  mastoid  cells. 

cells.  A  medium-sized  pea  would  probably  fill  the  antrum.  Pneumatic 
cells  are  found  on  the  hmer  and  posterior  sides  of  this  cavity  as  well  as  on 
its  outer  side.  They  also  extend  to  a  considerable  depth  beneath  its  floor. 
In  fact,  they  are  absent  only  along  the  roof  of  the  cavity.  At  this  point  a 
comparatively  thin  lamina  of  dense  bone,  often  less  than  a  millimetre  in 
thickness,  serves  as  a  dividing  partition  between  the  dura  mater  above  and 
the  tympanic  mucous  membrane  below.  The  distance  from  the  posterior 
extremity  of  the  antrum  to  the  groove  for  the  lateral  sinus,  varies  from  three 
to  six  millimetres  (see  Fig.  960);  that  from  the  outer  wall  of  the  cavity  to 
the  outer  surface  of  the  bone,  varies  from  twelve  to  twenty  millimetres  (one- 
half  to  three-fourths  of  an  inch).  In  cases  of  hyperostosis  the  antrum  may  be 
found  to  lie  at  even  a  greater  distance  from  the  outer  surface  of  the  bone. 
Finally,  there  are  several  points  at  which  the  bone  surrounding  the  antrum 
is  pierced  by  small  channels  which  give  passage  to  bloodvessels  and  lymph- 
vessels,  and  their  shea.ths  of  connective  tissue.  The  most  important  of  these 
are:  the  petro-squamous  fissure,  which  crosses  the  bony  roof  that  is  common 
to  both  cavities  (the  tympanum  and  the  antrum) ;  and  the  channels  for  the 
mastoid  emissary  veins,  which  traverse  the  bone  from  within  outward.  One 
of  these  canals  commonly  opens  near  the  centre  of  the  outer  surface  of  the 
process,  about  on  a  level  with  the  upper  wall  of  the  external  auditory  canal. 
Minute  bloodvessels  pass  from  the  mucous  membrane  of  the  middle  ear  to 
the  dura  mater  by  way  of  the  petro-squamous  fissure,  and  by  the  same  route 
an  inflammation  may  spread  from  the  ear  to  the  brain.  The  redness,  tender- 
oess,  and  swelling  of  the  mastoid  integuments,  in  cases  of  inflammation  of  the 


730 


INJURIES  AND  DISEASES  OF  THE  EAR. 


middle  ear,  may  be  explained  by  the  assumption  that  the  inflammation  has 
followed  the  course  of  the  mastoid  emissary  veins.    Finally,  I  have  still 

to  mention  the  close  proximity  of  the 
facial  canal  to  the  mastoid  cells.  In  the 
immediate  neighborhood  of  the  mouth  of 
the  antrum,  this  canal  turns  sharply  from 
its  previous  horizontal  course,  and  passes 
directly  downward  through  the  pneumatic 
and  diploetic  cells  of  the  mastoid  bone.  It 
is  therefore  easy  to  understand  why  the  fa- 
cial nerve  should  be  particularly  liable  to 
participate  in  any  pathological  changes 
that  may  take  place  in  the  mastoid  cells. 

Although  the  antrum  and  the  tympanic 
cavity  proper  are,  to  all  intents  and  pur- 
poses, one  and  the  same  region,  and 
although  we  have  no  just  grounds  for  believing  that,  in  an  acute  inflammation 
of  the  middle  ear,  the  larger  cavity  of  the  tympanum  is  much  more  actively 
involved  in  the  disease  than  the  smaller  cavity  of  the  antrum,  we  are  apt, 
it  appears  to  me,  to  entertain  this  very  belief.  Our  patients  would  fare 
better,  I  am  confldent,  if  we  adopted  the  more  rational  view,  and  utilized 
the  degree  of  inflammation  presented  by  the  drum-membrane  and  visible, 
adjacent  parts,  as  a  fairly  true  measure  of  that  which  must  at  the  same  time 
be  going  on  in  the  antrum.  In  this  connection,  however,  we  must  remember 
that  in  a  few  exceptional  cases  the  membrana  tympani  may  show  compara- 
tively insignificant  evidences  of  inflammation,  and  yet  an  abscess  may  be 
present  in  the  adjacent  mastoid  process.  The  mechanical  relations  of  the 
tympanum  propBr,  the  antrum,  and  the  pneumatic  cells  of  the  mastoid 
process,  exert  a  determining  influence  upon  the  course  of  the  inflammation 
that  may  from  any  cause  be  excited  in  them.  At  almost  the  very  outset  of 
such  an  inflammation,  the  only  natural  outlet  which  these  cavities  possess, 
viz.,  the  Eustachian  tube,  becomes  closed  by  the  swelling  of  its  walls.  The 
conditions  then  are  those  of  an  inflammation  taking  place  in  a  cavity  whose 
walls,  at  every  point  but  one,  consist  of  unyielding  bone.  The  membrana 
tympani  represents  the  only  point  at  which  the  accumulating  products  of  the 
inflammation  can  force  a  way  of  escape  for  themselves.  In  a  few  instances 
the  case  may  be  in  even  a  worse  plight  than  that  which  I  have  just  described. 
For  example,  the  mouth  of  the  antrum,  or  the  mouths  of  the  numerous 
pneumatic  cavities  which  open  directly  into  the  antrum,  may  become  closed  ; 
in  which  event  the  establishment  of  even  a  very  free  opening  in  the  mem- 
brana tympani  would  fail  to  afford  an  exit  for  the  secretions  confined  in 
those  more  remotely  situated  cavities.  This  occurrence  is,  I  believe,  not 
uncommon.  The  question  then  presents  itself,  what  is  likely  to  be  the 
succession  of  pathological  events  if  the  products  of  inflammation  are  allowed 
to  remain  pent  up  in  these  cavities  ?  If  we  possess  some  knowledge  with 
regard  to  the  individual's  previous  aural  history,  we  may  form  a  tolerably 
correct  notion  of  v\'hat  is  likely  to  take  place  in  these  inflamed  parts.  In  an 
individual  who  has  not  been  subject  to  frequent  or  prolonged  attacks  of 
discharge  from  the  ear,  we  may  assume  that  the  pneumatic  cells  still  contained 
air  at  the  time  of  the  attack.  In  that  case,  the  inflammatory  exudation  in 
the  cells  will  soon  change  from  a  mere  bloody  serum  to  a  thick  pus,  and,  as 
the  pressure  increases,  the  lining  mucous  membrane  of  many  of  the  cells 
will  die  and  break  down  into  purulent  detritus.  Even  the  thin  bony  parti- 
tions may  soften  and  become  detached.  At  all  events,  loose  fragments  of  the 


Fig.  962. 


Relations  of  facial  canal  to  middle  ear  proper 
and  mastoid  cells  ;  oblique,  vertical  section  of 
temporal  bone. 


DISEASES  OF  THE  MASTOID  PROCESS. 


731 


bony  septa  are  sometimes  found  in  recent  abscesses  of  the  mastoid  process. 
In  favorable  cases,  the  pus  may  burrow  a  way  for  itself  along  one  of  the 
emissary  canals,  and  pour  its  contents  into  the  space  between  the  outer 
surface  of  the  bone  and  the  periosteum,  and  through  the  latter  into  the 
cellular  tissues  behind  the  ear;  or  it  may  travel  downward  and  develop  an 
abscess  in  the  soft  parts  below  the  mastoid  process,  between  the  skin  and  the 
muscles  of  the  neck.  In  a  third  series  of  cases,  the  pus  may  work  for  itself 
a  channel  through  the  mass  of  bone  wdiich  separates  the  floor  and  anterior 
part  of  the  antrum  from  the  upper  and  posterior  wall  of  the  auditory  canal. 
Finally,  it  the  resistance  in  these  directions  be  too  great,  or  if  the  channels 
of  communication  between  the  antrum  and  the  intra-cranial  cavity  be  unusu- 
ally free,  pus  will  And  its  way  to  the  latter  region,  and  w\\\  induce  either  a 
diffuse  meningitis  or  an  abscess  in  the  very  substance  of  the  brain.  It  is 
possible,  also,  that  in  recent  cases  a  carious  process  maybe  set  up  in  that  part 
of  the  bone  which  lies  next  to  the  groove  for  the  lateral  sinus,  and  that 
ulceration  of  this  vein,  with  accompanying  phlebitis,  pyaemia,  etc.,  may  result 
therefrom.  This  issue,  how^ever,  is  to  be  looked  for  rather  in  chronic  cases, 
in  which  the  main  portion  of  the  pneumatic  cells  has  been  obliterated  by 
sclerosis. 

If  a  severe  inffammation  of  the  middle  ear  goes  on  unchecked,  in  an  indi- 
vidual whose  previous  aural  history  points  to  the  frequent  occurrence  or 
prolonged  continuance  of  a  discharge  from  this  region,  we  may  assume,  with 
considerable  confidence,  that  the  majority  of  the  pneumatic  cells  have  become 
obliterated  through  a  process  of  sclerosis.  It  will  be  seen  at  once  that  in 
such  an  ear  the  chances  of  a  spontaneous  cure  are  seriously  diminished. 
When  the  antrum,  in  such  a  case,  takes  on  a  more  acute  type  of  inflammation, 
and  when  at  the  same  time  its  natural  outlet  becomes  obstructed  or  closed, 
the  confined  pus  can  no  longer  burrow  a  way  for  itself  outw^ard  through  the 
thick  mass  of  ivory-like  bone.  The  bony  roof  of  the  antrum  is  then  likely 
to  become  carious,  and  the  pus  finds  an  outlet  in  this  dangerous  direction. 
Or  the  mass  of  bone  which  separates  the  antrum  from  the  lateral  sinus,  and 
which,  I  believe,  is  largely  composed  of  diploetic  spaces,  breaks  down  under 
the  effects  of  caries,  and  then  the  fatal  issue  is  not  long  delayed. 

In  addition  to  these  destructive  forms  of  inflammation  of  the  mastoid 
process,  there  is  one  which  partakes  rather  of  the  nature  of  hypernutrition 
of  the  bone.  To  this  form,  which  leads  to  the  condition  known  as  sclerosis 
of  the  mastoid  cells^  w^e  shall  give  the  name  of  condensing  osteitis  of  the  mastoid 
process.  This  type  of  mastoid  inflammation  has  now  been  accepted,  thanks 
chiefly  to  the  w^ritings  of  Dr.  J.  Orne  Green,  of  Boston,  as  a  fairly  distinct 
disease,  characterized  by  certain  well-marked  symptoms,  and  requiring,  for 
the  relief  of  the  most  prominent  of  these,  a  particular  therapeutic  procedure. 
A  chronic  hyperaemia  of  the  mucous  membrane  lining  the  pneumatic  cells, 
and  also  of  the  vascular  connective  tissue  that  fills  the  diploetic  spaces,  un- 
doubtedly constitutes  the  essence  of  this  osteitis.  A  chronic  inflammation  of 
the  mucous  membrane  of  the  tympanum  proper,  and  of  the  antrum,  furnishes 
the  provocation  for  this  hyper?emia.  Increase  in  the  amount  of  bone  follows 
this  chronic  hyper?emia,  and  in  the  course  of  time  this  increase  may  even  go 
so  far  as  to  obliterate  the  pneumatic  spaces  entirely.  The  constantly  increas- 
ing pressure  exerted  upon  the  mucous  membrane  lining  these  spaces,  explains 
the  severe  pain  experienced  by  patients  who  are  aftected  with  this  disease. 

A  periostitis  of  the  mastoid  process  is  always,  I  believe,  to  be  interpreted 
as  the  result  of  direct  violence  (a  blow  or  a  fall),  or  as  an  extension  of  an 
inflammation,  located  either  in  the  external  auditory  canal  or  in  the  mastoid 
cells.    I  have  never  seen  anything  that  I  could  consider  as  a  primary,  idio- 


732 


INJURIES  AND  DISEASES  OF  THE  EAR. 


pathic,  mastoid  periostitis,  although  such  a  disease  has  been  described  by 
different  writers  on  otology. 

In  actual  practice  we  find  that  no  two  cases  of  mastoid  disease  are  exactly 
alike.  At  the  same  time,  it  is  not  a  difficult  matter  to  distinguish  among 
them  a  few  groups,  in  each  of  which  there  are  certain  distinguishing  features 
which  belong  to  the  members  of  the  group  in  common.  Formerly  I  made 
a  subdivision  of  these  cases  into  five  groups,  but  I  am  satisfied  now  that  it 
is  a  better  plan  not  to  recognize  more  than  three  types  of  mastoid  disease. 
They  are  as  follows :  (1)  Subacute,  condensing,  mastoid  osteitis ;  (2)  Acute, 
diffuse,  mastoid  osteitis ;  (3)  Chronic  ulcerative  inflammation  of  the  mastoid 
antrum.  These  three  groups  difter  materially  from  the  three  classes  into 
which  I  have  divided  mastoid  affections  in  my  work  on  ear  diseases.  It  is 
my  belief  and  hope  that  this  new  subdivision,  which  simplifies  the  subject 
considerably,  will  enable  the  practitioner  to  arrive  more  quickly  and  surely 
at  a  correct  diagnosis. 

Subacute  Condensing  Mastoid  Osteitis. — {Sclerosis  or  Hyperostosis  of  the 
Mastoid  Process.) — ^It  is  only  a  short  time  since  the  independent  nature  of  this 
affection  has  been  made  known  to  us.  It  owes  its  origin  to  a  chronic  puru- 
lent inflammation  of  the  antrum  and  other  parts  of  the  middle  ear,  but  it  may 
continue  as  an  active  disease  for  some  time  after  the  exciting  cause  has  been 
removed.  In  very  many  cases  it  probably  runs  its  course  without  giving 
rise  to  any  decided  symptoms,  but  in  other  instances  severe  pain  and  outward 
evidences  of  mastoid  periostitis  accompany  the  disease  and  reveal  its  exist- 
ence to  us.  The  protracted,  subacute  inflammation  of  the  mucous  membrane 
which  lines  the  pneumatic  cells,  and  also  probably  of  the  connective  tissue 
which  fills  the  diploetic  spaces,  leads  to  the  gradual  filling  up  of  both  these 
cavities  with  bone  substance.  This  form  of  osteitis  rarely  comes  before  us  as 
a  disease  requiring  treatment.  It  usually  assumes  importance  when  we  are 
called  upon  to  investigate  and  treat  the  other  varieties  of  mastoid  disease. 
The  question  is  then  sure  to  present  itself:  What  is  the  condition  of  the  mas- 
toid cells  which  lie  between  the  antrum  and  the  outer  surface  of  the  bone  ?  The 
following  rule  may  safely  guide  us  under  these  circumstances :  If  the  history 
of  the  case  reveal  the  previous  existence  of  chronic  purulent  inflammation  of 
the  middle  ear,  we  may  assume  that  the  mastoid  cells  have  been  greatly 
reduced  in  size,  if  not  obliterated,  by  earlier  attacks  of  subacute  osteitis.  In 
the  few  cases  of  condensing  osteitis  which  are  likely  to  come  under  our 
observation  because  they  require  treatment  for  the  disease  itself,  we  may  very 
readily  be  led  into  the  error  of  supposing  that  we  are  dealing  with  a  case  in 
which  the  essential  lesion  is  an  acute,  diffuse,  mastoid  osteitis  of  a  serious 
nature.  The  pain  is  sometimes  so  severe  that  no  other  diagnosis  seems  pos- 
sible. Under  these  circumstances,  we  may  be  guided  by  the  following  con- 
siderations :  If  the  case  be  one  of  simple,  condensing,  mastoid  osteitis,  our 
attention  cannot  fail  to  be  drawn  to  the  persistence  of  decided  pain  in  and 
around  the  mastoid  region,  despite  the  existence  of  an  adequate  outlet  in  the 
drum-membrane  for  the  pus  secreted  in  the  middle  ear,  despite  the  absence  of 
anything  like  an  acute  inflammation  of  the  middle  ear  or  external  auditory 
canal,  or,  finally,  despite  the  employment  of  such  therapeutic  measures  as 
would  be  likely  to  allay  any  ordinary  inflammation  of  the  mastoid  structures. 
Furthermore,  if,  in  addition  to  the  pain,  there  be  redness,  tenderness,  and 
swelling  of  the  mastoid  integuments — in  the  supposed  case  which  we  are  now 
considering — these  manifestations  must  be  interpreted  as  furnishing  corro- 
borative evidence  of  the  existence  of  a  persistent,  subacute  inflammation  of 
the  underlying  bony  structures.    Actual  enlargement  of  the  bone  itself  may 


DISEASES  OF  THE  MASTOID  PROCESS.* 


738 


be  considered  as  furnishing  almost  positive  proof  that  the  mastoid  cells  have 
been  obliterated,  or  are  still  being  obliterated,  by  a  process  of  hyperostosis. 

As  far  as  the  affection  itself  is  concerned,  the  prognosis  is  by  no  means  bad. 
The  obliteration  of  the  mastoid  cells  by  the  conversion  of  all  this  part  of  the 
mastoid  process  into  solid  bone,  is  apt  to  do  harm  o\\\y  in  two  ways  :  It  shuts 
off  the  possibility  of  a  spontaneous  cure  in  the  event  of  the  development  of 
serious  inflammation  in  the  antrum  ;  and  it  is  also  apt  to  prevent  the  develop- 
ment of  those  outward  evidences  which  afford  so  valuable  a  warning  of  the 
existence  of  deep-seated  disease  in  this  part. 

T'reatinent. — Hot  poultices,  leeches,  and  even  Wilde's  incision,  will  probably 
fail  to  give  more  than  temporary  relief  If  such  prove  to  be  the  case,  and  if 
the  pain  continue  unabated,  we  should  not  hesitate  to  resort  to  perforation  of 
the  painful  bone,  with  a  drill  or  other  suitable  instrument.  One  opening  will 
probably  suffice,  provided  that  it  be  carried  to  a  depth  of  full}^  half  an  inch. 
As  the  beneflcial  effects  of  this  operation,  in  a  case  of  this  nature,  depend  not 
upon  the  establishment  of  an  outlet  for  pent-up  products  of  inflammation,  but 
rather  upon  the  derivative  eflects  exerted  by  such  a  wound  in  the  bone,  no 
effort  need  be  made  to  reach  the  antrum.  A  straight,  vertical  incision  may 
therefore  be  made  through  the  mastoid  integuments,  and  the  point  of  the 
drill  may  be  applied  as  far  in  front  of  this  line,  on  a  level  with  the  upper  w^all 
of  the  meatus,  as  the  stretching  of  the  divided  periosteum  will  permit.  The 
healing  of  the  wound  may  be  delayed  to  advantage,  by  inserting  into  it  a 
tent  of  sheet-lint,  well  anointed  with  carbolated  vaseline.  At  the  end  of 
twenty-four,  or  at  the  most  forty-eight  hours,  the  tent  should  be  removed. 
In  addition  to  these  measures,  which  are  directed  more  particularly  to  the 
osteitis,  we  must  not  neglect  to  do  whatever  may  be  found  necessary  for  the 
relief  of  the  disease  which  involves  the  middle  ear  proper.  The  systematic 
cleansing  of  the  antrum,  by  means  of  the  douche,  w^ill  often  be  found  to  serve 
an  excellent  purpose  in  these  cases,  though  as  a  matter  of  course  the  local 
conditions  may  not  always  be  such  that  we  can  resort  to  this  procedure. 

Acute  Diffuse  Mastoid  Osteitis. — This  variety  of  mastoid  disease  in- 
cludes all  the  different  degrees  of  inflammation  which  may  develop  in  a  pre- 
viously healthy  mastoid  process.  A  widespread  congestion  of  the  antrum 
and  pneumatic  cells  represents,  therefore,  the  simplest  type.  The  inflamma- 
tion may  cease  spontaneously,  or  may  be  arrested  by  therapeutic  interference, 
when  it  has  reached  this  stage,  and  the  parts  may  then  gradually  return  to 
their  normal  condition.  However,  if  the  inflammation  continue,  both  the 
antrum  and  the  pneumatic  cells  will  soon  be  filled  with  exudation,  and 
whatever  be  the  character  of  this  exudation  at  first,  it  is  sure  before  long  to 
become  distinctly  purulent.  I  think  it  possible  that,  even  after  the  disease 
has  reached  this  advanced  stage,  a  spontaneous  recovery  may  still,  under 
favorable  circumstances,  take  place,  without  the  formation  of  an  abscess  in 
the  bone.  I  may  mention,  as  one  of  these  favorable  circumstances,  the 
sudden  escape  of  part  of  the  exudation,  through  one  of  the  channels  which 
naturally  give  passage  to  the  mastoia  emissary  veins,  into  the  soft  parts  on 
the  side  of  the  neck.  It  is  more  likely,  however,  that  the  disease,  if  left  to 
itself,  will  pass  from  this  second  stage  into  a  third,  which  is  characterized 
by  the  death  of  some  part  or  parts  of  the  mastoid  process.  Pressure  con- 
tinued beyond  a  certain  period  is  sure  to  result  in  the  death  of  the  mucous 
membrane  pressed  upon  ;  and,  in  the  case  of  the  pneumatic  cells,  the  mucous 
membrane  is  probably  the  only  source  of  nourishment  which  very  many  of 
them  possess.  Hence  the  death  of  those  bony  septa  which  have  been  de- 
prived of  their  periosteal  coverings.  Softening  and  disintegration  of  the 
bone  follow  next  in  order,  and,  if  the  pressure  continue,  w^e  may  expect  the 


734 


INJURIES  AND  DISEASES  OF  THE  EAR. 


area  of  dead  bone  to  increase.  In  cases  belonging  to  this  second  group  of 
mastoid  affections,  this  progressive  death  and  ulceration  of  the  bone  are  for- 
tunately somewhat  more  likely  to  follow  an  outward  course  tow^ard  the  skin 
than  an  upward  direction  toward  the  brain,  or  a  backward  one  toward  the 
lateral  sinus.  In  this  way  a  spontaneous  cure  has  often  taken  place,  the  pus 
finding  an  outlet  through  a  carious  channel  in  the  outer  part  of  the  mas- 
toid bone.  I  have  said  that  such  a  favorable  issue  is  somewhat  more  likely 
to  take  place  than  the  fatal  one  which  is  sure  to  follow  ulceration  either 
toward  the  lateral  sinus  or  toward  the  brain,  but  I  base  my  statement  simply 
on  an  impression,  and  consequently  I  may  easily  be  in  error  with  regard  to 
this  point ;  and  it  is  at  least  certain  that  the  fatal  cases  belonging  to  this 
second  group  are  numerous  enough  to  warn  us  against  trusting  very  much  to 
the  chances  of  spontaneous  cure. 

The  symptomatology  of  this  form  of  mastoid  disease  is  at  first  precisely  the 
same  as  that  of  an  ordinary,  acute,  purulent  inflammation  of  the  middle  ear. 
The  pain,  however,  shows  a  marked  tendency  to  persist,  even  when  active  meas- 
ures are  adopted  for  the  purpose  of  alleviating  it,  and  is  apt  gradually  to  in- 
volve the  entire  side  of  the  head.  Usually  there  is  a  moderate  elevation  of  the 
body-temperature,  though  I  have  known  even  this  symptom  to  be  lacking. 
In  a  boy  of  eighteen,  I  once  noted,  just  before  establishing  an  artificial  open- 
ing in  the  mastoid  bone,  a  temperature  of  105°  Fahr.  This  is  the  highest 
temperature  that  I  have  ever  observed  in  a  case  of  acute  inflammation  of  the 
ear.    It  fell  to  99°  T.  soon  after  the  operation.    Kedness,  tenderness,  and 


Fig.  963. 


Henle's  diagram  showing  relations  of  all  parts  of  the  temporal  hone  to  each  other.  1,  Varions  cavities  consti- 
tuting the  labyrinth  ;  2,  External  auditory  canal;  2',  Tympanum  ;  2",  Pharyngeal  mouth  of  the  Eustachian  tube. 
3,  Vault  of  pharynx.  4,  Cartilaginous  framework  of  auricle.  5,  Inner  cartilaginous  lip  of  orifice  of  Eustachian 
tube  ;  5'  Cartilaginous  plate  at  tympanic  orifice  of  Eustachian  tube.  6,  Pterygoid  process  of  sphenoid  bone.  7, 
Mastoid  cells.  8,  Glenoid  fossa  of  temporal  bone,  *  Membraua  tynipani.  A m  a,  Mastoid  antrum.  Cca,  Carotid 
canal.  M  a  i,  Meatus  auditorius  internus.  O,  Basilar  process  of  occipital  bone.  S,  Sphenoid  bone.  T,  Temporal 
bone.   Z,  Zygoma. 

swelling  of  the  skin  covering  the  mastoid  process,  indicate  the  existence  of 
a  mastoid  periostitis ;  and  the  development  of  a  mastoid  periostitis,  in  the 
progress  of  an  undoubted  acute  inflammation  of  the  middle  ear,  admits  of 
only  one  interpretation,  viz.,  it  indicates  the  existence  of  an  inflammation  of 


DISEASES  OF  THE  MASTOID  PROCESS. 


735 


the  mastoid  cells.  Unfortunately,  it  does  not  indicate  liow  far  the  inflamma- 
tion has  progressed,  but  this  important  fact  can  be  ascertained  approximately 
in  other  ways.  For  example,  the  degree  of  redness  and  swelling  of  the  upper 
and  posterior  cutaneous  wall  of  the  auditory  canal,  in  the  neighborhood  of 
the  membrana  tympani,  furnishes  a  safe  criterion  of  the  activity  of  the 
inflammation  in  the  antrum.  A  glance  at  Fig.  963  will  show  how  near  the 
cavities  are  to  each  other  at  this  point.  The  duration  and  severity  of  the 
pain,  both  in  tiie  mastoid  region  and  throughout  the  entire  side  of  the  head, 
must  also  be  remembered  when  we  are  endeavoring  to  decide  in  our  minds 
what  is  the  exact  condition  of  the  mastoid  structures.  In  the  presence,  there- 
fore, of  well-marked  mastoid  periostitis,  of  decided  redness  and  appreciable 
swelling  of  the  skin  along  the  posterior  and  upper  wall  of  the  meatus,  close 
to  the  clrum-membrane,  and  of  a  history  of  pain  behind  the  ear  and  through- 
out the  entire  side  of  the  head  for  a  period  of  not  less  than  one  week,  we 
may  unhesitatingly  assume  that  the  inflammation  of  the  antrum  and  pneu- 
matic cells  has  reached  a  stage  in  which  pus  has  certainly  formed  in  the 
antrum,  and  probably  in  many  of  the  pneumatic  cells.  If  a  prolapse  of  the 
posterior  and  upper  cutaneous  wall  of  the  meatus  has  already  taken  place, 
we  can  feel  confident  that  the  disease  has  gone  even  farther,  and  that  caries 
is  liable  to  ensue  at  any  time  if  it  have  not  already  occurred.  This  droop- 
ing or  separation  of  the  skin  from  that  portion  of  the  bony  wall  which 
serves  at  the  same  time  as  the  floor  or  anterior  wall  of  the  antrum,  indicates 
a  high  degree  of  inflammation  in  this  particular  region  of  bone ;  and  if 
the  adjacent  body  of  the  mastoid  process  is  still  pneumatic — and,  in  the  class 
of  cases  which  we  are  now  considering,  we  have  a  right  to  assume  that  it  is 
still  in  that  condition — it  is  scarcely  conceivable  that  it  should  not  be  parti- 
cipating, to  a  more  or  less  marked  degree,  in  the  inflammation. 

Treatment. — The  moment  we  have  gained  a  reasonably  clear  conception  of 
what  is  the  nature  and  extent  of  the  disease  which  we  are  called  upon  to 
treat,  the  course  which  we  ought  to  pursue  lies  clearly  marked  out  before  iis. 
We  should  ask  ourselves,  first,  this  question :  Is  the  outlet  for  the  discharge, 
by  way  of  the  external  auditory  canal,  as  free  as  it  can  be  made  by  any 
reasonable  operative  interference  ?  If  obstructions  still  remain — if  granula- 
tion-growths or  masses  of  epidermis  and  pus  block  the  way,  or  if  the  opening 
in  the  membrana  tympani  be  too  small — these  hindrances  should  be  removed. 
Our  next  question  should  be :  To  what  stage  has  the  inflammation  of  the 
mastoid  structures  progressed  ?  If  we  have  reason  to  believe  that  the  parts 
are  simply  congested,  we  may  trust  to  the  application  of  from  two  to  five 
leeches,  according  to  the  age  and  strength  of  the  patient,  and  afterward  to  a 
thoroughly  carried  out  system  of  hot  poulticing.  The  leeches  may  all  be 
applied  directly  over  the  mastoid  process,  or  some  of  them  may  be  applied 
at  that  point  and  the  others  directly  in  front  of  the  outer  orifice,  as  close  as 
possible  to  the  tragus.  Rest  in  bed  is  a  far  more  important  feature  of  the 
successful  treatment  of  these  acute  affections  of  the  ear  than  very  manj"  of 
us  suppose.  On  the  other  hand,  if  our  minds  are  somewhat  in  doubt  about 
the  wisdom  of  trusting  to  these  simpler  and  less  powerful  measures,  or  if  we 
have  tried  them  and  they  have  failed  to  relieve  the  pain,  we  should  promptly 
resort  to  a  "  Wilde's  incision."  In  this  operation,  the  skin  and  subjacent 
tissues,  including  the  periosteum,  are  divided  b}^  an  incision  extending  from 
the  base  very  nearly  to  the  apex  of  the  mastoid  process,  the  external  wound 
measuring  from  three-fourths  of  an  inch  to  an  inch  in  length.  If  the 
patient's  head  is  in  the  erect  position,  the  point  of  the  knife  should  be  intro- 
duced into  the  skin  about  on  a  level  with  the  upper  wall  of  the  external 
orifice  of  the  auditory  canal.  If  we  begin  the  incision  higher  up,  we  shall 
be  apt  to  divide  a  branch  of  the  posterior  auricular  arteiy,  which  usually 


736 


INJURIES  AND  DISEASES  OF  THE  EAR. 


crosse?.  the  bone  at  about  that  level.  On  the  other  hand,  if  we  make  the 
incision  a  little  too  far  forward,  we  may  nick  this  artery  or  incise  it  longi- 
tudinally, and  so  prepare  the  way  for  the  development  of  a  false  aneurism, 
as  has  already  twice  happened,-  once  in  my  own  practice  and  once  in  that  of 
Dr.  Charles  J.  Ivipp,  of  Kewark,  IS".  J.  After  the  bleeding  from  the  wound 
has  ceased— and,  within  reasonable  limits,  the  more  protracted  and  the  more 
copious  the  bleeding,  the  better — I  usually  introduce  a  small  tent  well-smeared 
with  vaseline,  for  the  purpose  of  preventing  the  wound  from  Healing  by  first 
intention.  Hot  flaxseed-meal  poultices  should  then  be  applied  to  the  mastoid 
region  as  often  as  may  be  found  necessary  to  keep  the  parts  warm  and  moist. 
As  Sir  William  "Wilde,  of  Dublin,  Ireland,  was  the  first  to  call  attention  to 
the  decided,  restraining  influence  which  such  deep  incisions  of  the  mastoid 
integuments  exert  upon  an  inflammation  of  the  body  of  that  bone,  it  is 
eminently  proper  that  the  name  of  "  Wilde's  incision"  should  be  retained 
for  this  most  efiicient  therapeutic  procedure. 

Finally,  in  those  eases  in  which  the  pain  has  persisted  steadily  for  several 
days,  and  has  perhaps  resisted  all  the  measures  that  may  have  been  adopted 
for  its  relief — and  in  which  all  the  local  signs  point  quite  clearly  to  a  serious 
degree  of  inflammation  in  the  body  of  the  mastoid  process — we  should  proceed 
without  further  delay  to  establish  a  broad  opening  in  the  outer  part  of  this 
bony  prominence.  The  steps  of  this  operation,  which  ordinarily  must  be 
performed  with  the  aid  of  an  anaesthetic,^  are  as  follows :  First,  the  outer 
surface  of  the  mastoid  bone  must  be  laid  bare.  Formerly  I  was  in  the  habit 
of  doing  this  by  means  of  a  longitudinal  incision,  which  terminated  below  at 
the  tip  of  the  process.  I  found,  however,  that  in  pushing  the  periosteum 
forward,  so  as  to  lay  bare  the  bone  in  the  vicinity  of  the  meatus,  I 
encountered  a  troublesome  degree  of  resistance  on  the  part  of  this  strong 
fibrous  sheath.  My  present  plan  is  to  make  an  obtuse-angled  or  crescent- 
shaped  incision,  of  which  the  upper  end  begins  above  the  meatus,  in  the 
hairy  scalp  (which  in  this  region  must  first  be  shaved),  while  the  lower  end 
reaches  nearly  to  the  tip  of  the  process.  If  this  sort  of  an  incision  be  made, 
no  difi3.culty  will  be  experienced  in  pushing  the  periosteum  forward,  and  in 
exposing  the  surface  of  the  process  fully  to  view.  If  the  periosteum  adheres 
firmly  to  the  underlying  bone,  I  find  it  desirable  to  employ  a  strong,  dull- 
edged  knife  such  as  is  represented  in  Fig.  964.    If  the  bone  be  found  softened 


Fig.  964. 


Strong  periosteum  knife. 


at  any  point,  the  attempt  should  be  made  to  break  through  it  at  this  spot, 
and  thus  complete  the  work  which  nature  has  begun.  The  outer  surface  of 
the  bone,  however,  is  usually  found  to  present  a  normal  appearance.  Under 
such  circumstances,  the  drill  should  be  applied  to  the  bone  at  a  point  about  a 
quarter  of  an  inch  distant  from  the  orifice  of  the  canal,  and  a  little  below  the 
level  of  its  upper  wall.  The  instrument  should  then  be  rotated  in  a  direction 
inward,  a  little  forward,  and  a  little  upward,  that  is,  in  a  direction  nearly 

1  In  three  instances  I  have,  at  the  patient's  earnest  request,  performed  the  operation  without 
the  aid  of  an  anaesthetic. 


DISEASES  OF  THE  MASTOID  PROCESS. 


737 


parallel  with  the  auditory  canal.  The  forefinger  of  the  hand  which  guides 
the  drill  should  rest  firmly  against  the  bone.  If  this  precaution  be  taken, 
there  will  not  be  the  slightest  danger  of  our  suddenly  plunging  the  sharp 
point  of  the  drill  into  parts  which  might  thereby  receive  serious  damage. 
The  instrument  should  be  constructed  in  such  a  manner  that  its  cutting  edges 
shall  be  turned  in  opposite  directions.  The  accompanying  figure  shows  this 
feature  of  the  instrument  very  clearly.  An  operator  whose  fingers  are  un- 
usually short,  might  perhaps  find  the  drills  a  little  too  long  ;  in  which  case  he 


Fig.  965. 


Mastoid  drills. 


would  find  it  necessary  to  have  them  shortened.  When  the  drill  has  pene- 
trated into  the  bone  to  an  appreciable  distance,  it  should  be  withdrawn,  and 
the  exact  depth  of  the  opening  should  be  ascertained.  After  a  few  more 
turns  of  the  instrument  have  been  made,  the  depth  should  be  measured  a 
second  time.  The  antrum  should  be  reached  at  a  depth  not  exceeding  three- 
fifths  of  an  inch.  My  rule  is,  never  to  force  the  instrument  beyond  a  depth 
of  twenty  millimetres,  or  three-quarters  of  an  inch.  Scliwartze,  of  Halle, 
in  Germany,  who  has  probably  had  more  experience  in  this  class  of  cases 
than  any  other  surgeon  living,  places  the  extreme  limit  at  twenty-five  milli- 
metres. When  the  end  of  the  drill  reaches  the  pneumatic  cells,  we  must 
manipulate  it  more  carefully,  as  our  object  is  to  establish  a  cylindrical  out- 
let, and  not  to  break  down  the  cell  walls  throughout  a  large  area.  I  always 
begin  the  operation  with  the  larger  drill,  and  then  employ  the  smaller  one, 
when  I  find  that  I  am  in  danger  of  using  too  great  leverage  force.  In  this 
connection  I  should  state  that  it  has  been  ascertained  by  experience  that,  in 
very  many  cases,  it  is  suflnicient  to  carry  the  drill  simply  far  enough  inward 
to  reach  one  or  more  of  the  pneumatic  cells.  I  have  repeatedly  stopped  short 
of  the  antrum,  in  operating  upon  the  mastoid  bone,  and  in  all  these  cases  I 
have  obtained  as  perfect  results  as  I  have  in  those  in  which  the  openino;  was 
made  to  terminate  directly  in  that  cavity.  Such  a  favorable  issue  is  to  be 
attributed,  in  some  cases,  to  the  fact  that  in  establishing  a  communication 
between  the  outer  air  and  some  of  the  pneumatic  cells,  we  have  in  reality 
established  a  communication— somewhat  indirect,  it  is  true — with  the  antrum 
itself.  In  other  cases,  the  benefit  derived  from  this  incomplete  operation  can 
only  be  explained  on  the  assumption  that  the  establishment  of  a  new  centre 
of  inflammation,  in  close  proximity  to  that  which  has  hitherto  been  the  real 
centre  of  disease,  produces  a  strongly  derivative  efl^ect,  and  so  checks  the 
progress  of  the  fundamental  malady.  Whether  these  speculations  about  the 
VOL.  IV. — 47 


738 


INJURIES  AND  DISEASES  OF  THE  EAR. 


mode  of  action  of  this  operation  be  true  or  not,  the  fact  Is  now  well  estab- 
lished, that  through  its  instrumentality  patients  experience  prompt  relief 
from  pain,  and  that  the  disease  is  rapidly  brought  under  control,  and  in  due 
time  cured. 

If  a  collection  of  pus  is  reached,  in  the  course  of  the  operation,  we  should 
search  carefully  for  loose  fragments  of  bone,  and  should  remove  them  with 
the  forceps,  if  any  be  found.  Then,  before  dressing  the  outer  wound,  we 
should  wash  out  the  channel  in  the  bone,  or  the  antrum,  as  the  case  may  be, 
with  a  five-per-cent.  solution  of  carbolic  acid.  In  carrying  out  this  proce- 
dure, it  is  well  to  employ  a  nozzle  or  tube  that  is  smaller  than  the  artificial 
channel,  so  as  to  allow  room  for  the  return  current  to  find  a  free  outlet  by 
the  side  of  the  instrument.  At  first  no  attempt  should  be  made  to  approxi- 
mate the  widely  separated  edges  of  the  wound.  The  more  open  the  outer 
wound,  the  more  easily  shall  we  be  able,  at  the  daily  dressing,  to  cleanse  the 
deeper  cavities.  As  an  outside  dressing  we  may  apply,  first,  a  suitable  patch 
of  lint  well  smeared  with  carbolated  vaseline.  Then  outside  of  this,  during 
the  first  twenty-four  hours,  fiaxseed-meal  poultices  should  be  applied  at  short 
intervals  of  time.  After  the  first  day,  the  channel  in  the  bone,  or  the  antrum, 
as  the  case  may  be,  should  be  thoroughly  washed  out  once  a  day  with  either 
a  warm,  saturated  solution  of  boracic  acid,  or  a  weak  (two-per-cent.)  solution 
of  carbolic  acid.  When  the  outer  wound  so  far  heals  up  that  the  nozzle  of 
the  douche  can  no  longer  be  introduced  into  the  opening  in  the  bone  without 
causing  the  patient  considerable  pain,  this  part  of  the  treatment  may  be 
omitted.  I  have  known  the  outer  wound  to  close  permanently  as  early  as 
on  the  tenth  day  after  the  operation.  Then  again,  I  have  known  it  to  remain 
unclosed  for  a  period  of  several  months. 

Chronic  Ulcerative  Inflammation  of  the  Mastoid  Antrum.-  From 

this  class  of  mastoid  afiections,  come  probably  the  greater  number  of  fatal 
cases  of  ear  disease.  Through  a  period  of  months  or,  more  commonly,  of 
years,  the  patient  is  affected  with  a  chronic  discharge  from  the  ear.  The 
underlying  disease  begins  as  a  simple  purulent  inflammation  of  the  middle 
ear,  and  then,  in  the  course  of  time,  usually  through  the  instrumentality  of 
an  obstructed  outlet,  the  solid  elements  of  the  discharge — pus-cells,  epithe- 
lium, detritus,  cholestearin-crystals,  etc. — begin  to  accumulate  in  the  antrum. 
While  these  changes  are  taking  place,  the  mastoid  cells  are  being  steadily 
reduced  in  size  by  a  chronic  osteitis,  and,  by  the  time  that  the  accumulating 
solid  matters  have  filled  the  antrum,  the  mastoid  process  will  be  found  to  have 
reached  the  condition  of  complete  sclerosis.  Ulceration  of  the  walls  of  the 
antrum,  in  whatever  direction  the  least  resistance  is  met  with,  follows  surely 
upon  the  formation  of  one  of  these  foul-smelling  masses  of  cheesy  material  in 
that  cavity.  The  directions  in  which  the  resistance  is  least  are,  first,  upward 
toward  the  brain,  and  next,  backward  toward  the  lateral  sinus.  In  one  or 
both  of  these  directions,  therefore,  a  destructive  carious  process  may  be  ex- 
pected to  take  place,  if  a  vent  be  not  established  by  artificial  means  sufiS- 
ciently  earlj^  to  prevent  such  an  issue. 

In  this  variety  of  mastoid  disease,  pain,  at  times  severe,  is  the  most  promi- 
nent symptom.  While  in  the  previously  described  variety  external  evidences 
of  the  underlying  mastoid  disease  are  rarely  wanting,  in  this  form  of  the  dis- 
ease they  are  rarely  present,  and  then  only  when  the  disease  is  far  advanced. 
On  the  other  hand,  one  can  usually  find  unmistakable  evidence  that  the  outlet 
through  which  the  pus  has  been  escaping  from  the  middle  ear  into  the  audi- 
tory canal,  is  too  narrow  to  permit  the  discharge  to  escape  freely  from  the 
more  deeply  situated  cavities.  The  persistence  of  pain,  therefore,  under  such 
circumstances,  becomes  a  very  important  indication — in  fact,  often  the  only 


DISEASES  OF  THE  MASTOID  PROCESS. 


739 


indication — of  the  severity  of  the  deeper-lying  ulcerative  inflammation.  If 
we  wait  for  the  development  of  additional  manifestations  of  this  treacherous 
disease  of  the  antrum,  before  taking  active  steps  to  check  it,  we  may  rest 
assured  that  in  many  cases  we  shall  let  slip  the  golden  opportunity  of  saving 
the  patient's  life. 

Cases  are  now  and  then  encountered  in  which,  by  skilful  interference,  we 
may  succeed  in  clearing  the  antrum  of  its  foul  contents,  and  in  re-establish- 
ing a  free  outlet  for  the  secretions  that  constantly  accumulate  in  it,  without 
boring  through  the  outer  portion  of  the  mastoid  process.  As  a  rule,  how- 
ever, this  is  not  practicable,  and  in  one  case  I  am  confident  that  my  efforts 
to  accomplish  this  difficult  task  only  resulted  in  adding  to  the  existing  pain, 
and  in  hastening  the  fatal  issue.  In  a  general  way,  we  may  say  that  this 
form  of  mastoid  disease  admits  of  only  one  safe  and  effective  plan  of  treat- 
ment, viz.,  that  which  consists  in  the  establishment  of  a  free  channel  of  com- 
munication between  the  antrum  and  the  outer  air,  through  the  mastoid  pro- 
cess. The  drill  must  be  carried  down  actually  to  the  antrum,  and  not 
merely  to  some  still  open  pneumatic  cell,  if  such  should  be  found. 

In  the  preceding  description  of  mastoid  diseases,  I  have  been  careful  to 
portray  only  uncomplicated,  well-defined  types  of  these  aftections.  I  will 
now  recapitulate  very  briefly  the  main,  distinctive  features  of  these  diseases, 
in  the  hope  of  rendering  this  branch  of  the  subject  still  clearer.  The  first 
variety  of  the  mastoid  disease — subacute,  condensing,  mastoid  osteitis — is 
really  nothing  but  an  accompaniment  of  an  ordinary,  chronic,  pumlent  inflam- 
mation of  the  middle  ear.  It  does  not  immediately  threaten  either  the  life 
or  the  health  of  the  patient.  It  may  not  even  cause  pain,  and  under  such 
circumstances  we  are  not  likely  even  to  have  our  attention  drawn  to  the  fact 
that  the  disease  is  present.  In  a  few  instances,  the  single  symptom  of  pain 
becomes  a  prominent  feature  of  the  disease — so  prominent,  indeed,  that  we 
may  be  obliged  to  resort  to  the  operation  of  boring  into  the  mastoid  bone 
in  order  to  secure  for  the  patient  the  desired  relief.  Here  then  we  have  a 
well-defined  and  very  important  type  of  mastoid  disease.  But  its  importance 
does  not  cease  here.  The  chief  result  of  this  condensing  osteitis  is  the  oblite- 
ration of  the  pneumatic  cells  of  the  mastoid  process.  In  ulcerative  disease 
of  the  antrum,  therefore,  this  condensing  osteitis  plays  an  important  part. 
It  commonly  prevents  the  development  of  certain  symptoms  which  are  of 
great  diagnostic  value,  and  at  the  same  time  it  interposes  a  solid  wall  of 
bone  between  the  cavity  of  the  antrum  and  the  outer  air,  thereby  greatly 
enhancing  the  serious  character  of  an  ulcerative  inflammation  of  that  cavity. 

The  second  and  third  varieties  differ  in  these  respects  :  in  the  former,  the 
pneumatic  cells  participate  in  the  inflammation  of  the  antrum,  while  in  the 
latter  they  play  no  part  as  a  separate  system  of  cavities,  but  a  very  important 
one  as  a  wall  of  bone  impenetrable  to  ulcerative  processes.  In  acute,  difiuse, 
mastoid  osteitis,  we  can  generally  limit  our  operative  interference  to  the  esta,b- 
lishment  of  a  free  communication  between  some  of  the  pneumatic  cells  and  the 
outer  air ;  while  in  chronic,  ulcerative  inflammation  of  the  mastoid  antrum, 
we  must  carry  the  artificial  canal  doAvn  to  this  cavity. 

Significance  of  Certain  Phenomena  occasionally  met  with  in  Diseases 
OF  THE  Mastoid  Process. — In  addition  to  the  symptoms  described  above, 
there  are  others  which  occur  more  or  less  frequently  in  aftections  of  the 
mastoid  process,  and  which  should  at  least  receive  mention  in  these  pages. 
Thus,  for  example,  partial  or  complete  paralysis  of  the  facial  nerve  often 
develops  during  the  progress  of  either  the  second  or  the  third  form  of 
mastoid  disease.    It  is  probably  brought  about  by  the  pressure  of  an  eflfusion 


740 


INJURIES  AND  DISEASES  OF  THE  EAR. 


that  has  been  poured  out  into  the  bony  canal  through  which  the  facial  nerve 
passes.  That  such  an  effusion  should  take  place,  shows  that  the  inflammation 
of  the  bone  in  the  vicinity  of  the  antrum  has  reached  a  serious  degree  of 
activity.  The  s^miptom  is  therefore  of  decided  diagnostic  value.  In  some 
eases  permanent  paralysis  remains  after  the  mastoid  disease  has  entirely 
subsided,  while  in  others  every  trace  of  the  paralysis  disappears  in  the  course 
of  a  few  weeks. 

Sometimes  the  tissues  on  the  side  of  the  neck,  a  short  distance  below  the 
tip  of  the  mastoid  process,  become  inflamed,  and  swell  rather  rapidly  into  a 
hard,  flattened,  and  very  sensitive  tumor.  The  skin  covering  this" matted 
cake  of  inflamed  glands  and  other  soft  parts  lying  outside  of  the  muscles  of 
the  neck,  is  red,  oedematous,  and  firmly  adherent  to  the  underljdng  tumor. 
I  have  sometimes  observed  that  the  development  of  such  a  swelling  takes 
place  simultaneously  with  a  decided  subsidence  of  the  pain  in  the  mastoid 
region  and  side  of  the  head,  and  for  this  reason  I  have  been  disposed  to 
believe  that  some  of  the  acrid  secretion  contained  in  the  antrum  or  pneumatic 
cells,  must  have  found  a  w^ay  of  escape  through  one  of  the  canals  for  the 
mastoid  emissary  veins,  thus  diminishing  the  degree  of  pressure  within  the 
mastoid  process,  and  at  the  same  exciting,  by  its  acrid  properties,  a  sharp 
inflammation  of  the  tissues  into  which  it  first  escaped.  It  is  also  possible, 
as  suggested  by  Dr.  J.  Orne  Green,  of  Boston,  that  a  phlebitis  of  one  of  the 
mastoid  emissary  veins  may  be  the  cause  of  such  a  swelling  of  the  soft  parts 
below  the  mastoid  process.  By  the  frequent  application  of  hot  flaxseed-meal 
poultices,  I  have  known  such  swellings  to  disperse  without  the  development 
of  an  actual  abscess.    However,  if  pus  forms,  the  knife  must  be  used. 

In  several  cases  I  have  observed  the  development  of  an  abscess,  or  at  least 
of  a  circumscribed  area  of  inflammation,  in  some  part  of  the  scalp  of  the 
corresponding  side  of  the  head.  I  believe  that  any  part  of  the  scalp  may 
become  the  seat  of  such  an  abscess,  or  of  such  a  localized  inflammatory  swelling, 
as  I  have  encountered  them  in  very  different  regions,  viz.,  in  the  vicinity  of  the 
occiput,  on  the  very  top  of  the  head,  midway  between  the  top  of  the  head  and 
the  mastoid  region,  and  in  the  temporal  region.  It  seems  to  me  reasonable  to 
suppose  that  the  lymphatics  carry  some  of  the  acrid  secretions  from  the 
mastoid  cavities  to  these  difterent  localities,  thus  starting,  by  transportation, 
new  centres  of  inflammation.  In  opening  such  abscesses  I  have  sometimes 
been  annoyed  by  the  profuseness  and  obstinacy  of  the  bleeding. 

As  a  rule,  the  body-temperature  may  be  taken  as  a  measure  of  the  activity 
of  the  disease  in  the  mastoid  process.  This  is  particularly  true  of  youthful 
subjects.  In  adults,  however,  we  must  not  allow  ourselves  to  be  lulled  into 
a  sense  of  security  by  reason  of  the  absence  of  noticeable  fever.  In  one  of 
my  cases,  which  terminated  fatally  (probably  from  abscess  of  the  brain),  the 
temperature,  during  the  last  thirteen  days,  did  not  once  rise  above  100°  F. 
Delirium  does  not  necessarily  indicate  a  fatal  issue.  Coma  and  strabismus, 
on  the  other  hand,  are  more  grave  symptoms,  for  they  point  clearly  to  the 
development  of  intra-cranial  processes  which  are  quite  likely  to  terminate  in 
death. 


FRACfURES  OF  THE  TEMPORAL  BoNE. 

As  the  subject  of  fractures  of  the  temporal  bone  is  considered  in  the  arti- 
cle on  Injuries  of  the  Head,  1  shall  confine  myself  in  this  place  to  a  very 
brief  presentation  of  those  aspects  of  the  subject  to  which  the  general  sur- 
geon as  a  rule  pays  very  little  attention.  The  so-called  "fractures  at  the  base 
of  the  skull"  probably  always  involve  the  temporal  bone.    These  cases  do 

• 


FRACTURES  OF  THE  TEMPORAL  BONE. 


741 


not  often  come  under  the  observation  of  the  aural  surgeon,  and  the  medical 
man  first  called  to  see  the  case  probably  never  thinks  of  making  an  examin- 
ation (with  the  speculum  and  reflected  light)  of  the  external  auditory  canal 
and  drum-membrane.  Hence  our  supply  of  facts  with  regard  to  the  lesions 
demonstrable  during  life  in  the  temporal  bone  of  a  person  who  is  believed  to 
have  a  fracture  at  the  base  of  the  skull,  is  very  scanty.  It  is  sufficient,  how- 
ever, to  justify  the  following  deductions. 

Fractures  of  the  temporal  bone  may  be  subdivided  into  two  classes : — 

1.  Fracture  or  diastasis  of  the  tympanic  or  squamous  portion,  in  the  region 
of  the  middle  ear,  without  implication  of  the  pars  petrosa. 

2.  Fracture  of  both  the  tympanic  and  the  petrous  portions. 

Both  of  these  kinds  of  fracture  are  produced,  not  by  direct  violence  to 
the  parts,  but  by  contrecoup  ;  that  is,  the  patient,  in  falling,  strikes  upon  the 
back  or  the  top  of  his  head,  while  the  fracture  occurs  at  the  base  of  the  skull. 
In  the  first  variety,  the  line  or  lines  of  fracture  correspond  with  the  lines  of 
union  of  the  three  bony  portions  which  together  form  the  temporal  bone,  and 
which  in  foetal  life  represent  separate  centres  of  growth,  viz.,  the  squamous 
portion  (together  with  the  zygoma),  the  tympanic  portion  (annulus  tympan- 
icus),  and  the  petrous  portion  (together  with  the  mastoid  process).  These 
fractures,  therefore,  partake  somewhat  of  the  nature  of  diastases.  In  the 
second  variety,  the  fracture  of  the  petrous  portion  of  the  temporal  bone  repre- 
sents a  genuine  fracture.  It  takes  place  in  the  middle  ]Dart  of  the  bone, 
where  it  is  greatly  weakened  by  the  presence  of  several  large  cavities  (the 
meatus  auditorius  internus,  the  cochlea,  the  vestibule,  and  the  semicircular 
canals),  wdiich  are  separated  one  from  another  by  comparatively  thin  parti- 
tions of  bone.  While  it  is  possible  that  a  fracture  may  take  place  in  the 
petrous  portion  of  the  temporal  bone  without  a  contemporaneous  fracture  or 
diastasis  in  the  adjacent  squamous  or  tympanic  portion,  we  possess  no  facts 
as  yet  which  will  justify  such  a  belief.  In  fact,  the  general  surgeon  is  not  in 
the  habit  of  recognizing  even  tw^o  subdivisions,  such  as  I  have  here  made. 
iS'ow  I  am  satisfied  that  these  subdivisions  are  by  no  means  fanciful,  but 
rather  the  reverse  :  they  are  eminently  practical.  Let  me  illustrate.  A  per- 
son falls  or  receives  a  blow  upon  the  head.  Bleeding  from  the  ear  follows, 
and  may  even  be  copious  in  amount.  He  is  unable  to  hear  the  ticking  of  a 
watch  in  the  affected  ear,  and,  when  the  good  ear  is  closed,  he  finds  difficulty 
in  distinguishing  spoken  words.  The  general  surgeon,  if  he  make  the 
attempt  to  locate  the  fracture  without  resorting  to  an  examination  of  the  ear, 
will  be  very  likely  to  make  this  diagnosis :  fracture  of  the  temporal  bone 
through  its  petrous  portion  ;  a  diagnosis  which  almost  necessarily  implies  the 
permanent  loss  of  the  hearing  of  the  corresponding  ear.  On  the  other  hand, 
an  examination  of  the  ear  with  the  speculum  and  reflected  light  might  show 
a  fracture  running  along  the  Glaserian  fissure,  and  a  tympanic  cavity  filled 
with  blood.  By  aid  of  the  tuning-fork,  the  fact  might  also  be  learned  that 
the  sonorous  vibrations  of  this  instrument  weve  heard  best  in  the  aftected 
ear.  The  diagnosis  would  then  have  to  be  made  of  a  fracture  involving  the 
squamous  and  tympanic  portions,  and  not  the  petrous ;  and  the  patient  could 
properly  be  encouraged  to  hope  for  a  partial,  if  not  a  complete,  restoration 
of  the  hearing.  Furthermore,  the  knowledge  gained  by  such  an  examina- 
tion of  the  ear  would  be  likel}'  to  materially  modify  the  treatment  that 
would  otherwise  be  adopted. 

There  are  still  other  phenomena  with  regard  to  which  the  general  surgeon 
is  more  than  likely  to  form  an  erroneous  opinion,  if  he  do  not  take  advantage 
of  the  light  which  an  examination  of  the  ear  is  competent  to  aflford  him.  I 
refer  particularly  to  two  symptoms,  viz.,  hemorrhage  from  the  ear,  and  a 
watery  discharge  from  the  same  region.    In  cases  of  fracture  of  the  temporal 


742 


INJURIES  AND  DISEASES  OF  THE  EAR. 


bone,  a  hemorrhage  from  the  ear  means,  as  a  rule,  a  rapture  of  the  bloodves^ 
sels  in  the  vicinity  of  Shrapnell's  membrane.  Such  a  hemorrhage  may  be 
copious,  and  may  continue  for  a  comparatively  long  time ;  and  the  mere  fact 
of  its  copiousness  does  not  indicate  that  a  communication  has  been  opened 
between  the  cavity  of  the  tympanum  and  any  of  the  large  vascular  channels 
which  surround  the  temporal  bone.  I  am  convinced,  from  actual  observation 
in  numerous  cases,  that  the  bloodvessels  in  the  neighborhood  of  Shrapnell's 
membrane,  are  amply  able,  under  favorable  circumstances,  to  provide  both  a 
copious  and  a  prolonged  bleeding.  I  am  also  satisfied,  from  examinations 
which  I  have  made  in  cases  of  injury  to  the  head  of  recent  occurrence,  that 
fractures  of  the  temporal  bone  often  occur  witliout  the  slightest  bleeding 
from  the  external  auditory  canal.  That  these  views,  however,  are  at  variance 
with  those  of  the  best  surgical  authorities,  may  be  gathered  from  the  follow- 
ing statement,  which  I  have  copied  from  Sir  Prescott  Hewett's  remarks  on 
Fractures  of  the  Base  of  the  Skull,  in  Holmes's  System  of  Sur2:ery : — 

"  Bleeding  from  the  ears,  in  severe  injuries  of  the  head,  has,  tor  many  years  past, 
been  held,  and  deservedly  too,  as  one  of  the  most  valuable  diagnostic  signs  of  fractured 
base.  But  this  bleeding,  to  be  of  any  value  as  a  means  of  diagnosis,  must  be  of  a 
serious  nature,  and,  above  all,  it  must  continue  for  some  time.  With  such  a  bleeding 
it  may  be  safely  diagnosed  that  there  is  a  fracture  of  the  base  running  through  the 
petrous  bone,  and  opening  up  a  communication  between  the  cavity  of  the  tympanum 
and  some  of  the  numerous  and  large  vascular  channels  which  surround  this  bone,  or 
with  an  extravasation  of  blood  within  the  cranium  itself." 

The  other  symptom,  which  is  considered  to  be  of  so  great  diagnostic  value 
in  cases  of  suspected  fracture  of  the  temporal  bone,  is  that  of  a  w^atery  dis- 
charge from  the  external  auditory  canal.  While  our  direct  knowledge  with 
regard  to  this  symptom  is  almost  a  blank,  apparently  no  examinations  having 
been  made  of  the  ear  in  suitable  cases,  a  general  knowledge  of  ear-diseases 
and  of  the  anatomy  of  the  temporal  bone  w^ould  prevent  me  from  accepting 
in  their  entirety  the  views  put'forward  by  Sir  Prescott  Hewett  in  the  follow- 
ing paragraphs,  taken  from  the  article  quoted  above : — 

"  There  are,  then,  as  far  as  is  known  at  present,  three  classes  of  cases  of  this  watery 
discharge.  In  the  first  class,  where  the  fluid  from  the  ear  is  plentiful  and  of  a  decidedly 
watery  character  immediately  after  the  accident,  there  need  be  no  doubt  as  to  the 
nature  of  the  injury — the  watery  discharge  is  due  to  the  escape  of  the  cerebro-spinal 
fluid,  which,  as  already  stated,  can  only  take  place  through  a  fracture  of  the  petrous 
bone  implicating  the  internal  auditory  canal  and  its  membranes. 

"  In  the  second  class  of  cases,  characterized  by  a  copious  and  prolonged  bleeding 
from  the  ear,  followed  by  a  watery  discharge,  a  fracture  of  the  petrous  bone  may  also 
be  safely  diagnosed  ;  but  it  cannot  be  said  that  the  fracture  follows  any  particular 
course.  In  these  cases  it  must,  however,  be  clearly  understood  that  it  is  not  to  the 
watery  discharge  that  we  can  trust  for  our  diagnosis,  but  to  the  copious  and  prolonged 
bleeding. 

"  Thus  far  there  is  no  difflculty.  Not  so,  however,  in  the  third  class  of  cases,  in 
which  there  is  at  first  a  discharge  of  blood  only,  neither  copious  nor  prolonged,  which 
is  followed  by  a  watery  discharge,  varying  as  to  the  time  of  its  appearance — varying  as 
to  its  quantity.  It  may  be  present  within  a  very  few  hours  after  the  accident — it  may 
be  profuse  within  a  few  hours  after  its  appearance.  These  are  the  cases  in  which  expe- 
rience has  of  late  proved  that  the  diagnosis  ought  to  be  doubtful.  The  discharge  of 
blood  is  certainly  not  of  a  character  to  warrant  a  diagnosis  of  fracture  of  the  petrous 
bone  ;  and  as  to  the  watery  discharge,  it  is  now  well  known  that  such  a  discharge  maj 
occur  within  a  few  hours  after  the  accident,  that  its  quantity  may  even  be  profuse,  and 
yet  there  may  be  no  fracture." 

I  may  be  in  error  with  regard  to  this  matter,  and  yet  it  appears  to  me  to 
be  a  very  simple  problem,  at  least  as  far  as  the  existence  or  non-existence  of 
a  fracture  is  concerned.    To  determine  the  full  extent  of  the  fracture,  is  quite 


MISCELLANEOUS  CONDITIONS  OF  THE  EAR. 


743 


another  matter ;  although  even  here,  as  I  have  said  before,  it  is  easily  possi- 
ble to  define  rather  coarsely  the  parts  of  the  temporal  bone  affected.  If  we 
consider  for  a  moment  the  solid,  masonry-like  construction  of  the  temporal 
bone,  we  can  scarcely  resist  the  conclusion  that,  when  a  blow  upon  the  top, 
back,  or  opposite  side  of  the  head  is  followed  by  any  decided  symptom  what- 
ever in  the  ear  (as,  for  instance,  bleeding,  a  watery  discharge,  or  even  simply 
pain),  a  fracture  or  a  diastasis  must  have  taken  place  in  the  corresponding 
temporal  bone.  A  mere  jar  of  the  head  is  not  competent  to  produce  a  hemor- 
rha2:e  from  the  external  auditory  canal.  On  the  other  hand,  an  actual  stretch- 
ing of  the  soft  parts  to  such  a  degree  as  to  tear  one  or  more  bloodvessels,  is  not, 
under  such  circumstances,  physically  possible  in  the  vicinity  of  the  drum- 
membrane,  unless  at  the  same  time  there  shall  have  been  an  actual  giving 
way  of  some  part  of  the  surrounding  arch  of  bone.  Such  a  laceration  of  the 
parts  is  sure  to  be  followed  by  inflammation,  and  this  inflammation  w^ill  be 
proportionate  to  the  degree  of  damage  done  to  the  parts.  A  profuse,  and 
sometimes  long-continued  watery  discharge  from  the  middle  ear,  by  way  of 
the  external  auditory  canal,  is  a  well-known  characteristic  of  an  ordinary,  non- 
traumatic, acute  inflammation  of  the  middle  ear,  provided  that  an  opening 
has  been  established,  either  by  natural  or  by  artificial  means,  in  the  membrana 
tympani.  In  the  severer  cases  of  fracture  of  the  temporal  bone,  the  drum- 
membrane  is  very  apt  to  be  lacerated,  and  it  is  in  precisely  these  severe  cases 
of  fracture  that  we  encounter  this  symptom  of  a  watery  discharge  from  the 
ear.  In  estimating,  therefore,  the  diagnostic  value  of  a  watery  discharge 
from  the  ear,  in  cases  of  fracture  of  the  temporal  bone,  I  am  disposed  to  go 
no  farther  than  this  :  it  aftbrds  a  good  measure  of  the  degree  of  damage 
done  to  the  temporal  bone  and  contiguous  parts.  It  is  by  no  means  neces- 
sarily a  fatal  symptom,  for  I  have  known  several  such  cases  to  recover.  I 
should  perhaps  not  be  justified  in  insisting  that  all  of  this  watery  discharge 
came  from  the  middle  ear  and  parts  bordering  upon  it.  Such,  however, 
appears  to  me  to  be  the  more  rational  belief. 

The  treatment  ordinarily  employed  to  arrest  an  acute  inflammation  of  the 
middle  ear,  is  the  treatment  that  can  best  be  adopted  for  the  relief  of  the  in- 
flammation caused  by  the  fracture.  I  do  not  see  why  it  may  not,  in  certain 
cases,  turn  the  scale  in  favor  of  recovery. 

Miscellaneous  Conditions  of  the  Ear. 

In  our  examinations  of  the  ear,  we  often  encounter  conditions  which  in  part 
represent  the  final  results  of  some  of  the  diseases  described  in  the  preceding 
chapters,  and  in  part  are  quite  distinct  from  those  diseases.  It  is,  therefore, 
simply  as  a  matter  of  convenience  that  I  bring  some  of  the  more  important 
of  them  together  here  under  the  title  of  Miscellaneous  Conditions. 

Atrophy  of  the  Membrana  Tympani. — The  membrana  tympani  may  un- 
dergo atrophy  through  the  operation  of  two  very  difterent  causes ;  and,  in 
harmony  with  these  etiological  differences,  w^e  may  distinguish  two  well- 
marked  types  of  atrophy.  In  one  form,  continued  atmospheric  pressure  upon 
the  outer  surface  of  the  membrane,  without  an  equally  great  counter-pressure 
(also  atmospheric)  upon  the  inner  side,  produces  a  progressive,  symmetrically 
distributed,  and  sometimes  very  marked  atrophy  of  all  its  constituent  parts. 
The  inextensible,  radial  fibres  of  the  substantia  propria  undergo  absorption, 
in  well-marked  cases,  and  as  a  result  we  may  find  the  drum-membrane  spread 
out,  like  a  thin  film,  over  the  long  process  of  the  anvil,  the  head  of  the 
stirrup,  and  the  inner  wall  of  the  tympanic  cavity.    In  the  slighter  grades, 


744 


INJURIES  AND  DISEASES  OF  THE  EAR. 


the  membrane  simply  appears  to  be  more  hollowed  out  or  sunken  than  it 
should  be,  and,  according  to  the  degree  of  congestion  of  the  mucous  mem- 
brane of  the  middle  ear,  and  to  the  presence  or  absence  of  fluid  exudation  in 
the  drum-cavity,  its  color  may  be  either  of  a  reddish  or  purplish  tone,  or 
simply  of  a  dark,  greenish  hue.  Such  a  membrane,  when  inflated  by  Polit- 
zer's  or  Valsalva's  method,  wdll  instantly  change  its  entire  appearance; 
becoming  as  convex,  on  the  side  towards  the  observer,  as  it  before  was  con- 
cave. As  the  air  encaged  in  the  middle  ear  escapes  by  way  of  the  Eustachian 
tube,  we  can  see  the  membrane  recede  to  or  beyond  its  natural  position. 
Another  change  will  also  attract  our  attention  ;  the  surface  of  the  membrane, 
perfectl}^  smooth  and  polished  while  in  its  sunken  condition,  becomes  dull 
and  sometimes  even  creased  after  it  has  been  inflated.  Sometimes,  under 
too  forcible  an  inflation,  the  membrane  ruptures.  Enlarged  tonsils  and  a 
well-marked  naso-pharyngeal  catarrh  are  probably  always  associated  with 
this  condition  of  the  membrana  tympani.  If  we  fail  to  find  them,  we  may 
well  doubt  the  correctness  of  our  diagnosis.  Such  an  atrophied  drum-mem- 
brane is  precisely  like  a  newly-produced  or  "  cicatricial"  drum-membrane. 
It  is  now  a  well-established  fact  that  the  membrana  tympani  may,  through 
the  ulcerative  action  of  disease,  be  totally  destroyed,  and  then,  afterw^ard, 
upon  the  return  of  the  region  to  a  healthy  condition,  an  entirely  new  mem- 
brane may  be  re-created.  The  latter,  however,  lacks  the  unyielding  charac- 
ter of  the  normal  drum-membrane,  by  reason  of  the  fact  that  the  inextensible 
radial  fibres  are  not  reproduced,  except  perhaps  to  a  very  limited  degree. 
A  careful  inquiry  into  the  previous  history  of  the  case  can  alone  enable  us  to 
decide  which  of  the  two  conditions  is  the  one  under  observation. 

In  the  second  form  of  atrophy  of  the  membrana  tympani,  the  picture  pre- 
sented is  markedly  difierent  from  that  observed  in  the  form,  just  described. 
The  membrane  occupies  a  perfectly  natural  position,  or  at  all  events  it  is  not 
sunken  sufiiciently  to  attract  our  attention.  It  is  remarkably  transparent, 
however,  and  looks  like  very  tightly- stretched  parchment.  Through  its 
posterior  superior  quadrant,  we  can  see  distinctly  the  whitish  mass  of  the  end 
of  the  long  process  of  the  anvil.  Below,  a  shadowy  area,  corresponding  to 
the  niche  of  the  fenestra  rotunda,  attracts  our  attention.  Anterior  to  these 
regions  lies  the  apparently  white  and  perfectly  smooth  promontory,  or  inner 
bony  wall,  of  the  tympanum.  This  whitish  appearance  is  due  to  the  fact 
that  the  mucous  membrane,  which  should  naturally  conceal  the  whiteness  of 
the  underlying  bone,  has  been  reduced  to  such  a  state  of  thinness  and  non- 
vascularity  that,  to  all  intents  and  purposes,  the  bone  lifes  exposed  to  view. 
The  same  wasting  away  of  the  mucous  membrane  takes  place  on  the  inner 
side  of  the  drum-membrane,  and  thus  renders  it  unusually  transparent.  The 
radial  fibres  do  not  participate  to  any  marked  degree  in  this  atrophy,  and 
consequently  the  drum-membrane  retains  its  firm,  unyielding  character. 

In  the  first  form,  our  treatment  should  be  directed  to  the  naso-pharyngeal 
catarrh,  upon  which  the  atrophy  of  the  drum-membrane  depends.  IJntil 
recently,  I  had  always  believed  that  a  drum-membrane,  which  had  once 
been  allowed  to  undergo  atrophy  of  its  substantia  ])ro2:>ria  through  prolonged, 
undue  atmospheric  pressure  upon  its  outer  surface,  would  never  afterward 
recover  any  material  part  of  its  inextensibility.  I  am  quite  sure  now  that 
under  proper  treatment,  the  eftect  of  which  shall  be  to  remove  undue  atmo- 
spheric pressure  upon  the  outer  side  of  the  membrane,  it  will  slowly  regain 
at  least  some  of  this  valuable  acoustic  property.  As  far  as  the  second  form 
of  atrophy  is  concerned,  I  know  of  no  treatment  that  is  likely  to  prove  of 
any  service  whatever. 

Rupture  of  the  drum-membrane,  from' a  blow  upon  the  side  of  the  head, 
or  from  a  violent  concussion  of  the  air  in  the  immediate  neighborhood  of  the 


AFFECTIONS  OF  THE  AUDITORY  NERVE. 


745 


ear,  as  when  a  gun  or  a  cannon  is  fired,  is  a  comparatively  rare  occurrence. 
Ko' special  treatment  is  required.  The  rupture  usually  heals  promptly.  It 
an  acute  inflammation  follow  the  accident,  it  must  be  treated  in  i>recisely 
the  same  manner  as  if  it  had  developed  through  the  effects  of  a  cold. 

Otalgia,  that  is,  a  pain  in  the  ear  not  attributable  to  any  discoverable 
lesion  in  either  the  middle  or  the  external  car,  is  not  an  affection  of  common 
occurrence.  I  have  seen  only  a  few  such  cases,  and  in  the  majority  of  them 
I  have  found  that  the  real  cause  of  the  pain  Avas  a  decayed  or  ulcerated  tooth. 
In  these  cases,  the  pain  in  the  ear  must  be  looked  upon  as  a  reflex  nervous 
phenomenon.  In  a  few  instances  I  have  known  the  pain  to  yield  to  quinine 
taken  internally,  and  from  this  circumstance  I  have  been  disposed  to  consider 
the  aftection,  in  these  cases,  as  a  malarial  neuralgia.  It  is  probable  also  that 
rheumatism  is  sometimes  to  blame  for  these  attacks  of  pain  in  the  ear. 

There  are  many  other  comparatively  rare  conditions  and  diseases  of  the 
•  ear,  but  as  they  are  of  minor  iipportance,  I  must  utilize  the  small  space 
allotted  to  the  subject  of  this  article,  in  describing  the  nature  and  treatment 
of  the  more  important  affections  of  the  organ. 

Affections  of  the  Auditory  I^erve. 

The  knowledge  which  we  possess  with  regard  to  affections  of  the  auditory 
nerve,  is  very  scanty.  This  is  due  to  various  circumstances.  In  the  first 
place,' the  auditory  nerve,  at  all  points  throughout  its  course,  is  concealed 
from  view.  AVhile  the  retina,  or  terminal  apparatus  of  the  optic  nerve,  lies 
comparatively  near  the  surface  of  the  body,  and  may  be  examined  thoroughly 
by  direct  inspection  upon  the  living  subject,  the  lamina  basilaris,  with  its 
delicate  superincumbent  structures,  is  solidly  encased  in  bone,  far  beyond  the 
reach  of  sight,  and  difficult  to  expose  to  view  even  in  the  cadaver.  In  the 
next  place,  we  very  rarely  have  the  good  fortune  to  examine,  after  death,  the 
condition  of  an  auditory  nerve  that  has  been  believed  to  be  diseased  a  short 
time  previously.  A  few  facts,  however,  have  been  ascertained  in  this  manner, 
and  others  still  have  been  learned  by  post-mortem  examinations  of  the  ear 
in  individuals  with  regard  to  whose  aural  history  during  life  nothing  what- 
ever has  been  known.  "  Thus,  for  example,  evidences  of  disease,  in  the  shape 
of  minute  extravasations  of  blood,  have  been  found  in  the  brain,  in  the 
neighborhood  of  the  rhomboid  fossa,  from  which  region  the  auditory  nerve 
orio-inates.  New  growths  (syphilitic  gumraata,  sarcomata,  and  cai'cinomata) 
involvino-  the  trunk  of  the  auditory  nerve,  have  been  found  at  the  base  of  the 
brain.  ^Evidences  of  atrophy  of  the  nerve-trunk  have  been  observed. 
Extravasations  of  blood  have  been  found  in  different  parts  of  the  labyrinth 
— in  the  vestibule,  in  the  semicircular  canals,  and  in  the  cochlea.  The  ring- 
shaped  elastic  membrane,  which  surrounds  the  foot-plate  of  the  stirrup,  has 
been  found  converted  into  an  immovable,  calcareous  or  osseous  plate.  Essen- 
tially the  same  changes  have  been  observed  in  the  secondary  tympanic 
membrane  which  span's  the  inner  end  of  the  niche  called  the  round  window 
These  and  other  conditions  have  been  observed  after  death,  but  unfortunately 
we  can  connect  only  a  few  of  them  with  particular  trains  of  symptoms  observed 
during  life.  We  are  therefore  obliged  to  infer  what  the  condition  of  the 
auditory  nerve  is,  in  any  given  case,  from  the  state  in  which  we  find  the 
middle  ear  to  be,  from  the  manner  in  which  the  nerve  performs  its  functions 
and  in  which  the  other  organs  lying  near  the  auditory  nerve  perform  theirs, 
from  the  presence  or  absence  of  certain  constitutional  symptoms,  and  finally 
from  our  knowledge  of  the  lesions  which  may  be  found  in  the  auditory 


746 


INJURIES  AND  DISEASES  OF  THE  EAR. 


nerve  proper,  in  its  terminal  apparatus,  or  in  some  part  of  the  labyrinthine 
system  of  chambers.  Such  a  diagnosis  partakes  necessarily  of  a  speculative 
character,  but  in  the  present  state  of  our  knowledge  we  are  prevented  from 
reaching  anything  of  a  more  definite  character. 

From  time  to  time,  w^e  encounter  cases  in  which  the  prominent  symptom 
is  a  sudden  or  comparatively  rapid  loss  of  hearing  in  one  or  both  ears.  Inas- 
much as  a  careful  examination  of  all  the  accessible  parts  of  the  ear  fails  to 
reveal  any  lesions  adequate  to  explain  the  deafness,  and  inasmuch  as  all 
sounds,  whether  transmitted  through  the  bones  of  the  skull  or  through  the 
air,  seem  to  be  perceived  only  by  the  sound  ear  (in  those  cases  in  which  the 
deafness  is  one-sided),  we  are  accustomed  to  make  the  diagnosis  of  disease 
of  the  auditory  nerve.  In  many  of  these  cases  we  feel  as  if  we  might 
safely  go  a  step  farther,  and  locate  the  disease  in  that  part  of  the  auditory 
nerve  which  lies  within  the  system  of  chambers  called  "  the  labyrinth." 
The  temptation  to  do  this  is,  I  confess,  very  strong ;  but  at  the  same  time  we 
must  remember  that  our  actual  knowledge,  whether  pathological  or  physio- 
logical, does  not  justify  us  in  making  any  such  diagnosis. 

The  terms  Meniere'' s  disease  and  apojolectiform  deafness  are  applied  to  a  group 
of  symptoms  of  which  the  most  prominent  are  a  sudden  loss  of  hearing  (on 
one  or  on  both  sides,  and  usually  complete),  well-marked  vertigo,  inability  to 
maintain  one's  balance,  nausea,  and  tinnitus.  In  a  case  of  this  kind,  Meniere 
found  the  different  chambers  of  the  labyrinth,  at  the  post-mortem  exami- 
nation, filled  with  clotted  blood.  From  that  time  to  the  present,  it  has  been 
the  custom  to  associate  these  lesions  with  the  train  of  symptoms  enumerated 
above ;  but  whether  correctly  or  not,  I  am  not  prepared  to  say.  In  a  very 
small  number  of  these  cases,  the  hearing  returns  after  the  lapse  of  a  few  days, 
either  to  a  large  extent,  or,  more  commonly,  only  to  a  slight  degree.  Leech- 
ing, counter-irritation  behind  the  ear,  and  rest  in  bed,  may  accomplish  some 
good,  but  as  a  rule  no  treatment  is  found  to  be  of  any  use  in  restoring  the 
lost  hearing. 

A  second  and  very  striking  type  of  disease  of  the  auditory  nerve  is  that 
observed  in  the  course  of  constitutional  syphilis.  The  loss  of  hearing  takes 
place  gradually,  though  generally  in  from  one  to  four  weeks  the  deafness 
becomes  almost  or  quite  complete.  The  symptoms  of  dizziness,  difficulty  in 
maintaining  one's  balance,  and  nausea,  are  often  absent,  and  when  they  are 
present,  they  are  usually  much  less  marked  than  they  are  in  Meniere's 
disease.  The  prognosis  is  not  favorable.  Dr.  Roosa,  of  New^  York,  once  suc- 
ceeded, in  a  case  of  total  deafness  dependent  upon  sj^philis,  in  restoring  a  large 
fraction  of  the  hearing.  I  have  repeated  the  same  treatment — administration 
of  iodide  of  potassium  in  increasing  doses — in  two  or  three  cases,  but  it  has 
not  been  my  good  fortune  to  restore  more  than  a  small  part  of  the  lost 
function.  In  one  of  these  cases,  I  pushed  the  treatment  with  the  iodide  of 
potassium  up  to  the  point  at  which  my  patient  took  three  hundred  grains  of 
the  remedy,  every  day,  for  a  period  of  several  days. 

There  are  various  general  diseases  in  the  course  of  which  the  auditory 
nerve  is  believed  to  be  seriously  affected.  All  the  infective  fevers  seem  to 
predispose  the  patient  to  a  sudden  or  rapid  loss  of  hearing,  without  any 
demonstrable  simultaneous  affection  of  the  middle  ear.  Epidemic  cerebro- 
spinal meningitis  is  particularly  liable  to  induce  a  sudden  loss  of  hearing, 
commonly  in  both  ears.  In  these  cases,  it  is  a  well-established  fact  that  the 
inflammation  at  the  base  of  the  brain  spreads  to  the  labyrinth,  and  probably 
does  the  chief  damage  in  the  cochlea.  The  pathology  of  the  loss  of  hearing 
which  is  occasionally  observed  in  mumps,  is  much  more  obscure.  The  same 
is  true  of  the  sudden  deafness  which  occurs  after  a  confinement.  In  the 
great  majority  of  all  these  cases  treatment  is  of  no  avail,  and  the  loss  of 
hearing  is  permanent. 


PLATE  XXIX. 


9. 


10. 


,xvLi'J\iJUxJx^  ''MAeuckA^yn^  S/umvnud^eiL 


APPEAKANCES  OF  MEMBRANA  TYMPANI  IN  HEALTH  AND  DISEASE.  747 


EXPLANATION  OF  PLATES  REPRESENTING  APPEARANCES  OF 
MEMBRANA  TYMPANI  IN  HEALTH  AND  DISEASE/ 


PLATE  XXIX. 

Fig.  1  represents  a  view  of  the  normal  membrana  tympani  (left  ear),  as  seen  by  the 
light  reflected  from  an  unclouded  sky  in  broad  daylight.  The  lighter  shade  of  color 
observed  in  the  centre  of  the  membrane,  around  the  tip  of  the  handle  of  the  hammer, 
is  due  to  the  reflection  of  light  from  that  portion  of  the  inner  wall  of  the  tympanum 
which  is  called  the  promontory.  This  area  of  lighter  coloring  will  vary  in  extent  and 
intensity  according  to  the  distance  of  the  membrane  from  the  promontory,  and  also 
according  to  the  degree  of  transparency  of  the  membrane  itself.  The  color  of  the 
remaining  portions  of  the  membrane  may  be  described  as  a  neutral  gray.  The  handle 
of  the  hammer  begins  on  the  left-hand  side  of  the  figure,  above  the  middle  line,  as  a 
whitish-yellow  knob,  the  "short  process,"  and  terminates  at  or  near  the  centre  (or 
"umbo")  of  the  membrane.  The  so-called  "bright  spot"  extends  from  this  central 
point  almost  to  the  periphery  of  the  membrane,  a  little  in  front  (that  is,  to  the  left)  of  the 
median  line  of  the  figure.  In  shape  it  is  a  well-defined  triangle,  whose  base  corresponds 
with  the  periphery  of  the  membrane.  It  is  produced  by  the  reflection  of  light  from  a 
polished  surface,  and  whatever  other  significance  it  may  have,  it  certainly  furnishes  a 
valuable  criterion  by  which  we  may  judge  of  the  state  of  nutrition  of  the  membrane. 

Fig.  2  represents  a  normal  membrana  tympani  belonging  to  the  right  ear.  The 
more  solid  tissues  which  fill  the  gap  between  the  neck  of  the  hammer  and  the  spina 
tympanica  posterior,  and  which  are  commonly  known  as  the  "posterior  fold,"  are  re- 
presented here.  They  begin  at  the  "short  process,"  and  run  backward  (that  is,  to  the 
left)  in  the  shape  of  a  sickle,  along  the  upper  boundary  of  the  membrane.  The  halo- 
like reflection  from  the  promontory  is  less  marked  than  in  Fig.  1,  and  the  bright  spot 
does  not  extend  quite  to  the  periphery  of  the  membrane. 

In  the  case  from  which  Fig.  3  was  taken,  an  oil  lamp  was  used  for  illuminating  pur- 
poses. Hence  the  reddish-yellow  hue  of  the  membrane.  The  delicate  red  line  which 
forms  the  posterior  limit  of  the  handle  of  the  hammer,  represents  a  congested  condition 
of  what  are  technically  known  as  the  "manubrial  vessels."  These  vessels,  which  are 
considerably  larger  than  any  of  those  which  traverse,  the  membrane  proper,  are  the 
first  to  respond  to  any  irritation  of  the  adjacent  auditory  canal,  or  to  show  the  effect 
of  pressure  (such  as  a  speculum  is  apt  to  produce)  upon  the  efferent  veins  of  this  part 
of  the  ear.  It  will  also  be  noticed  that  the  "bright  spot"  is  interrupted  midway  be- 
tween the  "  umbo"  and  the  periphery  of  the  membrane. 

The  membrane  pictured  in  Fig.  4  is  classed  by  Prof.  Politzer  with  the  three  which 
precede  it,  as  a  normal,  but  unusually  transparent,  membrana  tympani.  The  triangular 
figure  seen  to  the  left  of  the  handle  of  the  hammer  is  made  up  in  part  of  the  lower 
portion  of  the  long  process  of  the  anvil  (the  whitish  line  which  runs  in  a  direction 
parallel  with  that  of  the  handle  of  the  liammer),  and  in  part  of  the  posterior  arm  or 
limb  of  the  stirrup  (the  more  delicate  whitish  line  which  runs  in  a  direction  continuous 

'  These  illustrations  are  copied,  by  permission,  from  the  admirable  colored  plates  drawn  by 
Prof.  Adam  Politzer,  of  Vienna,  and  published  in  his  well-known  work  "  Die  Beleuchtungsbilder 
des  Trommelfells  im  gesunden  und  kranken  Zustande"  (Wien,  1865). 


748 


INJURIES  AND  DISEASES  OF  THE  EAR. 


with  that  of  the  "bright  spot").  The  anterior  limb  of  the  stirrup  is  concealed  behind 
the  long  process  of  the  anvil. 

It  is  quite  possible  that  at  the  present  time — these  colored  drawings  were  made 
twenty  years  ago — Prof.  Politzer  might  feel  disposed  to  interpret  the  appearances  pre- 
sented in  this  figure  as  indicating  a  condition  of  atrophy  (from  sclerosis),  rather  than 
one  of  normal,  though  unusual,  transparency  of  the  membrane.  The  absence  of  an 
unusual  whiteness  of  the  inner  wall  of  the  tympanum  is  the  only  feature  which  seems 
to  me  to  be  lacking,  if  my  supposition  is  correct. 

Fig.  5  represents  a  markedly  congested,  but  otherwise  only  slightly  altered,  membrana 
tympani,  such  as  is  commonly  seen  in  the  early  stage  of  an  acute  catarrhal  (non-puru- 
lent) inflammation  of  the  middle  ear.  The  chief  redness  is  noticed  along  the  handle 
of  the  hammer  (manubrial  vessels),  and  near  the  circumference  of  the  membrane 
(peripheral  vessels).  In  the  intermediate  space  between  the  manubrial  and  the 
peripheral  vessels,  may  be  seen  a  few  superficial  ones,  which  serve  as  connectir  «y  ^*nks 
between  the  two  systems. 

In  Fig.  6,  the  inflammatory  changes  are  represented  as  having  gone  a  step  further. 
The  epidermoid  surface  is  less  polished  (commencing  serous  infiltration),  and  ecchymoses 
may  be  seen  at  several  points,  especially  between  the  handle  of  the  hammer  and  the 
posterior  periphery  of  the  membrane. 

Figs.  7  and  8  show  an  advanced  stage  of  inflammation  of  the  membrana  tympani. 
The  parts  are  so  much  swollen  and  gorged  with  blood  that  the  handle  of  the  hammer 
can  no  longer  be  distinguished.  Masses  of  desquamating  epithelium,  infiltrated  with 
pus,  appear  like  irregularly  shaped  patches  of  a  reddish  or  yellowish-white  color  upon  a 
purplish  or  bright  red  background.  In  Fig.  7,  a  process  of  granulation  has  raised  the 
tissues  of  the  membrane  into  low  prominences.  In  Fig.  9,  the  circular  dark  spot  in  the 
lower  part  of  the  inflamed  membrane  represents  a  sharply  cut  perforation. 

In  Fig.  10,  the  following  peculiarities  should  be  noted:  the  marked  foreshortening  of 
the  handle  of  the  hammer,  its  tip  at  the  umbo  being  somewhat  indistinct,  while  the 
short  process,  which  lies  nearer  to  the  observer's  eye,  is  unusually  prominent  and  well 
defined ;  and  the  decided  prominence  of  the  posterior  fold. 

The  grayish-white  margin  at  the  periphery  of  the  membrane  represented  in  Fig.  12, 
corresponds  to  the  annulus  cartilagineus,  or  that  portion  of  the  membrana  tympani 
which  fits  into  the  sulcus  tympanicus.  The  grayish-white  color  is  probably  due  to  the 
presence  of  fat  cells.  Politzer  compares  it  to  the  arcus  senilis  of  the  cornea.  The 
free  portion  of  the  membrane  in  this  figure  seems  to  be  unnaturally  curved  inward. 

PLATE  XXX. 

The  different  figures  in  this  plate  represent  the  lesions  which  often  remain  after  the 
subsidence  of  a  purulent,  destructive  inflammation  of  the  tympanum. 

In  Fig.  2,  the  appearances  are  as  if  the  greater  part  of  the  right  membrana  tympani 
had  been  destroyed.  The  white  circular  spot  above  and  to  the  right,  represents  the 
short  process  of  the  hammer,  whose  very  much  foreshortened  handle  runs  (in  the  draw- 
ing) downward  and  backward  until  it  seems  to  touch  the  exposed  inner  wall  of  the 
tympanum.  A  thickened  remnant  of  the  original  membrane  is  still  attached  to  the 
handle  of  the  hammer.  It  somewhat  resembles  in  shape  a  new  moon.  The  rounded 
surface  over  which  two  or  three  bloodvessels  may  be  seen  to  ramify,  represents  either 
the  mucous  membrane  of  the  inner  wall  of  the  tympanum,  or  a  thin  reproduction  of 
that  part  of  the  drum  membrane  which  ulceration  has  destroyed.  In  the  latter  case, 
as  the  newly-formed  membrane  would  be  closely  applied  to  the  inner  wall  of  the  tym- 
panum, mere  ocular  inspection  would  scarcely  suffice  to  determine  accurately  the  true 
relations  of  the  parts. 

Fig.  3  represents  an  ear  (left  side)  from  which  the  greater  part  of  the  membrana 
tympani  has  been  removed  by  disease.    Anteriorly  (that  is,  toward  the  left)  a  whitish, 


PLATE  XXX. 


i. 

I 


1> 

■ 

* 

10. 


8. 


11. 


Ik 


APPEARANCES  OF  MEMBRANA  TYMPANI  IN  HEALTH  AND  DISEASE. 


749 


thickened  remnant,  representing  about  a  third  of  the  entire  membrane,  still  remains 
in  situ.  The  hammer  has  probably  been  destroyed,  but  the  familiar,  triangular  figure, 
which  represents  the  long  process  of  the  anvil  and  the  posterior  limb  of  the  stirrup, 
may  still  be  seen  in  the  upper  part  of  the  drawing.  P^nlarged  bloodvessels  traverse  the 
promontory.  Below  and  to  the  right,  will  be  observed  a  sharply  outlined  excavation, 
which  represents  the  niche  for  the  round  window  (fenestra  rotunda). 

In  Figs.  5  and  6,  the  evidences  of  former  perforations  are  easily  recognized,  the 
newly-formed  membranes,  or  "cicatrices,"  as  they  are  technically  called,  being  thinner 
and  more  transparent  than  the  surrounding,  original  membrana  tympani.  In  Fig.  4, 
the  lower  perforation  still  remains  open,  and  its  thickened  edges  seem  to  have  under- 
gone calcareous  degeneration.  Two  other  small  patches  of  calcareous  material  lie 
between  it  and  the  short  process  of  the  hammer.  The  upper  and  much  larger  perfora- 
tion appears  to  have  healed  by  cicatricial  new-formation  of  membrane. 

Fig.  7  represents  one  of  two  conditions,  viz.,  either  a  highly  atrophied  and  sunken 
membrana  tympani,  or  one  which  has  been  entirely  reproduced  after  total  destruction. 
The  picture  presented  would  be  the  same  for  either  condition.  The  handle  of  the 
hammer  apparently  presses  with  its  tip  against  the  tissues  of  the  promontory  or  inner 
wall  of  the  tympanum.  The  deep  shadow  between  the  handle  of  the  hammer  and  the 
posterior  fold,  shows  how  atmospheric  pressure  or  adhesions  have  forced  this  part  of  the 
membrane  far  inward  beyond  the  plane  which  it  naturally  occupies. 

Extensive  calcareous  deposits  are  shown  in  Figs.  9,  10,  and  11.  Extensive  thick- 
ening, with  still  lingering  inflammatory  action,  may  be  seen  in  Fig.  8.  In  Fig.  12, 
healing  seems  to  have  taken  place  despite  extensive  proliferative  and  destructive  pro- 
cesses.   In  the  midst  of  the  ruins,  the  handle  of  the  hammer  is  barely  recognizable. 


DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS 
ACCESSORY  SINUSES. 


BY 

GEORGE  M.  LEFFERTS,  M.A.,  M.D., 

CLINICAL  PROFESSOR  OF  LARYNGOSCOPY  AND  DISEASES  OF  THE  THROAT  IN  THE  COLLEGE  OF  PHYSICIANS 
AND  SURGEONS,  MEDICAL  DEPARTMENT  OF  COLUMBIA  COLLEGE,  NEW  YORK  ;  CONSULTING 
LARYNGOSCOPIC  SURGEON  TO  ST.  LUKE'S  HOSPITAL,  ETC. 


Introduction  :  Description  of  Instruments,  etc. 

The  direct,  visual  examination  of  the  nasal  passages  and  upper  pharyngeal 
space,  first  undertaken  and  rendered  possible,  by  means  of  his  "light-con- 
ductor," by  Bozzini,  was  an  obsolete  art  until  amplified  and  rendered  readily 
practicable  by  the  genius  of  Czermak,  and  still  further  elaborated  and  better 
utilized,  both  from  a  pathological  and  therapeutical  standpoint,  by  Fraenkel 
and  Michel,  and  especially  by  Voltolini  and  Zaufal.  The  method  introduced 
by  Ozermak  is  that  generally  employed  to-day,  the  innumerable  modifica- 
tio.ns  which  represent  the  inventive  ingenuity  of  many  specialists  yielding 
upon  practical  trial  to  the  more  simple,  yet  fully  as  efiicient,  method  and 
apparatus  of  the  first-named  operator.  Complete  rhinoscopy  consists  in  both 
the  direct  inspection  of  the  nasal  passages  anteriorly,  through  the  nostrils 
held  dilated  by  means  of  a  suitable  speculum,  and  the  examination  of  the 
posterior  portions  of  the  same  passages,  the  supra-palatine  walls  and  their 
contents,  the  posterior  surface  of  the  velum,  and  the  upper  pharyngeal  space, 
with  the  necessary  aid  of  a  femall  mirror  which  is  introduced  through  the 
mouth,  and  which  is  held  in  a  position  midway  between  the  relaxed  soft 
palate  and  the  posterior  pharyngeal  wall.  The  former  method  may  properly 
be  designated  anterior  rhinoscopy  and  the  latter  poster  tor  rhinoscopy^  or,  more 
exactly,  pharyngo-rhinoscopy. 

Instruments  for  Examination  of  the  ]N"asal  Cavities. — These  are  but 
few  and  simple :  (1)  A  forehead  reflector  and  (2)  an  argand  gas-burner,  or 
some  equally  efl3.cient  source  of  illumination  ;  and  in  addition,  for  anterior 
rhinoscopy,  (3)  a  nasal  speculum ;  and  for  the  posterior  examination,  (4)  a 
small  mirror  and  (5)  a  tongue  spatula. 

The  forehead  reflector  is  a  round,  slightly  concave  mirror,  either  three  and 
a  half  or  four  inches  in  diameter,  with  a  perforation  in  its  centre,  or  with  the 
glass  simply  left  unsilvered  at  that  point.  Its  focal  distance  should  be  about 
fifteen  inches.  It  is  attached  either  to  an  elastic  headband,  with  ball-and-socket 
support  (Kramer),  or  to  a  spectacle  frame  (Mackenzie),  and  may  be  worn 
over  either  eye,  or  upon  the  forehead  ;  the  former  method  is  the  more  correct 
one,  and  the  right  eye  is  to  be  preferred. 

Illumination. — The  form  of  "  light"  apparatus  that  shall  be  employed 
depends  upon  the  choice  of  the  surgeon  ;  this  may  have  a  wide  ransre,  for  the 

(  <  ^1 ) 


752      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


Forehead  reflector. 


varieties  are  legion  ;  bat  the  basis  of  each  is  the  same,  and  they  vary  only  in 
their  nature,  their  details,  and  the  number  of  condensing  lenses  that  are  used 

to  intensify  their  illuminating  pow^r.  For 
ordinary  purposes,  there  is  no  better  nor  more 
convenient  light  that  that  which  is  furnished 
by  the  argand  gas-burner,  mounted  upon  a  drop- 
light  or  stand,  w^hich  permits  of  the  flame  be- 
ing lowered  or  elevated  at  will,  or  upon  the  arm 
of  a  gas  bracket  fastened  to  the  wall.  Such  a 
light  certainly  is  easily  procurable,  and  at  a 
slight  cost  if  gas  is  obtainable ;  if  not,  as  in 
the  country,  the  ordinary  lamp  known  as  the 
"  student,"  which  burns  petroleum  or  oil,  forms 
a  very  efficient  substitute.  It  is  no  difficult 
matter  to  attach  to  either  of  these  lights  a 
single  plano-convex  lens,  two  and  one-half 
inches  in  diameter,  which  fits  into  the  metallic 
tube  or  chimney  known  as  Mackenzie's,  if  it 
be  deemed  desirable  to  intensify  their  illumi- 
nating powers,  as  will  probably  be  the  case  when  it  is  remembered  that  the 
light  for  rhmoscopy  should  necessarily  be  more  intense  than  that  used  for 
laryngoscopy,  and  that  sunlight  is  here  unavailable. 


Fig.  967. 


Illuminating  apparatus  for  rhinoscopy. 

Nasal  specula  exist  in  great  variety.  The  forms  here  figured  will  be  found 
to  be  the  most  efficient,  as  well  as  the  most  recent.    Fraenkel's  possesses  the 


Fig. 


Fig.  969. 


Fig.  970. 


Robert  and  Collin's  Fraenkel's  nasal  speculum.  Nasal  speculum, 

nasal  speculum. 

advantage  of  allowing  the  dilatation  of  both  nostrils  simultaneously.  An 
ordinary  ear  speculum  answers  a  good  purpose  in  children.    Zaufal  has 


DESCRIPTION  OF  INSTRUMENTS,  ETC.  753 


devised  a  long  tube  of  metal  or  hard-rubber,  ending  in  an  expansion  similar 
to  that  of  the  ear  speculum  (3-7  mm.  in  diameter,  and  10-12  cm.  in  length), 
by  means  of  which,  when  it  has  been  introduced  into  and  through  the  nasal 


Fig.  971.  Fig.  972. 


Elsberg's  nasal  speculum.  Thudichum's  nasal  speculum. 


passage,  the  pharyngeal  orifice  of  the  Eustachian  tube  and  the  posterior 
wall  of  the  pharynx  become  visible.  Voltolini,  Troltsch,  Roth,  and  others, 
use  a  double-bladed  metal  speculum,  in  which,  after  introduction,  the  blades 

Fig.  973. 


Rhinoscopic  mirror. 

are  separated  by  a  screw  arrangement  at  the  handle.  Schnitzler  has  modi- 
fied this  instrument  by  making  longitudinal  openings  along  the  blades, 
to  permit  a  lateral  inspection.  Elsberg  uses  a  trivalve  speculum  similar  to 
the  tracheal  dilator  of  Laborde ;  Thudichum,  one  in  which  two  narrow 
metallic  blades  are  separated  by  the  resiliency  of  a  bowed  spring  of  wire, 
which  holds  them  attached  to  each  other.  It  is  well  adapted  to"^  facilitate 
operations  upon  the  nasal  passages.  Finally,  a 
hook,  a  bent  hair-pin,  a  probe,  or  some  equally  sim-  Fig.  974. 

pie  instrument  often  sufiices,  by  pulling  the  wing 
of  the  nostril  aside,  to  allow  of  a  good  view  being 
obtained  of  the  deeper  parts  of  the  passage. 

Rhinoscopic  i][/^>ror.— Specially  constructed  mir- 
rors are  not  necessary  for  rhinoscopic  purposes, 
though  many  have  been  devised.  Those  of  Fraen- 
kel,  Yoltolini,  Mackenzie,  and  Stork,  are  perhaps 
the  best  known,  but  the  combination  of  tongue 
spatula  and  mirror  that  exists  in  some  of  these,  is 
inconvenient  and  often  impracticable,  and  the  same 
may  be  said  of  the  apparatus  of  Duplay,  which  aims 
to  combine  a  retractor  for  the  soft-palate  with  the 
mirror.  The  ordinary  rhinoscopic  mirror  resem- 
bles precisely  that  used  for  laryngoscopic  examina- 
tion, except  that  it  is  usually  smaller,  and  that  the 
glass  stands  at  nearly  a  right  angle  to  the  shaft,  or 
that  this  is  bent  somewhat  in  the  form  of  an 
italic  aS'  (Lennox  Browne).  The  glass  is  circular, 
is  covered  with  amalgam  posteriorly,  has  a  plane 

reflecting  surface,  and  is  set  in  German  silver.    Its         Tiirck's  tongue  spatma. 
VOL.  IV. — 48 


754      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

diameter  is  half  an  inch,  and  its  thickness  one-twentieth ;  to  it  is  soldered,  at 
the  nearly  right  angle  described,  a  partly  flexible,  and  preferably  a  straight 
shank  of  metal,  which  terminates  in  a  convenient  handle,  where  it  can  be 
lengthened  or  shortened  at  will  by  means  of  a  screw.  The  size  of  the  mir-  > 
ror  that  should  be  used  in  a  given  case,  depends  entirely  upon  the  amount  of 
space  existing  between  the  patient's  relaxed  velum  and  the  posterior  pharyn- 
geal wall.  This  will  be  found  to  vary  greatly,  but,  as  a  rule,  the  small  mirror 
described  is  the  most  practical. 

Tongue  Spatula, — The  tongue  spatula  modelled  after  the  pattern  of  Tiirck 
is  well  adapted  to  fulfil  its  purpose.^ 

Anterior  Rhinoscopy.— The  position  of  the  patient,  of  the  surgeon,  and 
of  the  source  of  illumination,  do  not  vary  from  those  necessary  for  laryngo- 
scopy;  that  is,  the  patient  is  seated  erect,  in  a  straight  backed  chair, 
with  his  head  thrown  slightly  backward ;  the  surgeon,  seated  in  front  of 
him,  so  adapts  the  position  of  his  head,  upon  which  he  has  fastened  the 
concave  forehead  reflector,  as  to  place  it  on  a  level  with  that  of  the  patient, 
and  then  looks  directly  forwards  through  the  perforation  in  the  mirror,  with 
his  right  eye,  towards  the  latter's  nose  ;  the  rays  of  light,  as  they  come  from 
the  lamp  which  is  placed  upon  the  right  of  the  patient,  at  the  level  of  his 
ear,  are  then  caught  upon  the  forehead  reflector,  focused,  and  thence  reflected 
forwards  into  the  nasal  speculum,  which  is  now  introduced  into  the  nostril 
of  the  patient,  care  being  taken  not  to  pass  it  too  high  up  into  the  narrow 
space  between  the  cartilaginous  septum  and  the  outer  bony  wall  of  the 
nostril,  v/here  it  would  cause  pain.  Its  blades  are  next  dilated  or  separated, 
and  the  focus  of  light  is  carefully  thrown  between  them  and  into  the  nasal 
passages  ;  the  parts  of  the  latter  now  come  into  view,  and  will  be  seen  to  vary 
in  their  normal  configuration,  and  likewise  according  to  the  nature  and  degree 


Fig.  975. 


Anterior  rhinoscopy. 


of  their  diseased  condition.  Ordinarily  the  anterior,  and  parts  of  the  inferior, 
surfaces  of  the  two  lower  turbinated  bones,  the  side  of  the  septum,  and  the 

'  See  also  Baginsky  (Rhinoscopic  methods  of  examination  and  operation),  Volkmann, 
Klin.  Vortrage,  No.  160,  1879  ;  Harrison  Allen,  Aids  to  Diagnosis  in  Nasal  Diseases,  Pliila.  Med. 
Times,  1880-1,  vol.  xi.  p.  613  ;  Voltolini,  Rhinoskopie  und  Pharyngoskopie.  Breslau,  1879  ;  and 
Schnitzler,  Laryngoskopie  und  Rhinoskopie.    Wien,  1879. 


DESCRIPTION  OF  INSTRUMENTS,  ETC. 


755 


inferior  meatus  are  distinctly  visible,  the  extent  of  the  view  of  the  two 
latter  depending,  however,  upon  the  natural  formation  of  the  parts ;  for  it  is 
exceedingly  common  to  find  a  deflection  of  the  septum  nasi  to  one  side, 
usually  the  left,  narrowing  more  or  less  the  respective  naris,  occasionally 
occluding  it,  and  preventing  all  view  of  the  deeper  parts.  On  the  other  hand, 
cases  are  met  with  in  which  a  very  wide  and  roomy  meatus  permits  of  a 
view  directly  through  it  into  the  pharynx,  and  of  the  pharyngeal  orifice  of 
the  Eustachian  tube. 


Posterior  Rhinoscopy. — For  the  purposes  of  the  posterior  examination — 
to  illuminate  and  convey  to  the  eye  the  picture  of  the  upper  pharyngeal 
space,  the  posterior  nares,  and  more  or  less  of  the  posterior  portions  of  the 
nasal  passages  themselves — the  position  of  the  patient  and  surgeon,  and 
the  direction  and  method  of  employing  the  light,  are  the  same  as  for 
anterior  rhinoscopy,  with  two  exceptions  :  first,  that  the  focal  point  of  light 
is  to  be  thrown  into  the  open  mouth,  and  on  the  base  of  the  uvula ;  and 
second,  that  the  patient,  with  widely  opened  mouth,  allows  the  tongue  to  lie 
quietly  behind  the  lower  incisor  teeth,  and  depresses  it  well  down  upon  the 

Fig.  976. 


Posterior  rhinoscopy. 


floor  of  the  mouth  with  the  spatula  or  depressor.  The  rhinoscopic  mirror 
having  been  warmed,  is  now  carefully  introduced  from  the  corner  of  the 
mouth,  with  its  reflecting  surface  upwards,  carried  over  the  tongue  to  one 
side  or  other  of  the  uvula,  until  it  passes  beneath  the  motionless  velum,  and 


756      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

stands  midway  between  it  and  the  posterior  pharyngeal  wall,  touching  neither, 
and  at  an  angle  of  about  130°.  In  this  position,  it  will  be  impossible  to 
obtain  the  whole  picture  of  the  parts  at  once,  except  in  exceptional 
instances ;  and  the  face  of  the  mirror  must  therefore  be  turned  from  side  to 
side,  to  view  the  lateral  pharyngeal  walls  ;  upwards,  to  view  the  vault  of  the 
pharynx ;  and  at  more  or  less  different  angles  and  inclinations,  to  see  com- 
pletely the  parts  embraced  within  the  posterior  openings  of  the  nares. 

8uch  is  the  method ;  and  a  complete  examination  is  almost  always  practicable, 
though  comparatively  seldom  with  the  facility  which  attends  the  use  of  the 
larjaigoscopic  mirror.     Three  difficulties  may  present  themselves  to  prevent 
the  examination.    One  is  insuperable — a  long  hard  palate  which  approaches 
so  nearly  to  the  posterior  pharyngeal  w^all,  that  there  is  no  practicable  degree 
of  space  left  through  which  an  examination  can  be  effected.     A  second  is 
common,  and  may  require  an  additional  instrumental  procedure ;  this  condi- 
tion is  that  in  w^hich  a  long,  broad  soft  palate,  a  long  uvula,  and  a  short  dis- 
tance between  them  and  the  posterior  pharyngeal  w^all,  coexist,  and  in  which 
an  examination  can  only  be  made  when  the  former  are  drawm  away  from  the 
latter.    This  can  be  accomplished  by  means  of  the  so-called  palate  hook, 
made  of  metal,  or,  still  better,  a  broad,  well-curved  hook  of  hard  rubber,  or 
a  bougie  with  a  wire  centre  to  give  the  necessary  firmness.    The  latter  are 
much  better  tolerated  than  the  former ;  they  are  introduced  by  the  left  hand 
gently  under  the  palate  (the  right  hand  holding  the  mirror),  and  the  palate 
is  then  drawn  with  moderate  force  towards  the  operator — that  is,  away  from 
the  posterior  pharyngeal  wall.    This  procedure  rarely  succeeds,  however,  at 
the  first  trial,  though  successive  and  persevering  attempts        generally  end 
in  tiring  the  palatine  muscles  or  in  training  them  to  a  point  of  toleration,  and 
will  thus  overcome  the  spasmodic  contraction  which  at  first  follows  any  attempt 
to  draw  the  velum  forwards.    As  a  rule,  how^ever,  it  will  be  found,  that  the 
same  time  that  is  devoted  to  trainmg  the  patient  to  tolerate  this  hook,  or  any 
of  the  other  forms  of  instrument  that  have  been  devised  (Tiirck,  Lorry, 
Stork),  will  be  all-sufficient  to  train  him  to  "breathe  quietly  through  the  nose, 
and  to  cause  the  palate  to  hang  immovable  in  the  mouth.   The  third  and  last 
difficulty  exists  at  first  in  the  majority  of  cases.  It  is  caused  by  the  drawing 
up  of  the  velum  and  uvula  tightly  against  the  pharyngeal  w^all,  as  soon  as 
the  patient  opens  his  mouth  and  places  the  spatula  upon  the  tongue,  or  Avhen 
instruments  are  about  to  be  introduced  by  the  examiner.    Quiet  respiration, 
carried  on  through  the  nose,  wall  overcome  this  difficulty,  however,  at  once, 
Avhen  the  velum  will  be  found  to  hang  motionless  and  free  from  the  pharyn- 
geal wall.    If  the  patient  cannot  succeed  in  maintaining  respiration  through 
the  nose,  the  palate  may  be  made  to  fall  forwards  by  causing  him  to  emit 
certain  nasal  sounds,  such  as  the  French  eii.    The  first  plan  is  however  the 
best ;  the  examination  is  then  to  be  made  with,  celerity,  accuracy,  and  com- 
pleteness. 

Eeflex  irritability  of  the  pharyngeal  parts,  it  may  here  be  remarked,  is  a 
far  greater  disadvantage  than  when  it  occurs  as  an  impediment  to  laryngo- 
scopy. A  skilful  and  certain  hand,  with  some  training  of  the  parts,  will  do 
much  to  facilitate  the  examination. 

I  believe  that  it  will  rarely  be  found  necessary  for  the  purposes  of  exami- 
nation alone,  though  it  may  be  for  operative  procedures,  to  acquire  absolute 
control  of  the  soft  palate,  or  a  wider  patency  of  the  palato-pharyngeal  space, 
by  tying  the  palate  forwards,  as  advised  by  Stork  and  more  recently  by  Wales. 
This  procedure  consists  in  passing  a  cord  through  each  nostril  to  the  pharynx, 
drawing  the  ends  out  through  the  mouth,  passing  them  over  the  ear  on  each 
side,  and  tying  them  behind  the  head,  the  soft  palate  yielding  under  gentle 
traction,  and  being  folded,  as  it  were,  upon  itself.    Bos  worth  suggests  that  a 


DESCRIPTION  OF  INSTRUMENTS,  ETC.  757 

linen  cord,  stiffened  with  'mucilage,  or  a  piece  of  catgut,  might  be  passed  in 
the  same  way,  but  more  conveniently,  by  means  of  a  small  catheter  shaped 
like  that  used  for  the  Eustachian  tube.  The  ends  of  the  cords  are  tied  by  a 
surc^-eon's  knot  of  three  turns,  over  the  upper  lip,  or  are  held  by  an  ingenious 
littfe  clamp  devised  by  Jarvis.  The  operation  should  be  performed  quickly 
and  skilfully,  when  it  is  fairly  well  tolerated  by  the  patient.  ^ 

The  Rhinoscopic  Image. — As  the  mirror  is  passed  into  position  behind  the 
velum,  the  first  object  which  attracts  attention  is  the  posterior  surface  of  the 
u  vula,'and  the  next  the  posterior  surface  of  the  velum,  a  broad,  reddish  expanse, 
which  arches  upwards  so  as  to  cut  off  from  view,  in  the  majority  of  instances, 
more  or  less  of  the  inferior  portions  of  the  nares  proper,  and  thus  partly 
hides  the  posterior  extremities  of  the  inferior  turbinated  bones.  The  septum 
nasi  now  comes  into  view,  and  as  it  is  the  most  easily  recognizable  of  all  the 
parts,  it  serves  as  a  landmark  or  guide  for  the  rhinoscopic  picture,  as  the 
vocal  cords  do  for  that  of  the  larynx.  It  is  a  thin,  sharp  ridge,  whitish  in 
color,  and  its  sides  are  readily  seen  for  some  distance ;  above,  it  widens,  be- 
comes of  a  deeper  color,  and  merges  into  the  parts  which  go  to  make  up  the 
vault  of  the  pharynx.  To  either  side  of  it  are  seen  dark,  ovoid  openings, 
the  posterior  nares,  which  are  more  or  less  occupied  by  the  three  turbinated 
bones,  bulbous  bodies  of  a  gray  or  ashy-red  color.  The  middle  one,  with 
part  of  the  middle  meatus  of  the  nose, 

is  the  most  distinct.    Parts  only  of  the  Fig-  ^^^'^ 

superior  and  inferior  bones  are  visible ; 
the  former  appears  simply  as  a  nar- 
row projection  from  the  outer  wall  of 
the  nasal  fossa,  extending  downwards, 
inwards,  and  backwards,  to  lose  itself 
behind  the  middle  turbinated  bone; 
the  inferior,  which  overlaps  the  middle 
bone,  and  the  upper  portions  of  which 
alone  are  visible,  appears  as  a  rounded, 
hard  tumor,  with  an  irregular  and  gray- 
ish colored  surface.  Of  the  meatuses  The  rhinoscopic  image, 
of  the  nose,  the  middle  is  the  most  dis-  ^  •  n  - 
tinct,  the  upper  appearing  only  as  a  dark  line  or  depression,  while  the  inferior 
is  only  occasionally  seen.  About  the  level  of  the  inferior  turbinated  bone, 
further  towards  the  sides  of  the  picture  seen  in  the  mirror,  and  upon  a  differ- 
ent plane,  is  seen  on  either  side  a  rounded,  smooth  projection,  of  a  bright- 
red  color.  This  is  continuous  below  with  two  sharp,  elevated  ridges  of 
mucous  membrane,  the  anterior  of  which  contains  the  fibres  of  the  levator 
pala,ti  muscle,  w^hich  pass  downwards  and  inwards  to  the  dorsum  of  the 
velum,  where  they  are  finally  lost.  These  are  the  pillars  of  the  pharyngeal 
orifice'of  the  Eustachian  tube,  the  rounded  mouth  of  which  lies  between  them 
at  the  point  where  they  leave  the  rounded  protuberance  above  mentioned. 
If  this  latter  be  follow^ed  upwards,  backwards,  and  outwards,  it  will  be  seen 
to  bound  and  define  a  deep  groove,  which  lies  between  it  and  the  plane  of 
the  posterior  pharyngeal  wall,  the  fossa  of  Rosenmiiller.* 

If  the  inclination  of  the  mirror  be  now  changed  to  a  more  obtuse  angle, 
or  if  use  be  made  of  one  mounted  at  the  laryngoscopic  angle,  the  domelike 
cavity  of  the  vault  of  the  pharynx  will  be  brought  into  view.  This  presents 
an  irreo-ular  outline,  resembling  a  glandular  structure  upon  its  surface,  and 
extends'  downwards  towards  each  Eustachian  orifice  in  a  series  of  usually 

I  It  should  be  borr.e  in  mind  that  Fig.  977.  is  necessarily  somewhat  diagrammatic.  Fig.  97'« 
represents  the  parts  of  the  posterior  nares  more  as  in  reality  they  appear. 


758      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

longitudinal  furrows  and  ridges — the  adenoid  tissue  of  the  vault,  or  pharyn- 
geal tonsil  of  Luschka.  As  this  tumefaction — marked  in  some  cases,  absent 
in  others ;  frequent  in  children,  rare  in  adults  under  normal  conditions — 
merges  gradually  into  the  smooth  surface  of  the  posterior  pharyngeal  wall, 


Fig.  978.  Fig.  979. 


The  rhinoscopic  image.  Vault  of  the  pharynx  as  seen  by  posterior 

rhinoscopy. 


it  can  no  longer  be  traced ;  the  mucous  membrane  of  the  latter,  deep-red, 
smooth — with  the  exception  of  an  occasional  follicle — and  shining,  sup- 
plants it. 

Instruments  for  Treating  the  Affections  of  the  Nasal  Cavities. — The 
instruments  employed  for  the  preliminary  cleansing  of  the  nasal  passages 
being,  in  many  of  their  diseases,  identical  with  those  required  for  their  sub- 
sequent medication,  their  general  coAsideration  at  this  point  will  be  condu- 
cive to  both  brevity  and  clearness. 

Instruments  and  Methods  of  Cleansing. — The  best  known  apparatus,  cer- 
tainly the  one  most  widely  used  to-day,  is  the  so-called  nasal  douche  of 

Weber  and  Thudichum,  either  in  its  original  form 
Fig.  980.  or  in  one  of  its  many  modifications.  Without  enter- 

ing into  a  discussion  of  its  possible  merits  and  pos- 
itive disadvantages,^  and  while  questioning,  upon 
the  basis  of  a  practical,  clinical  experience,  the 
reality  of  the  dangers  to  the  middle  ear  from  its 
use,  which  have  been  so  vividly  pictured  by  Moos, 
Roosa,  Knapp,  and  others,  I  must  record  my  convic- 
tion that  it  is  an  inefficient  instrument  for  the  pur- 
pose for  which  it  was  designed,  inasmuch  as  it  does 
not  thoroughly  wash  or  cleanse  the  nasal  cavities  even 
when  carefully  used.  This  assertion  is  readily  sub- 
tantiated  by  observation,  and  I  may  even  add  that 
its  very  general  employment  by  the  laity,  unguided, 
too  often,  by  professional  advice,  is  productive  of 
much  harm  ;  that  even  apparent,  temporary  good 
effects  ultimately  fail ;  and  that  the  use  of  strong 
saline  solutions  in  large  quantity,  and  passed  through 
the  nares  under  high  pressure  in  a  divided  or  in- 
Nasal  douche,  terrupted  jet  or  stream,  is  not  unfrequently  an  effi- 

cient factor  in  the  propagation,  if  not  in  the  causa- 


Robinson,  Med.  Record,  July  15,  1874. 


DESCRIPTION  OF  INSTRUMENTS,  ETC. 


759 


tion,  of  a  chronic  inflammation  of  the  delicate  nasal  mucous  membrane,  with 
its  usual  result  of  permanent  infiltration  of  the  mucous  and  submucous 
layers,  rather  than  a  means  of  its  relief.  With  Robinson,  I  believe  that  the 
employment  of  these  instruments  should  be  restricted,  if  used  at  all,  to  excep- 
tional cases  of  very  aggravated  catarrhal  inflammation,  with  accumulation  of 
pent-up  and  hardened  s'ecretions ;  and  that  even  here  the  posterior  nasal  syringe 
answers  a  better  purpose.  In  ordinary  catarrhal  disease  the  douche  is  never 
required.  In  my  practice,  the  use  of  the 
nasal  douche  has  been  entirely  superseded  Fig.  981. 

by  that  of  an  instrument  made  of  hard 
rubbei',  fashioned  in  an  effective  and  conve- 
nient form,  and  so  arranged  as  to  throw  a 
powerful  coarse  spray.  This  apparatus,  I, 
and  others  with  me,  have  found,  upon  ex- 
tended trial,  to  be  efficient,  agreeable  to  the 
patient,  less  painful  than  the  douche,  and 
devoid  of  all  possible  danger.  With  it,  the 
entire  nasal  passages  and  upper  pharynx 
may,  except  in  exceptional  instances,  be 
thoroughly  cleansed  of  crusts  and  secretions 
by  the"  use  of  less  than  one  ounce  of  the 
medicated  fluid  in  spray.    (The  latter  prin-  Nasai  spr  ay  apparatus, 

ciple  is  an  essential  one,  in  the  nature  of 

the  apparatus.)  This  instrument  should  be  used,  proper  indications  existing, 
according  to  the  following  rules,  which  are  to  be  given  to  the  patient,  to 
insure  its  efficient  employment  on  his  part : — 

1.  Warm  the  medicated  fluid  in  the  bottle  before  using,  by  holding  the  filled  bottle 
for  a  few  moments  in  hot  water. 

2.  Hold  the  body  erect  and  incline  the  head  very  shghtly  forward  over  the  toilet 
basin. 

3.  Introduce  the  conical  nozzle  of  the  apparatus  into  the  nostril  (first  on  the  side 
most  occluded),  far  enough  to  close  it  perfectly,  holding  at  the  same  time  the  hori- 
zontal tube  of  the  apparatus  directly  outwards  from  the  face  ;  do  not  turn  it  from  side 
to  side,  or  downwards  ;  make  a  trial  of  the  spray  by  compressing  the  hand  ball  once, 
to  prove  that  the  opening  in  the  nozzle  is  not  occluded  in  the  nostril,  and  then — 

4.  Open  the  mouth  widely  and  l^reathe  gently,  but  quickly  through  it  in  a  snoring 
manner;  avoid  carefully  all  attempts  at  speaking,  swallowing,  or  coughing;  at  the  mo- 
ment that  the  fluid  passes  into  the  upper  part  of  the  throat  from  the  nostril  being  ope- 
rated upon,  a  desire  to  swallow  will  be  experienced — resist  it — and  the  next  second  the 
fluid  will  pass  forwards  through  the  opposite  nostril. 

5.  Hold  the  end  ball  of  the  apparatus  firmly  in  the  right  hand  (the  left  holds  the 
bottle)  and  operate  it  briskly,  until  the  spray  of  medicated  fluid,  which  should  be  felt 
at  once  to  enter  the  nasal  passage,  has  passed  around  it  and  appears  at  the  opposite  nos- 
tril ;  stop  at  this  moment. 

6.  Remove  the  nozzle  from  the  nostril,  allow  the  surplus  fluid  to  run  out  of  the  latter, 
and  blow  the  nose  gently.     Never  vigorously. 

7.  Repeat  the  operation  upon  the  opposite  nostril. 

Various  cleansing  solutions  may  be  used  in  the  apparatus ;  one  of  the  best 
is  as  follows :  Acidi  carbolici,  9]  (this  quantity  is  often  necessarily  varied  to 
suit  the  susceptibility  of  different  mucous  membranes) ;  sodii  biborat.,  sodii 
bicarb,  aa  5j  ;  aqupe  rosEe,  gl^^cerinpe,  aa  f  ;  aquae  ad  Oj.  Or  still  better,  sodii 
bicarbonat.,  sodii  biborat.,  aa  5ss;  "Listerine,"  f^j  ;  aquae  ad  f.liv.  Where  a 
much  larger  quantity  of  a  cleansing  solution  is  necessarily  used,  as  with  the 
anterior  or  posterior  nasal  syringe,  simple  warm  water,  with  the  addition  of 
borax,  ten  grains  to  each  ounce — or  "  Listerine,"  in  the  proportion  of  one  part 


760      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

to  from  two  to  ten  of  warm  water — will  answer  the  purpose  well.  Some- 
times, when  the  disagreeable  odor  is  strong,  I  use,  after  a  thorough  syringing 
with  one  of  these  alkaline  solutions,  a  spray  of  equal  parts  of  "  Listerine" 
and  water ;  it  destroys  fetor  very  quickly,  and  substitutes  for  it  the  pleasant 
odor  of  thyme.  It  will  be  noticed  that  I  use  no  sodium  chloride  in  any  of 
these  cleansing  solutions.  I  believe  that  it  does  more  harm  than  good  ;  that 
the  saline  solution  favors  endosmosis  as  it  passes  over  the  nasal  mucous  mem- 
brane, and  therefore  increases  rather  than  diminishes  intra-nasal  swelling. 
Many  other  formulse  will  suggest  themselves,  as,  for  instance,  Glycerini 
acidi  carbolici,  f5jss ;  sodii  biborat.  5j  ;  aquse,  ad  Oj.  Liquoris  potassii  per- 
manganatis,  f5jss;  sodii  biboratis,  3j  ;  aquee,  Oj.  Acidi  salicylici,  gr.  x  ;  sodii 
bicarbonatis,  5j ;  aquse,  Oj.  All  solutions,  whatever  their  nature,  should  be 
at  about  blood  heat  when  used.  In  the  severer  forms  of  nasal  disease — those 
attended  by  the  formation  and  firm  impaction  in  the  passages  of  hard,  dense 
crusts — as  in  simple  and  syphilitic  oz8ena,  atrophic  and  fetid  catarrh,  and  the 
like,  the  use  of  the  spray  apparatus  will  not  be  sufficient  to  dislodge  these, 
in  the  first  instance,  and  a  more  powerful  means  (short  of  direct  instrumental 
removal)  must  be  employed.  This  may  be  best  obtained  by  the  posterior 
nasal  syringe,  of  hard  rubber  or  metal,  which  is  used  to  cleanse  the  parts 
posteriori}^  by  way  of  the  pharynx  and  posterior  nares  ;  or  by  means  of  a  suit- 
ably curved  hard-rubber  tube  used  in  the  same  way,  its  terminal  extremity 


Fig.  982. 


Posterior  nasal  syringe. 


being  pierced  with  coarse  perforations,  presenting  forwards  when  the  instru- 
ment is  in  place;  or,  perhaps,  with  a  slit  sawn  transversely,  so  as  to  give 'a 
fan-like  stream,  and  this  fastened  to  the  well-known  double  hand-ball  rubber 

Fig.  983.  ♦ 


Posterior  nasal  tube  fitted  to  Davidson's  syringe. 

tube  of  the  Davidson  apparatus.  For  the  anterior  nares,  the  ordinary  hard- 
rubber  syringe  of  the  aurist  answers  the  purpose. 

Methods  and  Instruments  of  Medication. — If  I  exclude,  for  the  moment, 
the  use  of  caustics  and  of  surgical  measures  in  the  management  of  catarrhal 
conditions  of  the  nares,  the  treatment  is  based  both  clinically  and  practically 
either  upon  the  employment  of  various  medicated  fluids,  used  in  spray  by 


DESCRIPTION  OF  INSTRUMENTS,  ETC. 


761 


means  of  some  form  of  atomizer,  or  upon  the  use  of  medicated  powders^  applied 
with  the  anterior  or  posterior  nasal  powder-insufflator,  in  its  various  forms. 
Both  methods  have  their  warm  advocates,  and  both  are  now  extensively 
employed,  and  properly  so,  to  the  exclusion  of  the  older  and  much  less  efficient 
methods  of  medication  in  the  treatment  of  nasal  disease.  My  own  experience 
prejudices  me  strongly  in  favor  of  the  spray.  I  believe  that  with  a  proper 
spray-tube,  and  with  a  pressure  of  compressed  air  of  40  pounds  or  more 
to  the  square  inch,  no  more  perfect  application  can  be  made  to  the  parts. 
This  should  always  be,  if  possible,  through  the  posterior  nares,  the  spray 
being  driven  forwards  through  the  nose;  and  to  insure  completeness,  the 
velum  of  the  patient  must  be  held  forwards,  by  means  of  a  suitably  curved 
hook  in  the  operator's  left  hand,  in  order  that  space  may  be  afforded  through 
which  to  throw  the  spray.  This  procedure  I  regard  as  absolutely  essential, 
in  order  to  secure  a  complete  application. 

Atomizers  or  spray  producers  are  constructed  upon  two  principles,  both 
familiar  to  the  protession,  and  too  well  known  to  require  an  extended  de- 
scription. A  type  of  the  first  class  is  found  in  the  atomizer  of  Richardson  ; 
and  of  the  second,  in  that  constructed  upon  the  principle  of  Bergson  ;  of  both, 
modifications,  mainly  in  form,  exist,  the  principle  remaining  the  same. 

The  most  convenient  and  most  efiicient  apparatus  is  that  here  figured  ;  but 


Fig.  984. 


Compressed-air  atomizer,  or  spray-producer. 


its  cost,  though  this  has  recently  been  materially  lessened,  may  prove  an 
obstacle  to  its  introduction  into  the  armamentarium  of  the  general  practitioner. 
It  consists  of  a  metal  air-receiver,  an  air-pump,  and  glass  atomizing  tubes, 
curved  so  as  to  throw  the  spray  upwards  (posterior  nares),  downwards  (larynx), 
and  backwards  (pharynx),  together  with  the  necessary  connecting  rubber  tubes. 
The  cylinder  having  been  filled  with  compressed  air  up  to  a  pressure  of 
from  40  to  60  pounds  to  the  square  inch,  as  shown  by  the  indicator,^  the 
spray-tube,  with  its  proper  end  immersed  in  the  medicated  fluid  contained 
in  the  small  vial  or  test-tube,  is  held  in  the  right  hand,  and  the  pressure 
of  the  air,  which  is  now  allowed  to  pass  by  turning  the  small  cock  upon  the 
tube  with  the  other  hand,  is  controlled  by  the  right  thumb  of  the  operator, 
pressed  upon  the  end  of  the  glass  tube  so  as  to  compress  the  rubber  pipe 
at  this  point.    It  is  thus  under  complete  control,  and  the  spray  can  now  be 


762     DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

caused  to  pass  instantly  in  a  stream,  or  in  small  jets,  regulated  exactly  as 
to  amount,  at  the  will  of  the  surgeon.  The  rubber  tubing  from  the  cylinder 
is  usually  made  to  fit  to  that  on  the  glass  atomizers  by  means  of  a  bayonet- 
joint,  but  the  more  elaborate  device  here  shown  (Fig.  985)  may  be  employed. 


Fig.  985, 


Spray-tube  with  patent  cnt^ff. 


con 


In  default  of  this  apparatus,  the  ordinary  hard-rubber  atomizers, 
structed  upon  the  principle  of  either  Richardson  or  Bergson,  may  be  used 
with  good  effect.  In  both,  the  propelling  power  is  developed  by  the  use  of 
the  hand  air-bulbs.  These  should  always  be  double  ;  a  single  air-bulb  gives 
but  an  intermittent  current  of  spray ;  the  addition,  between  the  hand-bulb 
and  atomizer,  of  a  second  and  more  elastic  one,  which  becomes  distended, 
by  exerting  a  continuous  pressure  will  furnish  a  steady  and  constant  stream. 
The  hard-rubber  tube  of  the  instrument  is  provided  with  three  separate 
tips,  arranged  to  throw  the  spray  in  the  directions  necessary  ;  and  its  main 
disadvantages  are,  the  length  of  time  that  it  takes  to  develop  the  pro- 
pelling power  by  means  of  hand-ball  pressure,  an  important  point  when  the 


Fig. 


Atomizer  throwing  spray  downward. 

instrument  is  in  position  in  an  ir- 
ritable throat,  and  the  fact  that  the 
current  of  spray  is  not  absolutely 
and  quickly  under  the  control  of 
the  o|)erator.  Asa  rule,  then,  the 
apijlication  with  this  instrument 


Another  form  of  atomizer. 


DESCRIPTION  OF  INSTRUMENTS,  ETC. 


763 


will  have  to  be  made  through  the  anterior  nares,  the  spraj  being  driven  well 
back  into  the  pharynx. 

Other  simpler  and  less  costly  spray  producers  are  now  made  in  great 
variety,  upon  the  plan  of  Bergson,  and  as  they  are  furnished  with  metal  tubes 
of  various  lengths  and  directions,  and  are  easily  })rocurable,  they  play  a 
useful  part  in  the  treatment  of  nasal  and  pharyngeal  diseases. 

Powder  Insufflators. — The  most  useful  forms  are  shown  in  the  following 
cuts.  One  is  arranged  (Fig.  988)  to  deliver  a  charge  of  the  finely  pulverized 
powder   with    which   the    bottle  is 


charged,    into    the    anterior  nares 


Fig.  988. 


(Smith),  and  the  second  (Fig.  989),  with 
a  longer,  curved  tube,  performs  the 
same  operation  in  the  posterior  nares. 
(Robinson.)  In  both,  the  short  tube  is 
connected  with  a  single  hand-ball  by 
means  of  a  piece  of  rubber  tubing,  and 
one  or  two  rapid  and  more  or  less  forci- 
ble compressions  of  this  hand-ball  are 
sufficient  to  force  a  small  quantity  of  the 
medicated  powder  into  the  nasal  pas- 
sages, either  anteriorly  or  posteriorly, 
and  to  cover  the  surfaces  of  the  parts 
with  an  even  coating  of  it;  the  same  result  may  be  obtained  by  the  use  of  the 
series  of  hard-rubber  tubes  devised  by  Robinson,  which  are  so  arranged  that 


Insufflator  for  anterior  nares. 


Fig. 


Insufflator  for  posterior  nares. 


they  may  be  attached  to  the  tube  of  the  cylinder  of  compressed  air,  in  the  same 
manner  that  the  spray-tubes  are  connected  with  it ;  or,  in  default  of  the  latter, 
the  tubes  may  be  arranged  with  a  piece  of  soft-rubber  tubing  and  a  mouth- 
piece, or  even  with  a  hand-ball,  so  that  the  powder  may  be  either  blown 
or  forced  through  the  nasal  passages  by  the  operator  himself.  Although 
various  forms  of  inhaler  and  steam-atomizer  play  an  important  part  in  the 
popular  treatment  of  nasal  catarrh,  they  certainl}^  as  a  rule,  exercise  no 
evident  beneficial  effects,  and  can  readily  do  harm.  In  cases  of  acute  coryza, 
and  in  those  of  long-standing  catarrhal  inflammation,  with  a  dry  and  irritabk 


764      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


mucous  membrane,  simple  steam,  or  warm,  atomized  inhalations,  may  occa- 
sionally be  indicated.  Robinson  recommends  dry,  cold  inhalations  of  volatile 

Fig.  990. 


Robinson's  tube  for  insufflation  of  nares. 


matters  m  old  catarrhal  inflammations  of  the  nasal  fossse,  and  says  that 
excessive  secretion  is  diminished  by  their  use  to  a  notable  degree. 

Diseases  of  the  ISTasal  Passages. 

Acute  Coryza. — Sudden  exposure  to  a  draft  of  cold,  damp  air,  especially 
when  the  body  is  overheated,  or  the  sudden  chilling  of  any  part  of  the  cuta- 
neous surface — especially  of  the  extremities — under  the  same  conditions,  is  all- 
efficient,  even  in  healthy  individuals,  in  bringing  about  an  acute  inflamma- 
tion of  the  Schneiderian  mucous  membrane,  which  may  remain  in  exceptional 
cases  confined  to  one  nasal  passage,  but  usually  aflfects  both,  and  not  infre- 
quently extends  thence  into  the  neighboring  cavities  of  the  nose,  and  even 
involves  the  Eustachian  tubes ;  other  causes,  in  rarer  instances,  produce  the 
same  effects.  Acute  coryza  is  one  of  the  earliest  manifestations  in  several  of 
the  exanthematous  fevers.  Attacks  of  an  obstinate  character  are  produced 
by  the  inhalation  of  irritating  gases  and  vapors,  dusts,  and  powders ;  a  pecu- 
liar idiosyncrasy  often  exists  in  respect  to  the  irritation  caused  by  certain 
drugs,  such  as  ipecacuanha  and  iodine  in  some  individuals.  The  internal 
use  of  iodide  of  potassium  may  cause  an  acute  coryza,  and  the  same  is  true  of 
other  mineral  poisons.  Trousseau  has  called  attention  to  the  relationship 
existing  between  asthma  and  coryza,  and  the  latter  is  often  the  direct  result 
of  the  extension  of  a  catarrhal  inflammation  from  contiguous  mucous  sur- 
faces, such  as  the  conjunctival,  or  that  of  the  pharynx.  As  one  of  the 
initial  manifestations  of  congenital  syphilis,  it  is  seen  in  the  infant ;  and 
recently  Mackenzie^  has  called  attention  to  the  influence  of  irritation  of  the 
sexual  apparatus  as  an  etiological  factor  in  its  production.  Usually  sporadic, 
it  may  become  epidemic  under  special  conditions  of  the  atmosphere. 

The  question  of  its  contagiousness  has  attracted  some  attention,  and  is  still 
held  in  dispute.^  Robinson  believes  that  when  encountered  among  the  early 
conditions  w^hich  point  to  the  development  of  an  acute,  general  disease  of 
epidemic  nature,  it  is  so  without  doubt,  just  as  the  disease  of  which  it  forms 
an  integral  part ;  and  that  even  w^hen  sporadic,  and  when  not  followed  by 
ulterior  symptoms,  there  is  a  probability  of  its  being  communicable.  All 
practitioners  will  unquestionably  recall  instances  in  which  the  aflection  has 
developed  successively,  not  simultaneously,  in  members  of  the  same  family, 
without  other  reason  than  the  mere  fact  of  its  presence  in  some  one  person. 

1  Am.  Jour.  Med.  Sciences,  April,  1884. 

2  Blackwell,  Med.  Record,  Jan.  10,  1880. 


DISEASES  OF  THE  NASAL  PASSAGES.  765 

Fraeiikel  cites  instances  in  support  of  the  view  of  its  direct  contagious  influ- 
ence while,  on  the  other  hand,  various  experimenters  have  tailed  in  all 
attempts  at  hioculation  of  the  healthy  mucous  membrane  with  the  secretions 
of  coryza.  (Friedreich.)  I  believe  it  fair  to  assume,  in  the  light  of  our  pres- 
ent knowledge,  and  reasoning  from  analogy,  that  the  secretions  ot  an  acute 
coryza  are,  at  certain  times  and  under  certain  conditions,  contagious ;  and 
clinical  ex])erience  endorses  this  view.  These  conditions  depend  mainly 
upon  the  peculiar  susceptibility  of  the  subject  to  its  influence,  and  upon  the 
stao-e  of  the  nasal  disease  in  which  the  secretions  are  taken,  but  in  no  event 
is  the  occurrence  a  common  one ;  the  aftection,  in  the  great  majority  ot  cases, 
runs  its  usual  course  in  its  subject  without  being  communicatee  to  others, 
and  the  question  is  of  practical  interest  only  in  view  of  its  possible  bearing 
upon  proplilyactic  measures. 

The  symptoms  of  an  acute  coryza  are  well  known,  and  vary  within  consi- 
derable limits,  from  the  mere  consciousness  of  local  uneasiness  to  severe  pain, 
fever,  and  marked  constitutional  disturbance.    The  preliminary  chill,  or  at 
least  chilly  sensation,  is  usually  followed  by  a  slight  rise  of  temperature  and 
increase  of  the  pulse,  with  muscular  pain  and  a  general  leeling  ot  inalaise. 
The  local  irritation  and  sensation  of  dryness  in  the  nose  are  coincident 
with  the  stage  of  cono;estion  and  absence  of  secretion  which  mark  the  begin- 
nino-  of  any  acute  inflammation  of  a  mucous  membrane,  and  lead  to  constant 
sneezing ;  this  lasts  but  an  hour  or  two,  and  is  followed  by  an  acrid,  watery 
discharge  from  the  nasal  passages,  which  are  now  occluded  by  the  swelling 
and  eno-oro-ement  of  the  tissues,  so  that  oral  respiration  becomes  a  necessity, 
the  senses  of  smell  and  taste  are  both  blunted,  and  the  voice  becomes  rmsal 
in  character.    This  occlusion  is  variable— the  inter-vascular  communications 
between  the  nasal  passages  being  free  and  numerous  through  the  peculiar  erec- 
tile tissue,  with  large  vein  cavities,  demonstrated  by  Kohlrausch  and  Bigelow 
to  lie  between  the  periosteum  and  the  mucous  membrane  covering  the  tur- 
binated bones,  especially  the  inferior— and  gravitation  of  blood  and  serum 
from  one  nasal  passage  to  the  other  is  often  sudden  and  complete,  the 
glandular  structures  being  abnormally  stimulated,  the  discharge  increases 
])roo-ressively  in  quantity  and  changes  in  character,  being  at  first  mucous,  with 
epithelial  elements  alone  ;  and  afterwards  muco-purulent,  with  a  tew  red  blood 
corpuscles ;  or  even  purulent,  and  loaded  with  young  cells.    Meanwhile  the 
inflammatory  process  extends,  involving,  perhaps,  the  frontal  sinuses,  when  it 
gives  rise  to  severe  frontal  headache;  or  the  lachrymal  duct,  with  resultant 
sensitiveness  of  the  congested  conjunctivse  to  both  pressure  and  light;  or  the 
Eustachian  tubes,  with'pain  in  the  ears,  ringing  noises,  and  dulness  of  hear- 
ino-     If  it  extend  to  the  pharynx,  the  patient  will  complain  of  sore  throat,  a 
usual  complication ;  while  if  it  involve  the  larynx  and  trachea,  symptoms 
referable  to  those  regions,  with  increase  of  the  febrile  movement,  will  be 

present.  ^  .  .  •  • 

The  irritatino;  qualities  of  the  saline  discharge,  containing  ammonia  in  the 
earlier  stages,  inflame  and  excoriate  the  margins  of  the  nostrils  and  the  upper 
lip-  while  the  later  discharge,  muco-purulent,  and  greenish  or  yellowish  m 
color,  gives  rise  to  an  unpleasant  odor,  and  not  infrequently  desiccates  into 
crusts  which  are  removed  with  diflaculty.  Fibrin  is  occasionally  secreted, 
especially  in  infantile  coryza,  and  in  the  form  met  with  in  exanthematous 
fevers,  and  forms  a  membranous  layer  over  the  turbinated  bones,  resembling, 
and  requirino-  to  be  distinguished  from,  the  pseudo-membrane  of  diphtheria 
(see  page  787).  The  attack  lasts  from  three  days  to  one  week  or  more,  in 
severe  cases,  and  fresh  attacks  sometimes  supervene  when  the  first  undergo 
resolution.    Alternation  from  one  nasal  passage  to  the  other  may  occur ;  and 


766      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

recurrence  of  the  disease,  with  intervals  of  a  few  days,  and  for  an  indefinite 
period,  is  occasionally  met  with.  As  a  rule,  however,  complete  resolution 
occurs  within  the  above-mentioned  time,  especially  if  measures  have  been 
taken  to  control  the  inflammatory  process.  The  termination  of  the  disease 
in  suppuration  is  very  rare,  and  fatal  cases  of  coryza  have  been  recorded 
only  as  occurring  in  aged  persons  or  in  infants,  in  both  instances  death  being 
due  either  to  obstructed  respiration  or  to  interference  with  nutrition. 

Acute  coryza  in  the  infant  assumes  features  that  are  not  present  in  the 
same  disease  in  the  adult,  and  the  immediate  danger  is  correspondingly  in- 
creased. This  increased  danger  lies  both  in  the  obstruction  to  nasal  respi- 
ration caused  in  the  small  and  narrow  passages  by  the  tumefied  mucous  mem- 
brane, and  in  the  difiiculty  with  which  the  child  is  nourished,  owing  to  its 
inability  to  hold  its  mouth,  which  is  required  for  respiratory  purposes,  closed 
long  enough  to  take  the  breast.  If  the  attack  be  prolonged,  not  only  will  the 
infant  lose  strength,  but  the  prognosis,  in  not  a  few  instances,  will  become 
decidedly  grave. 

Syphilitic  coryza  in  the  infant  is  not  always  clearly  defined  as  regards  its 
true  nature.  An  acute,  persistent  coryza,  occurring  in  a  very  young  infant, 
must  always  be  regarded  with  suspicion ;  and,  if  a  clear  clinical  history  of 
the  disease  in  the  parents  fail,  resort  to  a  mercurial  course  of  treatment  is 
certainly  justifiable  in  attempting  to  establish  the  diagnosis. 

Gonorrhoeal  coryza  in  the  infant  is  the  result  of  infection  of  the  nasal  pas- 
sages by  secretions  from  the  vagina  of  the  mother  during  delivery ;  and, 
when  seen  in  the  advlt^  arises  from  the  direct  conveyance  of  the  poison  to 
the  nasal  mucous  membrane  by  the  fingers,  soiled  pocket  handkerchiefs,  and 
the  like.  The  symptoms  are  those  of  an  aggravated,  purulent,  catarrhal  in- 
flammation or  coryza. 

Treatment  of  Acide  Coryza. — The  success  of  the  abortive  treatment  of  an 
acute  coryza  depends  entirely  upon  the  promptness  with  which  it  is  instituted. 
Many  remedies  are  vaunted — none,  perhaps,  are  specific  and  unfailing  in 
their  action.  Among  the  commonest  is  the  administration  of  a  full  dose 
of  the  tincture  of  the  chloride  of  iron,  or  quinine  (gr.  x-xv),  followed  at 
bedtime  by  hot  alcoholic  drinks,  and  a  mustard  foot-bath  ;  or,  if  much  local 
pain  and  distress  exist,  a  Dover's  powder  (gr.  x).  Cohen  advises  the  admin- 
istration of  chloroform  to  produce  free  anaesthesia,  and  claims  that  an  attack 
may  thus  be  aborted.  Robinson  recommends  one  of  the  following  prescrip- 
tions : — 

R. — Spirit,  ammoniae  aromat.,  f^iss. 
Sig — Teaspoonful  in  water  (f^j-f^iss)  every  two  hours. 

Or, 

R. — Ammonii  carb.,  5j; 

Liq.  morph.  sulphat.  (U.  S.),  f5j  ; 
Mist  amygdalae,  ad  f^iij.  M. 
Sig — A  teaspoonful  in  water  (f  Jj)  every  hour  during  six  hours,  and  afterwards  every 
hour  and  a  half. 

If  there  be  much  fever,  tincture  of  aconite  root  (J  to  J  of  a  drop  to  each 
dose)  may  be  substituted  for  the  morphine  in  the  last  mixture ;  and  for  the 
relief  of  the  local  inflammation  and  its  attendant  pain  and  discomfort,  a 
powder  of — 

R. — Pulv.  fol.  belladonnas,  gr.  xx  ; 
Pulv.  morph.  sulph.,  gr.  ij  ; 
Pulv.  acaciae,  ad  ^ss. 

may  be  insufflated  into  the  nasal  passages  both  anteriorly  and  posteriorly. 


DISEASES  OF  THE  NASAL  PASSAGES. 


767 


The  inhalation  of  simple  hot  steam,  or  of  steam  medicated  with  compound 
tincture  of  benzoin,  is  also  often  grateful  to  the  patient ;  and  a  powder  of 
sugar  of  milk,  gum,  or  bismuth,  rubbed  up  with  a  little  morphine  (gr.  ij-3j), 
or  one  of  starch  powder  with  an  equal  part  of  camphor,  is  of  service,  if  used 
as  a  snuff.  After  the  discharge,  however,  has  once  set  in — in  other  words, 
after  the  inflammatory  process  has  once  been  flrmly  established — such 
measures  fail  as  abortive  means,  and  the  efforts  of  the  physician  must  be 
limited  to  curtailing  the  affection  by  controlling,  as  far  as  is  possible,  its  in- 
flammatory action.  '  To  this  end  the  above  remedies  may  be  continued,  aided 
and  combined  with  such  diuretic,  diaphoretic,  and  laxative  mixtures  as  are 
indicated  in  the  special  case. 

The  local  use  of  inhalations  of  iodine,  much  vaunted  creasote,  carbolic 
acid,  ammonia,  and  the  like,  in  this  stage  of  the  aflection,  are  of  little  if  any 
service,  aside  from  giving  temporary  relief,  and  are  sometimes  positively 
harmful. 

External  applications  of  emollients,  such  as  vaseline  or  suet,  occasionally 
o-ive  relief;  and  the  same  may  be  said  of  the  use  of  vapor  or  hot-air  baths. 

As  the  process  reaches  its  later,  inflammatory  stages,  and  the  muco-purulent 
discharge  sets  in,  local  treatment  may  be  employed  with  considei'able  success.^ 
It  should  consist  in  the  application,  by  means  of  the  spray  apparatus,  of 
some  watery  solution  of  an  astringent  (see  page  770)  to  all  parts  of  the 
inflamed  and  turgid  mucous  membrane,  and  this  should  be  continued  at  suit- 
able intervals  until  complete  resolution  has  been  established  ;  for  there  can  be 
no  question  that  it  is  to  neglect  of  these  cases  of  acute  coryza,^  especially 
in  this  stage,  and  to  indifference  to  the  fact  of  their  complete  or  incomplete 
resolution,  that  the  development  of  chronic  catarrh  can  be  charged  in  a 
majority  of  instances. 

Acute  coryza  in  the  infant  can  best  be  treated  by  thorough  cleanliness, 
attained  by  the  employment  of  a  camel's-hair  pencil,  used  with  a  weak  solution^ 
of  borax  to  wash  out  the  nasal  passages,  and  by  the  subsequent  insufflation  of 
powders  into  the  nasal  passages  anteriorly.  Robinson  recommends  one 
of  equal  parts  of  finely  pulverized  white  sugar  and  camphor  with  powdered 
tannin  (gr.  xl-^j),  and  speaks  enthusiastically  of  its  good  effects.  If  it  be 
determined  that  the  sy  philitic  taint  exist,  to  this  local  treatment  must,  of 
necessity,  be  added  the  use  of  some  form  of  mercurial,  or  of  mercury  and 
iodide  of  potassium,  in  doses  suited  to  the  age  of  the  child,  and  continued 
for  days  or  weeks,  according  to  the  judgment  of  the  practitioner  and  the  de- 
mands of  the  particular  case. 

Idiosyncratic  coryza — or,  as  it  has  been  variously  termed,  rose  or  June 
cold,  hay  fever  or  asthma,  and  autumnal  catarrh — may  be  defined  as  an 
acute  coryza,  showing  a  peculiar  periodicity^,  and  not  unfrequently  attended 
by  reflex,  asthmatic  symptoms.  It  is  due,  as  far  as  our  present  knowledge 
extends,  to  the  inhalation,  by  persons  possessing  some  peculiar  and  individual 
idiosyncrasy,  of  the  pollen  of  certain  grasses  or  flowers:  and  while  it  shows 
no  distinction  in  attacking  both  dwellers  in  cities  and  dwellers  in  the 
country,  it  shows  a  predilection  for  those  of  high  estate.  (See  page  843.) 

Its  treatment  will  not  vary,  in  general,  from  that  of  an  ordmary  acute 
coryza;  but  it  is  often  unsatisfactory  and  even  futile,  unless  a  temporary 
change  of  residence  be  made  during  the  usual  duration  of  the  attack.  With 
the  object  of  destroying  the  vegetable  organisms  upon  which  the  disease  is 
supposed  to  depend,  sprays  or  injections  of  carbolic  and  salicylic  acid  are  used. 
Helmholz  advises  the  use  of  an  injection  of  the  hydrochlorate  of  quinia  (1- 
100).    A  plan  of  treatment,  however,  which  succeeds  one  year  in  aborting  or 


768      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSOJIY  SINUSES. 

relieving  the  attack,  will  often  fail  the  next.  There  is  no  specific  remedy  for 
the  disease.  The  asthmatic  complication  may  often  be  quickly  relieved  by 
the  use  of  the  following  prescription : — 

R. — Potassii  iodidi,  ; 

Liq.  potassii  arsenitis,  f3j  ; 
Aquae,  f^iv.  M. 
Sig. — A  teaspoonful  every  four  or  six  hours. 

Chronic  Coryza. — The  term  chronic  coryza,  or  chronic  nasal  catarrh,  may 
very  properly  be  used  to  replace  a  variety  of  terms  which  are  to  day  employed 
in  literature  to  signify  one  and  the  same  affection.  I  believe  that  such  a 
multiplicity  of  names  falls  far  short  of  its  object,  can  but  serve  to  confuse  the 
subject,  and  leads  to  faulty  diagnosis  and  often  to  improper  treatment.  Bos- 
worth,  from  a  pathological  point  of  view,  if  not  correctly  from  an  anatomical, 
defines  the  nasal  cavities  as  extending  from  the  nostrils  to  the  free  border 
of  the  soft  palate,  thus  including  the  upper  pharynx.  Clinical  experience 
teaches  us  that  in  most,  if  not  in  all  cases  of  chronic  nasal  catarrh,  the 
vault  of  the  pharynx  is  involved  in  the  morbid  process ;  and  the  converse 
is  likewise  true :  though  the  pharyngeal  process  be  the  more  prominent,  few 
cases  exist  in  which  the  nasal  passages  also  are  not  implicated.  Chronic 
coryza,  or  chronic  nasal  catarrh,  may  therefore  be  defined  as  a  chronic, 
catarrhal  inflammation  of  the  nasal  mucous  membrane  and  that  of  the  vault 
of  the  pharynx,  and  the  term  should  be  understood  to  include  those  of 
post-nasal  catarrh,  post-pharyngeal  catarrh,  retro-nasal  catarrh,  and  adenoid 
hypertrophy  of  the  vault  of  the  pharynx,  which  are  so  commonly  used. 
Clinically,  several  varieties  of  chronic  coryza.  are  met  wdth,  each  possessing 
individual  appearances  upon  rhinoscopic  inspection,  giving  rise  to  widely 
different  symptoms,  and  requiring  a  distinct  method  of  treatment.  Upon  the 
correct  appreciation  of  the  differences  between  these  varieties,  depends  the 
success  of  the  measures  undertaken  for  their  relief. 

The  varieties  of  the  disease  are  classified  by  Bosworth^  in  a  form,  that, 
when  slightly  modified,  commends  itself  for  its  simplicity  and  clearness, 
and  can  be  proven  to  be  clinically  true.  1.  Simple  chronic  coryza^  a  chronic 
inflammation  of  the  nasal  mucous  membrane,  characterized  by  an  abundant 
discharge  of  mucus,  but  attended  by  no  marked  structural  changes.  2.  Hyper- 
trophic nasal  catarrh^  a  chronic  inflammation  of  the  mucous  membrane, 
characterized  by  an  excessive  secretion  of  mucus  or  muco-pus,  and  also 
marked  by  certain  structural  changes  in  the  membrane,  by  which  this  is 
thickened  or  hypertrophied.  This  hypertrophy  involves  not  only  the  mem- 
brane lining  the  nasal  cavity  proper,  but  also  the  glands  at  the  vault  of  the 
pharynx.  3.  Atrophic  nasal  catarrh^  a  chronic  inflammation  of  the  nasal 
mucous  membrane,  in  which  the  glandular  structures  are  implicated  to  such 
an  extent  as  to  interfere  seriously  with  their  function,  the  membrane  thus 
lacking  its  normal  supply  of  mucus,  and  becoming  dry,  and  secretions  accu- 
mulating subsequently  into  dry,  hard  crusts,  and  decomposing,  giving  rise 
to  a  purulent  fetid  discharge  and  to  an  offensive  odor  (fetid  catarrh). 

Simple  Chronic  Coryza. — Seen  as  a  rule,  perhaps,  as  the  evident  and  direct 
consequence  of  oft-repeated,  and  especially  of  neglected,  attacks  of  acute  in- 
flammation, it,  on  the  other  hand,  frequently  manifests  itself  by  a  slow  and 
gradual  progression,  without  previous  recognizable  cause,  and  by  no  means 
necessarily  dependent  upon  any  constitutional  taint  of  scrofula,  although  the 
possible  influence  of  the  latter,  as  well  as  of  syphilis,  herpetism,  and,  with 
adults,  diathetic  conditions,  upon  its  causation,  should  not  be  overlooked. 


•  Bosworth,  Diseases  of  the  Throat  and  Nose.    New  York,  1881. 


DISEASES  OF  THE  NASAL  PASSAGES. 


769 


The  main  symptom  is  the  increased  discharge  of  mucus  or  muco-puj>,  which, 
being  semi-fluid  and  thin,  is  easily  removed  by  blowing  the  nose,  or  by  being 
drawn  back  into  the  pharynx  and  thence  expectorated.  There  is  no  thicken- 
ing of  the  nmcous  membrane,  and  consequently  no  obstruction  to  nasal 
respiration  and  no  change  in  the  voice.  The  disease  being  confined,  as  a  rule, 
to  the  respiratory  portion  of  the  nasal  passage,  the  sense  of  smell  suffers 
no  interference,  and,  the  membrane  being  soft  and  moist,  there  is  no  tendency 
to  the  accumulation  of  secretions  into  crusts,  nor  to  decomposition.  The  main 
importance  of  the  affection  then,  its  symptomatology  being  but  slight  and 
giving  rise  to  no  annoyance,  lies  in  its  tendency  to  progress  into  the  further 
and  more  serious  forms  of  (catarrh  unless  it  be  promptly  arrested  by  judicious 
treatment.  Rhinoscopic  examination  will  show  a  reddened  and  congested 
mucous  membrane  flecked  with  mucus,  throughout  the  nasal  passages.  At 
the  vault  of  the  pharynx  the  appearances  are  more  marked,  and  the  glan- 
dular structures  here  present  are  swollen  and  covered  by  a  thicker  and  more 
tenacious  mucus. 

Aside  from  meeting  any  indications  for  constitutional  remedies  that  may 
exist  in  a  given  case,  the  treatnient  lies — and  the  statement  is  true  for  the  large 
majority  of  instances — solely  in  the  local  application  of  medicaments,  in  spray 
or  powder,  to  the  affected  nasal  passages.  To  insure  the  successful  use  of 
these,  thorough  preliminary  cleansing  of  the  passages  is  requisite.  This  may 
be  accomplished,  perhaps,  by  the  patient  using  his  handkerchief,  unaided 
by  any  form  of  artificial  apparatus.  Should  the  latter,  however,  be  found 
necessary  to  effect  the  complete  removal  of  the  secretions — and  I  repeat  that 
an  apparatus  is  nmch  oftener  used  than  is  really  needed  (see  page  758) — the 
coarse  spray -producer,  already  described,  may  be  employed  with  an  alkaline, 
cleansing  solution  to  the  best  advantage  (see  Fig.  981) ;  rarely,  if  ever,  in 
this  form  of  the  disease,  is  the  posterior  nasal  syringe  required.  Following  the 
cleansing  process,  Avhich  must  be  undertaken  by  physician  or  patient  with  at 
first  daily,  and  then  gradually  diminishing,  frequency,  the  next  step  consists 
in  the  application  of  the  medicamejit,  usually  a  mild  alterative,  resolvent,  or 
astringent  solution  or  powder.  If  the  spray  apparatus  in  one  of  its  forms — ■ 
preferably  the  spray  with  compressed  air  as  the  motive  power — be  chosen  as 
the  means,  some  one  of  the  following  solutions  may  be  used  with  the  anterior 
or  the  posterior  nasal  spray-tube,  or  both,  and  should  be  selected  with  due 
deliberation,  ui  view  of  the  special  indications  presented  by  the  case,  care 
being  exercised  that  the  application  is  of  such  a  strength  as  to  cause  no  irri- 
tation of  the  nasal  mucous  membrane,  one  much  more  susceptible  than  that 
of  either  pharynx  or  larynx,  A  preliminary,  careful  trial  with  the  chosen 
solution  or  powder  w^ill  quickly  serve  to  prove  the  membrane's  peculiar  sus- 
ceptibility, in  a  given  case,  to  both  the  drug  and  its  strength,  and  such  a  trial 
should  be  made  in  every  instance.  The  following  are  the  solutions  that  I 
most  commonly  use,  given  in  the  order  of  their  preference:  (1)  Zinci  iodidi, 
gr.  x-fjj;  (2)  Zinci  sulpho-carbolat.,  gr.  ij-f^j;  (3)  Zinci  sulphat,  gr.  v-f.lj; 
(4)  Ferri  et  ammonii  sulphat.,  gr.  iv-fjj;  (5)  Ferri  perchloridi,  gr.  v-f 5j ; 
(6)  Acidi  tannici,  gr.  v-xx-f^j  ;  (7)  Potassii  chlorat.,  9j-f^j.  In  any  one  of 
these  formulae,  "  Listerine'"^  may  be  substituted,  in  part,  for  the  water,  in  the 
proportion  of  one  part  of  the  former  to  three  of  the  latter.  If  the  simple 
rhinitis  has  advanced  far  towards  the  hypertrophic  stage,  then  I  commence 
at  once  with — 

'  This  preparation  contains  the  essential  antiseptic  constituent  of  thyme,  eucalyptus,  baptisia, 
gaultheria,  and  mentha  arvensis,  in  combination  ;  each  fluidrachm  also  contains  two  grains  of 
benzo-boracic  acid.  It  may  be  used  in  any  of  these  solutions,  in  part  with  water,  as  a  men- 
struum, and  will  be  found  to  serve  a  useful  and  pleasant  purpose  where  an  antiseptic  is  desirable. 


VOL.  IV. — 49 


770      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


R — lodini  cryst.,  gr.  iv  ; 

Potassii  iodidi,  gr.  x ♦ 
Zinci  iodidi, 

Zinci  sulpho-carbolat.,  aa  9j  ; 
"Listerine,"  ; 
Aquae,  ad  f^iv.  M.^ 

Id  case  the  solutions,  mainly  of  mineral  astringents,  that  have  been  given, 
are  not  well  borne,  a  powder  may  be  substituted  with  excellent  results,  and, 
indeed,  is  particularly  applicable  in  this  form  of  the  disease.  As  a  rule, 
however,  I  am  not  a  warm  advocate  of  the  use  of  powders  in  the  treatment 
of  rhinitis.  In  the  form  under  consideration,  where  the  secretions  are  readily 
removable,  and  the  parts  soft  and  absorptive,  they  will  do  good,  but  in  hyper- 
trophic rhinitis  they  are,  I  believe,  of  little  use,  and  in  atrophic  or  fetid 
rhinitis,  they  are  absolutely  contra-indicated.  The  powders  may  be  applied 
by  means  of  the  anterior  or  posterior  nasal  powder-blower,  after  the  parts 
have  been  well  cleansed.^ 

Whatever  be  the  plan  of  treatment  instituted — and  it  and  its  details  may 
readily  be  determined  upon  from  what  has  been  said — it  is  to  be  steadily  per- 
severed in,  not  necessarily  in  these  cases  under  the  direct  manipulations  of 
the  surgeon  himself,  but  certainly  under  his  general  supervision,  and  at 
suitable  intervals,  until  the  morbid  conditions  for  which  it  was  undertaken 
are  alleviated. 


Hypertrophic  I^'asal  Catarrh.— If  the  simple  form  of  chronic  catarrh  just 
described  be  permitted  to  run  its  course  without  interference,  in  certain 
cases  the  results  of  the  continued  chronic  inflammatory  process  are  sooner  or 
later  seen  in  marked  proliferation  of  all  the  normal  elements  of  the  delicate 
mucous  membrane — in  other  words,  in  a  true  hypertrophy  of  tissue.  This 
hypertroph}^,  specially  prone,  mainly  from  anatomical  reasons,  to  take  place 
in  the  nasal  passages,  affects  both  the  superficial  and  deep  layers  of  the 


'  In  order  to  save  repetition,  the  formulae  of  the  solutions  more  commonly  used  in  the  treatment 
of  the  various  forms  of  nasal  catarrh,  are  here  given  in  the  usual  strength  in  which  they  are 
employed.    Other  combinations  and  other  remedies  will  suggest  themselves. 


Acidi  tannici,  gr.  v-xx-f,^j. 

Aluminis,  gr.  v-f§j. 

Auri  chloridi,  gr.  x-f  §j, 

Cupri  sulphatis,  gr.  v-f§j. 

Ferri  et  ammonii  sulphat.,  gr.  v-f  §j. 

Ferri  perchloridi  gr.  v-f§j. 

Ferri  sulphatis,  gr.  v-f,^j. 

Potassii  chloratis,  Bj-f^j. 


Zinci  chloridi,  gr.  iij-f§j. 
Zinci  iodidi,  gr.  x-f§j. 
Zinci  sulphatis,  gr.  v-f5j. 
Zinci  sulpho-carbolatis,  gr.  ij-f^j. 
Argenti  nitrat.,  gr.  ij-iij-f^j. 
Ammonii  chloridi,  gr.  v-x-f^j, 
Tinct.  krameri?e,  f5j-f^j. 
Tinct.  kino,  fSj-f^j. 


^  The  following  formulae  for  powders  are 
— Acid,  salicylic,  gr.  x; 
Acid,  tannic, 

Bismuth,  subcarb.,  aa  5j'  M 

— Zinci  chloridi,  gr.  v  ; 
Pulv.  belladonnse,  gr.  x  ; 
Pulv.  amyli,  §ss.  M. 

I^. — Argenti  nitrat.,  gr.  ij  ; 

Bismuth,  subnit.,  5ij'  M. 

— Pulv.  cubebse,  §ss  ; 
Pulv.  sodii  bicarb.,  5ij  ; 
Pulv.  acid,  salicylici,  gr.  x; 
Pulv.  sacch.  alb.,  5ij.  M. 

— Ferri  sulphat.,  ; 
Pulv.  amyli,  ^j.  M. 


taken  from  Robinson  and  others  : 

R. — Pulv.  iodoform.,  5ij  > 
Pulv.  camphorse,  5j  I 
Pulv.  acidi  tannici,  gr.  v; 
Pulv.  acacise,  5ij'  M. 

^. — Hydrarg.  chlor.  mitis,  5j  » 
Pulv.  morph.  sulph.,  gr.  j  ; 
Pulv.  bismuth,  subnit.,  5ij  '. 
Pulv.  sacch.  alb.,  5ij- 

— Ferri  et  ammonii  sulph., 
Pulv.  amyli,  ^j.  M. 

— Aluminis,  5 

Pulv.  amyii,  ^j.  M. 

— Potass,  chlorat.,  5^8  ; 
Pulv.  amyli,  §j.  M. 


DISEASES  OF  THE  NASAL  PASSAGES. 


771 


mucous  membrane,  the  changes  consisting  in  the  development  of  new  con- 
nective-tissue elements  and  cellular  inliltration  in  the  deeper  structures ;  im- 
plication of  the  muciparous  glands,  which  become  distended,  and  their  walls 
thickened,  especially  those  located  at  the  vault  of  the  pharynx  where  the 
hypertrophic  process  expends  itself  more  upon  the  glandular  elements  than 
upon  the  mucous  membrane  proper;  and  increased  cell-groAvth  in  the  epithe- 
lial elements,  leading  rapidly  to  abnormal  thickening  of  the  superficial  layers  ; 
the  bloodvessels  of  the  parts,  at  the  same  time,  become  dilated  and  increased 
in  number,  their  hypertrophy  occurring  especially  over  the  inferior  turbinated 
bone,  in  the  reticulated  structure,  or  erectile  stroma,  which  lies  between  the 
periosteum  and  the  superjacent  mucous  membrane. 

This  hypertrophy,  involving  then  all  the  structures  which  overlie,  especially 
the  two  inferior  turbinated  bones,  seldom  presents  a  perfectly  smooth  surface. 
At  the  posterior  extremities  of  the  inferior  turbinated  bones,  the  nodulation 
and  irregular  thickening  are  most  marked. 

The  symptoms  of  this  affection  are  dependent  upon  the  pathological  changes 
which  have  been  described.  The  hypertrophy  of  the  tissues,  especially 
throughout  the  respiratory  channel  of  the  nose,  leads  to  intermittent  or  per- 
manent occlusion  and  obstruction  to  the  passage  of  the  air  current,  while  the 
involvement  of  the  glandules,  especially  at  the  vault  of  the  pharynx,  gives  rise 
to  an  excessive  discharge  of  thick,  tenacious  mucus,  or  muco-pus,  of  a  yel- 
lowish and  opaque  appearance.  Upon  this  obstruction,  caused  by  the  hyper- 
trophied  condition  of  the  parts,  depends  also  the  interference  with  the 
senses  of  smell  and  taste,  and  ultimately— from  this  cause,  and  also  from  the 
extension  of  the  inflammatory  process— with  the  sense  of  hearing,  through 
involvement  of  the  Eustachian  tubes  and  perhaps  of  the  middle  ear;  and  like- 
wise the  change  in  the  character  of  the  voice,  which  acquires  a  nasal  intona- 
tion. The  increased  flow  of  secretion,  prevented  from  passing  normally  from 
the  anterior  nares,  runs  into  the  pharynx  or  lodges  behind  the  velum,  and  is 
oidy  removed  thence  by  means  of  vigorous  and  disagreeable  efforts  at  hawk- 
ing and  clearing  the  throat.  (It  may  here  be  observed,  that  this  sensation  or 
syTnptom,  one  commonly  complained  of  by  the  patient,  needs  to  be  differen- 
tiated as  to  its  cause  from  the  precisely  similar  one,  to  which  the  presence  of 
an  elongated  uvula  will  give  rise.)  Contrary  to  what  is  generally  believed, 
fetid  or  offensive  secretions  are  not  an  accompaniment  of  this  variety^  of 
catarrh,  nor  is  the  occurrence  of  crusts  a  common  occurrence.  Ulceration 
never  occurs,  and  epistaxis  only  occasionally,  and  then  from  the  anterior  por- 
tions of  the  nasal  septum,  and  as  the  result  of  direct,  mechanical  interference 
with  the  parts  by  the  patient  (see  page  789).  Partly  by  the  gradual  extension 
of  the  inflammation,  from  the  nares  and  upper  pharynx  to  the  contiguous 
parts,  and  partly  through  the  pernicious  results  of  enforced  oral  respiration 
(see  page  402),  constantly  aggravated  also,  I  do  not  doubt,  by  the  violent 
efforts  at  hawking  made  by  the  patient,  the  inflammatory  process  extends  to 
the  lower  pharynx,  and  thence  invades,  in  course  of  time,  both^  the  larynx 
and  upper  trachea.  Symptoms  referable  to  the  chronic  inflammation  of  these 
or2;ans— mainly  sore  throat,  cough,  and  alteration  in  the  character  of  the 
votce— must  then  be  added  in  time  to  those  of  the  original  condition.^  The 
mucous  membrane  of  the  whole  upper  respiratory  tract,  under  these  circum- 
stances, becomes  irritable,  and  peculiarly  susceptible  to  the  influence  of  cold 
and  dampness. 

Upon  examination  of  the  nose  anteriorbj,  with  the  aid  of  a  nasal  speculum 
and  o'ood  illumination,  distinctive  appearances  can  be  easily  recognized.  The 
visible  mucous  membrane  is  red,  thickened,  velvety  in  appearance,  and  vas- 
cular. The  anterior  hypertrophied  extremity  of  the  inferior  turbinated  bone 
may  project  so  far  outwards  into  the  nasal  passage  as  to  touch  the  septum, 


772      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

opposite  to  it ;  its  tissues  are  soft  and  doughy,  and  when  indented  by  a  probe 
recover  themselves  slowly.  The  hypertrophy  seems  to  affect  the  tissues  upon 
the  inferior  surface  of  the  bone  most  decidedly,  and  the  inferior  meatus  of  the 
nose  is  often  occluded  by  the  mass ;  the  middle  meatus  may  be  overhung  by 
the  thickened  membrane  coming  from  the  middle  turbinated  bone,  but  to 
a  less  extent.  The  floor  of  the  nostril  is  free,  and  usually  the  side  of  the 
septum.  All  parts  are  more  or  less  decked,  unless  recently  cleansed,  with 
thick,  tenacious  mucus. 

Posteriorly^  by  the  aid  of  the  rhinoscopic  mirror,  the  posterior  extremities 
of  both  middle  and  inferior  turbinated  bones,  especially  the  latter,  will  be 
seen  to  present  peculiar  and  characteristic  appearances.  The  hypertrophy  of 
the  tissues  is  much  more  marked  usually  than  is  the  case  in  the  anterior 
nares,  and  the  parts  are  covered  by  a  thickened  mucous  membrane,  of  a 
whitish-gray  color,  and  with  an  irregular,  corrugated  and  fissured  surface ; 
the  extremity  of  the  inferior  turbinated  bone,  indeed,  resembles  an  irregular- 
shaped  tumOr,  lying  on  the  floor  of  the  nostril,  and  its  size  may  be  so  great 
as  to  nearly,  perhaps  completely,  occlude  the  posterior  orifice  of  the  iiaris. 
The  condition  here  described  may  exist  in  varying  degrees  in  both  nasal 
cavities,  and  the  obstruction  in  the  passages  that  it  causes,  is  still  further 
increased  by  the  thickening  of  the  tissues  upon  both  sides  of  the  nasal  sep- 
tum, especially  in  its  upper  portions. 

The  parts  at  the  vault  of  the  pharynx  have  been  alluded  to  both  in  respect 
to  their  peculiar  nature  and  structure,  made  up  as  they  are  mainly  of  glandu- 
lar tissue,  and  in  reference  to  the  fact  that  they  are  always  implicated,  to 
a  greater  or  less  extent,  in  any  case  of  chronic  inflammation  of  the  nasal 
passages,  of  some  duration ;  it  remains  to  be  added  that  the  physical  results 
of  a  chronic  inflammation  of  the  "  pharyngeal  tonsil,"  as  it  is  termed,  are 
peculiar.  The  gland ulse  are  involved  to  a  much  greater  extent  than  the 
mucous  membrane,  and  as  a  result  of  their  excessive  hypertrophy,  added  to 
and  increased  by  the  hyperplasia  of  their  connective  tissue  and  the  increase 
in  number  and  size  of  the  bloodvessels,  associated  with  the  thickening  of 
the  mucous  and  submucous  structures,  a  veritable  tumor  or  tumors  are  de- 
veloped, which  have  received  the  specific  name  of  adenoid  vegetations  of  the 
vaidt  of  the  pharynx,  and  are  often  treated  of  as  a  separate  and  distinct 
afiection.^  The  size,  configuration,  and  extent  of  these  vegetations,  or  adenoid 
hypertrophies,  are  variable ;  they  may  exist  only  to  such  a  degree  as  to  cause  a 
slight  elevation  of  the  tissues  at  the  vault  of  the  pharynx,  and  to  obliterate  its 
concavity ;  they  may  stud  the  entire  pharyngeal  roof,  from  side  to  side,  hang 
over  the  posterior  orifices  of  the  nostrils,  and  completely  hide  the  pharyn- 
geal orifice  of  the  Eustachian  tube ;  the  masses  may  be  fimbriated,  hang  in 
grape-like  clusters,  or  be  c^dindrical.  I  have  seen  them  so  large  that  the 
entire  upper  pharynx  was  occluded  and  occupied  by  the  tumor,  and  that  the 
lower  edge  of  the  mass  was  readily  brought  into  view,  through  the  mouth, 
by  simply  drawing  the  soft  palate  slightly  forwards.  Such  excessive  condi- 
tions, however,  are  unusual ;  generally,  a  rhinoscopic  examination  will  show 
the  rounded  vault  of  the  pharynx,  and  occasionally  its  upper  lateral  walls,  to 
be  occupied  by  a  thickened  and  nodulated  mass  projecting  strongly  here  and 
there  from  the  underlying  bony  surface  in  the  form  of  longitudinal  ridges, 
and  traversed  in  various  directions  by  seams  and  fissures.  As  a  rule  they 
appear  as  flattish  cushions,  and  only  occasionally  present  themselves  as  small, 
isolated  and  rounded  masses,  or  are  gathered  into  worm-like"  clusters.  The 
mass  here  described  tapers  ofl*  as  it  approaches  the  middle  pharynx,  until 

>  W.  Meyer,  Hospitals-Tidende,  Nov.  4  og  11, 1868.  Medico-Chirurgical  Transactions.  London, 
1870.    Lowenberg,  Les  Tumeurs  adenoides  du  Pharynx  Nasal.    Paris,  1879. 


DISEASES  OF  THE  NASAL  PASSAGES.^ 


773 


finally  a  smooth,  though  congested  mucous  membrane,  dotted  with  small 
rounded  eminences,  markinsc  the  site  of  the  outlying  hypertrophied  follicles 
of  the  pharyncreal  tonsil  is  reached ;  above,  it  is  separated  from  the  plane  of 
the  posterior  nares  by  a  sharp,  deep  line  of  demarcation.  The  consistency 
of  the  tumors  is  soft,  they  do  not  bleed  readily,  and  their  color  is  of  either  a 
light  pink  or  deep  bluish-red.  They  are,  as  a  rule,  seen  only  in  children  and 
young  persons.  Adults,  even  the  victims  of  an  old-standing  nasal  catarrh, 
seldom,  if  ever,  exhibit  the  appearances  of  excessive  hypertrophy  of  the 
glandular  tissues  at  the  vault  of  the  pharynx,  here  described.  Its  absence  in 
them,  and  its  frequency  in  children,  would  seem  to  argue  in  favor  of  an 
atrophy  of  these  structures,  as  life  advances;  or,  as  Cohen  suggests,  it  may 
be  that  changes  occurring  towards  middle  life,  render  this  tissue  like  the 
analogous  tissue  of  the  tonsils  and  agminated  glands  of  the  intestine,  insus- 
ceptible to  the  catarrhal  inflammations  of  youth. 

TreatmenLSincQ  hypertrophic  nasal  catarrh  is  the  form  of  the  affection 
which  more  frequently  presents  itself  for  treatment,  mainly  on  account  of  the 
annoying  symptoms  to  which  it  gives  rise  in  the  patient,  the  consideration  of 
the  medical  and  surgical  measures  adapted  for  the  relief  of  its  morbid  con- 
ditions, assumes  special  importance.  Fortunately,  the  surgeon  is  here  in  a 
position,  mainly  through  the  employment  of  surgical  means^  it  must  be  ad- 
mitted, to  attain  exceltent  and  often  brilliant  results. 

Aside  from  the  occasional  employment  in  these  cases,  as  well  as  in  the 
other  forms  of  nasal  catarrh,  of  a  general  remedial  course  of  treatment  suited 
to  the  existing  diathesis,  and  the  indications  for  the  employment  of  which 
will  suggest  ^themselves  in  each  individual  case,  the  question  here  arises, 
whether  any  of  the  special  agents  of  the  Pharmacopoeia,  that  have  been  from 
time  to  time  recommended  as  having  a  useful  therapeutic  effect  upon  the 
mucous  membrane  of  the  respiratory  passages  in  a  'diseased  condition,  is  in 
reality  of  great  value.  I  believe  that  this  is  questionable.  I  have  made  use 
of  many,  and  have  never  been  able  to  convince  myself  that  any  one  possessed  a 
decided,  specific  effect.  Cubebs,  ammoniacum,  muriate  of  ammonium,  and  per- 
haps sulphur,  have  given  the  best  temporary,  and  sometimes  permanent  results. 
In  each  case,  however,  their  use  has  been  associated  with  that  of  local  and 
direct  treatment  of  the  mucous  membrane.  The  latter  is  of  unquestionable 
value.  If  the  disease  is  moderate  in  extent,  and  the  hypertrophy  of  the  tissues 
not  excessive,  complete  resolution  may  be  effected  by  the  application  of  Such 
astringent  and  resolvent  solutions,  in  spray,  as  are  specially  indicated.  Pre- 
liminary instrumental  cleansing  of  the  nasal  passages  will  probably  be  requi- 
site in  the  majority  of  instances;  but  the  practitioner,  bearing  in  mind  that 
this  may  be  a  possible  source  of  irritation,  should  always  assure  himself  first 
that  the  removal  of  the  secretions  cannot  be  effected  by  the  patient's  blowing 
his  nose,  etc.  The  nasal  spray  apparatus,  w^ith  the  cleansing  solution  (see 
page  758),  here  renders  eftective  service  when  its  use  is  necessary.  Occasion- 
ally it  must  be  superseded  by  the  posterior  nasal  syringe,  when  the  secretions, 
especially  at  the  vault  of  the  pharynx,  are  thick  and  tenacious,  or  when  the 
occlusion  of  the  nasal  passages  anteriorly  is  so  great  that  a  spray  cannot  be 
forced  through  them.  Following  the  cleansing  process  comes  the  next  pro- 
cedure, viz.,  the  application  of  medicated  spray,  suited  both  in  strength,^ 
amount,  and  nature  to  the  individual  case  (see  page  769) ;  or,  if  solutions  of 
astringents  or  other  drugs  are  not  well  tolerated,  the  insufilation  of  the  proper 
powder. 

On  the  other  hand,  if  the  catarrhal  process  be  first  seen  in  its  advanced 
stages,  when  a  firmly  organized  neoplastic  tissue  exists  in  large  degree,  and 


I  Seller,  Surgical  Treatment  of  Nasal  Catarrh.   Pliila.  Med.  Times,  No.  362.  1881. 


774      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

seriously  encroaches  upon  the  nasal  cavities,  associated  with  a  chronic  inflam- 
mation involving  the  greater  part  of  the  naso-pharyngeal  mucous  membrane, 
the  best  that  can  be  gained  by  the  above  plan  of  treatment  will  be  the 
alleviation  of  some  only  of  the  more  prominent  symptoms,  and  more  heroic 
measures  will  be  required,  chiefly  the  use  of  some  means  by  which  the  hyper- 
trophied  membrane  can  be  destroyed.  Attempts  to  eftect  absorption  of  the 
neoplastic  tissue,  through  the  introduction  of  hollow  bougies  into  the  nasal 
passages,  where  they  are  left  for  a  time  in  situ  (Hoppe),  or  the  use  of  sponge 
tents,  metallic  bougies  (Wagner),  and  the  like,  fail  to  give  more  than  tempo- 
rary relief,  and  the  surgeon  is  obliged  to  turn  to  one  of  the  following  de- 
structive agents,  viz.,  the  forceps,  nitric  acid,  chromic  acid,  glacial  acetic 
acid,  nitrate  of  silver,  the  actual  or  galvano-cautery,  or  the  ecrase/ur.^ 

Forceps,  formerly  commonly  used  in  the  nares  for  this  purpose,  have  been 
justly  supplanted  by  some  one  of  the  other  means.  The  operation  of  tearing 
away  portions  of  the  hypertrophied  tissue,  over  the  turbinated  bones,  is  harsh 
and  attended  by  profuse  hemorrhage. 

JVitric  acid  has  often  served  a  good  purpose  in  my  hands.  It  is  a  powerful 
destructive  agent,  and  with  some  care  its  action  can  be  limited  dh-ectly  to  the 
part  to  be  treated.    The  guarded  canula  of  Smith  will  perhaps  here  be  of 


Fig.  991. 


Smith's  guarded  canula  for  applying  nitric  acid  to  the  nasal  passages. 


service.  A  small  probe,  its  end  wrapped  in  absorbent  cotton  and  saturated 
with  the  acid,  is  passed  through  a  suitable  nasal  speculum  into  the  naris  to 
be  operated  upon,  and  drawn  along,  or  firmly  pressed  upon,  the  turbinated 
bone  at  the  point  of  its  greatest  convexity,  contact  being  kept  up  for  a  few 
seconds ;  the  pain  quickly  passes  away,  and  on  withdrawing  the  probe  the 
parts  are  seen  to  have  become  well  whitened  or  blanched ;  moderate  inflam- 
matory reaction,  with  a  slough  of  varying  depth,  follows,  while  the  consolidation 
of  the  submucous  structures  by  the  hyperplastic  results  of  the  inflammatory 
process  and  the  contraction  of  the  cicatricial  tissue,  occupying  the  site  of  the 
destroyed  parts,  serves  to  reduce  the  hypertrophy  and  its  resultant  nasal  ob- 
struction in  a  most  satisfactory  manner.  Frequently,  one  application  answers 
all  purposes  in  freeing  the  nasal  passage  to  the  extent  of  allowing  of  uninter- 
rupted respiration.  The  process,  however,  may  require  repetition.  This 
little  operation  is  one  that  I  very  frequently  employ,  and  one  in  which  I 
have  much  confidence.  Owing  to  the  danger  of  an  excess  of  acid  flowing 
over  the  healthy  parts,  and  the  diflaculty  of  controlling  this  in  a  locality 
hard  of  access,  this  caustic  is  not  adapted  for  use  in  the  destruction  of  the 
adenoid  hypertrophies  met  with  at  the  vault  of  the  pharynx.  Its  use  should 
be  limited  to  the  i)arts  reached  through  the  anterior  nares. 

Chromic  acid  is  less  painful  in  its  use  than  nitric  acid,  but  possesses  no 
other  special  advantage  over  it.  It  is  well  adapted  for  treating  the  glandular 

•  Gelatine  bougies,  moulded  to  a  suitable  form  and  medicated  with  various  astringents,  are 
advised  by  Guttman. 


DISEASES  OF  THE  NASAL  PASSAGES. 


775 


hypertropliies  located  in  the  pharyngeal  vault,  the  small  acicular  ei-ystals 
beino;  easily  taken  up  upon  a  suitably  curved,  cotton-covered  probe,  and  car- 
ried T^ehind  the  velum  to  the  desired  point. 

Glacial  acetic  acid  is  highly  recommended  by  Bosworth  and  others  as  an 
application  to  the  hypertrophied  tissues  located  in  the  nasal  passages,  on 
account  of  its  well-known  affinity  for  epithelial  cells,  and  its  action  on  the 
localized  hypertrophies  of  the  superficial  layers  of  the  integument.  It  is 
certainly  efficient  in  destroying  tissue,  and  easy  of  application  by  means  of  the 
probe ;  it  causes  no  secondarylntlammation,  nor  too  inuch  destruction,  and  it 
gives  rise  to  no  excessive  pain.  I  have  used  it  also  in  many  instances  with 
complete  satisfaction,  and  I  regard  it  as  specially  adapted  for  the  more  recent 
and  more  moderate  cases  of  hypertrophy. 

Nitrate  of  silver,  iovmQv\y,2i\\^  even  to-day,  extensively  employed  in  this 
class  of  cases  as  a  destructive  agent,  does  not  sustain  its  reputation.  It 
causes  but  a  superficial  slough,  and  the  application  is  of  necessity  frequently 
repeated  in  treating  hypertrophied  tissue  of  any  extent.  Moreover,  owing 
to  its  powerfully  stimulating  qualities,  it  excites  cell -proliferation  and  causes 
structural  changes  that  are  not  desirable. 

After  the  use  of  any  form  of  caustic  in  the  nasal  passages,  immediately 
upon  the  withdrawal  of  the  probe,  the  parts  should  be  flooded  with  an  alka- 
line solution  ;  the  subsequent  treatment  of  the  case,  at  least  until  the  slough 
has  separated  and  the  resultant  ulcer  healed,  is  based  upon  ordinary  princi- 
ples of  cleanliness. 

The  actual  cautery  \Q  seldom  used,  and  possesses  no  special  value  to  com- 
mend it. 

The  galvano-cautery  offers  a  most  radical  and  efficient  means  of  destroying 
the  hypertrophic  and  vascular  obstructions  of  both  nares  and  upper  pharyn- 
geal space,  and  is  to-day  widely  employed  for  this  purpose.  Its  action  is 
rapid,  but  complete,  and  its  use  is  not  excessively  painful.  I  believe,  how- 
ever, that  we  may  accomplish,  in  very  many  cases,  the  same  results  by  the 
use  of  less  heroic  measures.  When  the  hypertrophies  are  extensive.  Seller 
justly  observes,  that  the  knife  should  be  at  a  cherry  red  when  the  incision 
is  made,  when  there  will  be  neither  hemorrhage  nor  much  pain.  If  the 
heat  be  too  great,  bleeding  will  follow  the  incision,  and  if  not  hot  enough, 
the  pain  wilfbe  severe.  The  immediate  result  of  the  incision  or  cauteriza- 
tion is  the  formation  of  an  eschar,  and  acute  inflammation  surrounding  the 
burned  portion  of  tissue;  the  ultimate  result,  the  formation  of  bands  of 
cicatricial  tissue  which  by  their  contraction  bind  down  the  tissues,  and 
thus  relieve  the  stenosed  condition  of  the  nasal  passage  for  which  the  opera- 
tion has  been  undertaken.  The  form  of  instrument  to  be  employed  to  effect 
a  given  purpose,  depends  upon  the  choice  of  the  operator  and  the  special 
indications.  Many  varieties  of  electrode  and  apparatus  exist.  Voltolini  uses 
an  electrode  with  a  single  wire-loop  point;  Michel,  a  wire-loop  ecraseur ; 
Thudichum,  a  wire  loop ;  Browne,  a  bullet-shaped  electrode  ;  Shurley  and 
Bosworth,  a  slender  knife-electrode.  Probably  as  convenient  forms  of  elec- 
trode and  handle  as  can  be  obtained  for  general  use  are  shown  in  the  accom- 
panying figures  (Figs.  992,  993).  As  will  be  seen,  they  are  adapted  for  the 
treatment  of  both  the  nasal  passages  and  the  vault  of  the  pharynx. 

To  protect  the  nasal  passage  during  the  introduction  of  an  electrode  into 
the  anterior  nares,  the  ingenious  speculum  of  Shurley,  with  its  movable  ivory 
slide  to  cover  the  septum,  will  be  found  convenient. 

During  galvano-cautery  operations  upon  the  tissues  at  the  vault  of  the 
pharynx,  it  may  be  necessary,  especially  in  patients  with  irritable  throats,  to 
tie  the  soft  palate  forwards,  in  the  manner  described  upon  page  756. 

In  many  instances,  the  hypertrophy  of  the  tissues  over  the  inferior  turbi- 


776      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


nated  bone  will  be  found  to  exist  almost  exclusively  at  its  anterior  extremity, 
and  in  such  a  case  the  procedure  recommended  by  Jar  vis  will  be  found 


Fig.  992. 


Nasal  electrodes. 


well  adapted  for  its  removal.  The  growths  are  usually  sessile,  but  can  be 
readily  engaged  in  a  loop  of  fine  wire  passed  through  the  ecraseur  devised 

Fig.  993. 


■Nasal  electrodes. 

by  this  surgeon  (see  Fig.  994),  if  their  base  be  first  transfixed  with  a  slightly 
curved  needle  until  the  point  projects  above  the  growth  into  the  nasal 
cavity ;  the  loop  is  then  arranged  in  such  a  manner  that  both  the  portion 
of  the  needle  projecting  from  the  nostril  and  the  needle's  point  are  encircled 
by  it,  very  much  after  the  manner  of  a  hare-lip  suture ;  the  wire  is  thus  pre- 
vented from  slipping  oft',  and  the  hypertrophy  is  readily  secured,  and  is 


DISEASES  OF  THE  NASAL  PASSAGES. 


777 


removed  by  screwins;  down  the  milled  nut  of  the  instrument  and  drawing 
the  wire  home.  The  little  operation  is  quick  and  almost  painless,  as  well  as 
bloodless.    The  relief  that  it  affords  is  great. 

Excessive  hypertrophy  of  the  mucous  membrane  covering  the  posterior 
extremity  of  the  inferior  turbinated  bone,  and  localized  there,  is  no  unusual 
condition,  and  may  be  of  such  an  extent  that  the  whole  posterior  naris  is 
occluded  by  a  rounded,  sessile  tumor  of  irregular  surface,  which  grows  down- 
wards and  backwards,  until  it  rests  partly  upon  the  dorsum  of  the  velum, 
and  protrudes  above  into  the  upper  pharyngeal  space.  It  receives  special 
mention  here,  because,  owing  to  its  peculiar  position  and  shape,  it  ca,nnot  be 
safely  reached  and  destroyed  by  any  caustic  method.  The  small  wire  kra- 
seur  of  Jarvis  hel'e  again  certainly  affords,  when  properly  used,  the  most 
efficient  and  most  satisfactory  means  of  dealing  with  these  localized  hyper- 
trophies, and  of  effecting  their  entire  removal.* 


Fig.  994. 


Jarvis's  wire  Scraseur. 

The  instrument  is  light,  and  at  the  same  time  powerful ;  it  can  be  passed 
throuo;h  a  narrowed  nasal  passage  without  difficulty,  and,  if  the  size  and  loca- 
tion of  the  hypertrophic  tumor  have  been  carefully  studied  previous  to  its 
introduction,  and  if  the  wire  loop  have  been  arranged  accordingly,  no  great 
difficulty  is  experienced  in  ensnaring  the  growth.  Slight  traction  on  the 
instrument,  and  a  few  turns  of  the  milled'nut,  will  now  secure  it  tirmly, 
and  the  mass  is  then  slowly  cut  through,  to  insure  freedom  from  hemorrhage. 
The  details  of  this  little  operation,  which,  if  judged  by  its  results,  constitutes 
one  of  the  more  marked  advances  of  recent  rhinoscopic  surgery,  have  been 
fully  described  by  its  originator  in  several  recent  articles.^ 

Fig.  995. 


Nasal  curette. 


If  the  vault  of  the  pharynx  be  involved  in  the  disease,  as  is  usually  the 
case,  especially  in  young  subjects  (adenoid  vegetations  or  hypertrophies),  active 
surgical  treatment  will  be  required,  for  sprays  will  be  found  ineffectual  in 
producing  any  marked  resorption  of  the  hypertrophic  masses.    The  choice 

>  Seiler,  Medical  Record,  October  29,  1881 ;  Bosworth,  Medical  Record,  July  9,  1881. 
2  Archives  of  Laryngology,  vol.  ii.  No.  2  and  vol.  iii.  No.  2  ;  Transactions  of  the  Americaa 
Medical  Association,  1881. 


778      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

practically  lies  between  the  use  of  the  galvano-cautery,  the  curette,  caustics, 
and,  finally,  the  forceps.  Other  means  are  advised,  such  as  the  use  of  the 
sharp  spoon — a  cutting  edge  fastened  to  a  finger-guard — the  Jarvis  wire- 
snare,  modified  for  use  in  the  pharyngeal  vault,  and  the  like ;  but  they  do 
not  possess  the  advantages  of  the  first-named  instruments  and  methods. 
The  use  of  the  curette  is  indicated  when  the  hypertrophy  of  the  tissues  ex- 
tends broadly  in  the  shape  of  small  nodulated  masses  over  the  entire  pha- 
ryngeal vault.  Caustics  are  only  to  be  employed  when  the  hypertrophy  is  of 
limited  extent,  and,  as  has  been  stated,  chromic  acid  is  preferred.  Forceps, 
curved  at  a  suitable  angle  to  be  passed  behind  the  velum,  and  furnished 
with  cutting  blades,  are  extensively  employed  by  foreign  operators.  I  have 
of  late  used  them  exclusively  in  many  operations,  and  have  been  well  satisfied 
with  the  results. 

Atrophic  ^Tasal  Catarrh. — As  the  result  of  the  process  of  intra-nasal 
hypertrophy  described  in  the  last  section — in  certain  cases  following  it,  when 
it  has  lasted  some  time,  or,  more  rarely,  occurring  early  in  the  disease,  before 
hypertrophy  is  far  advanced — atrophic^  or  as  it  is  sometimes  termed, /eifz^Z  rhi- 
nitis^ is  developed.  It  is  much  rarer  than  the  preceding  varieties.  Its  etiology 
is  as  follows.  The  deposition  of  newly  developed  connective  and  elastic 
tissue  in  the  deeper  layers  of  the  nasal  mucous  membrane,  in  hypertrophic 
rhinitis,  leads  to  two  results :  first,  by  its  mere  presence  and  amount,  it  may 
press  upon,  cause  atrophy  of,  and  destroy  function  in,  the  glands  and  follicles 
which  thickly  stud  the  mucous  membrane ;  this  may  occur  early  in  the  dis- 
ease, but  when  seen  at  a  later  period,  as  commonly  is  the  case,  the  process  of 
atrophy  in  the  glands  and  other  tissues  has  a  different  explanation.  I  believe 
it  to  be  then  due  to  the  contraction  w^hich  takes  place  in  the  elastic  and  con- 
nective tissue  above  alluded  to.  The  more  firmly  this  becomes  organized  in 
the  course  of  time,  the  more  firmly  it  compresses  and  consequently  destroys 
the  function  of  the  secreting  glands  and  follicles,  mainly  and  primarily  the 
serous  glands,  and  with  them  the  mucous  membrane  in  which  they  lie,  and 
the  submucous  structures  undergo  atrophy,  and  even  more.  If  the  process  be 
long  continued,  the  effect  of  this  constant  pressure,  aided  by  the  ])ressur(' 
exerted  by  the  inspissated  secretions  and  hard  crusts,  upon  the  turbinated 
bones,  is  to  cause  an  interstitial  absorption,  an  atrophy,  in  them ;  the  result 
is  shown,  in  the  course  of  time,  in  the  abnormally  wide,  roomy  nasal  passage, 
and  in  the  almost  rudimentary  appearance  of  the  turbinated  bones,  especially 
the  inferior.  From  the  process  of  atrophy  here  described,  to  the  condition 
accompanied  by  fetor,  or  to  the  form  of  rhinitis  termed  fetid,  is  but  a  step : 
the  latter  condition  follows  the  former  closely — indeed  is  part  of  it,  if  it  has 
lasted  any  time — and  I  see  no  need,  clinically,  to  make  a  distinction  between 
the  two. 

Fetor  is  the  direct  result  of  the  atrophy,  in  this  way :  the  secretions  are 
scanty  and  tenacious,  as  has  been  said,  and  become  more  and  more  so  as 
atrophy  of  successive  follicles  and  glands  takes  place.  (The  explanation  is 
simple:  the  atrophic  process  has  affected,  first  and  chiefly,  the  serous  glands, 
which  are  numerous  in  the  nasal  mucous  membrane ;  their  function  is,  as  is 
well  known,  by  their  secretion  to  render  the  nasal  mucus  thin  and  watery ; 
but  this  function  being  abolished  by  their  gradual  destruction,  the  mucus  se- 
creted by  the  mucous  glands,  large  numbers  of  which  still  remain  intact,  is 
viscid  and  tenacious.)  This  secretion  adheres  to  the  mucous  surfaces,  and 
rapidly  desiccates  in  the  respiratory  current  of  air.  Large  crusts  and  scabs 
thus  readily  form,  and  cling  closely,  in  the  nasal  passages  and  at  the  vault  of 
the  pharynx.  Impacted  in  the  narrowed  parts  of  the  canals,  pent  up  beneath 
the  turljinated  bones,  and  constantly  growing  in  size  by  the  addition  of  the 


DISEASES  OF  THE  NASAL  PASSAGES. 


779 


secretions  poured  out  beneath  them  and  prevented  from  escaping,  putrefactive 
changes  set  in,  the  matter  thus  imprisoned  decomposes,  and  fetor  is  estab- 
lished. The  irritation  of  the  mucous  membrane  caused  by  the  presence  of 
these  pent-up  purulent  discharges — for  they  rapidly  change  from  nmco-puru- 
lent  to  purulent — excites  further  discharge,  and  thus  constantly  aggravates, 
the  disease.^ 

The  syyaptoias  are  mainly  if  not  wholly  due  to  the  presence  of  the  large, 
inspissated  crusts  of  mucus  in  the  nasal  passages,  with  their  resultant 
obstruction  to  the  respiratory  current,  and  to  their  decomposition,  which  gives 
rise  to  the  fetid  and  offensive  odor  which  is  the  main  characteristic  of  the 
disease.  Quantities  of  inspissated  muco-pus  mixed  with  blood,  together 
with  more  or  less  fluid  secretion  of  a  muco-purulent  character,  are  dis- 
charged daily.  Pain  and  irritability  of  the  mucous  membrane  are  also  com- 
plained of  Attacks  of  epistiixis  (due  to  the  erosions  of  the  membrane 
caused  by  the  mechanical  irritation  produced  by  the  hard  crusts  of  mucus), 
are  not  infrequent.  In  the  later  stages,  when  atrophy  has  taken  place,  there 
is  less  obstruction,  and  the  sense  of  smell  is  either  more  markedly  interfered 
with  or  probably  abolished.  When  the  vault  of  the  pharynx  is  involved, 
the  accumulations  of  the  hard  secretions  at  this  point,  give  rise  to  pain,  dis- 
comfort, and  the  sensation  of  a  foreign  body  being  present.  Phalangitis 
sicca  is  usually  associated  wdth  the  latter  condition,  and  symptoms  referable 
to  this  locality  are  manifested. 

Rliinoscopic  examination  will  seldom  fail  to  show  appearances  characteristic 
of  the  disease:  in  its  early  stages,  a  dry  and  glazed  mucous  membrane,  and 
as  it  progresses,  constant  increase  in  the  crust-accumulation  and  change  in 
the  character  of  the  diminished  secretion,  until  the  stage  of  atrophy  is  reached, 
when  the  nasal  passage  will  be  seen  to  be  wide  and  roomy.  Curiously 
enough,  the  mucous  membrane  of  both  the  nares  and  pharynx,  when  cleansed 
of  its  overlying,  thick  and  discolored  mucous  accumulations,  presents  a  fairly 
healthy  appearance. 

Treatment. — Beyond  question,  atrophic  nasal  catarrh  is  an  intractable 
affection  ;  that  it  not  infrequently  baffles  all,  even  persistent,  efforts  for  its 
cure,  clinical  experience  shows.  Much,  however,  may  be  done  by  regular 
and  faithful  treatment,  to  mitigate  at  least  the  most  offensive  of  its  charac- 
teristics, and  ultimate  cure  need  not  be  despaired  of  if  the  case  be  seen  in 
its  earlier  stages. 

The  lirst  and  most  important  indication  is  the  thorough,  regular,  and  care- 
ful removal  of  all  crusts  and  inspissated  secretions  from  the  nasal  passages 
and  vault  of  the  pharynx.  This  process,  I  repeat,  must  be  regularly  and 
persistently  repeated  at  suitable,  probably  daily,  intervals.  Instrumental  aid, 
such  as  that  of  the  forceps,  probe,  brush,  and  the  like,  may  occasionally  be 
required,  especially  in  the  later  stages,  to  insure  thoroughness.  The  nasal 
spray-apparatus,  used  wdth  a  cleansing  and  disinfectant  solution  (page  759), 
may  serve  the  purpose  of  cleanliness  when  once  it  has  been  established  by 
other  means.  When  more  powerful  measures  are  required,  the  anterior  or 
posterior  nasal  syringe  must  be  employed.  In  the  earlier  stages,  remedies 
are  suitable  which  from  their  nature  tend  to  restore  the  normal  secreting 
power  of  the  mucous  membrane,  through  stimulation  of  its  glandular  appa- 
ratus, probably  by  their  irritant  effect.  Certain  of  them  may  be  applied  in 
solution,  by  means  of  the  compressed-air  spray,  and  others  in  powder. 
Bosworth  recommends  especially  : — 

B  Pulv.  sanguinariae,  R — Pulv.  galangae, 

Pulv.  myrrhne,  aa  5j  ;  Pulv.  amyli,  aa  3j.  M. 

Lycopodii,  5ij- 


1  See  also  the  section  on  Ozsena. 


780      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


Seiler^  extols  the  use  of  a  powder  of  nitrate  of  silver,  or,  in  certain  cases, 
a  spray  of  an  iron  solution.  Carbolic  acid,  salicylic  acid,  iodine,  bromide  of 
potassium,  belladonna,  and  the  like,  are  also  employed. 

In  the  later  stages,  after  the  cleansing  process,  the  use  of  disinfectant 
solutions  plays  an  important  part,  succeeded  probably  by  the  use  of  some 
powder  containing  pulverized  iodoform.  The  treatment  of  so-called  ozsena, 
as  described  in  the  next  section,  is  also  applicable  here. 

Oz^NA. — The  affection  which  has  just  been  described,  atrophic,  or  as  it 
is  sometimes  called  in  its  later  stages  fetid,  nasal  catarrh,  is  precisely  iden- 
tical in  its  pathology,  appearances,  symptoms,  and  results,  with  the  dis- 
ease which  is  commonly  termed  ozoena.  Of  this  I  think  there  can  be  no 
doubt,  certainly  in  the  majority  of  cases.  But  it  is  possible,  as  claimed  by 
Michel,  that  in  exceptional  instances  the  original  seat  of  the  disease  may  be 
in  the  accessory  sinuses  of  the  nose,  and  only  ultimately  lead  to  the  changes 
described  below.  The  term  ozoena,  however,  as  it  is  generally  used— to 
indicate  a  disease,  rather  than  describe  a  symptom,  and  to  cover  a  class 
of  nasal  affections,  varied  in  their  causation,  but  all  possessing  one  promi- 
nent symptom  in  common,  viz.,  an  intensely  disagreeable  smell  or  fetor, 
associated  usually  with  a  thick  crust-formation  in  the  nasal  passage— leads 
to  much  misconception.  Of  these  nasal  diseases,  syphilis,  with  its  destructive 
inroads  upon  both  the  bones  and  cartilages  of  the  organ,  is  the  most  com- 
mon. But  the  same  symptom  is  also  present  in  other  ulcerative  affections  of  the 
parts,  such  as  struma,  lupus,  and  glanders,  and  it  is  even  not  wanting,  in  a  lesser 
degree,  in  obstruction  of  the  nasal  passages  from  any  cause,  especially  long 
retention  of  a  foreign  body,  with  resultant  accumulation  of  the  discharges 
and  their  decomposition.  To  class,  however,  all  these  affections  under  one 
name,  on  account  of  the  similarity  of  one  of  their  symptoms,  is  manifestly  to  vary 
widely  from  the  truth,  leads  but  to  confusion,  and  detracts  attention  from  their 
true  nature,  the  correct  appreciation  of  which  is  of  importance  both  on  diag- 
nostic and  therapeutic  grounds.  It  seems  to  me  preferable,  therefore,  to  re- 
strict the  term  ozsena — if  it  be  deemed  desirable  to  retain  it — to  those  cases 
of  ulcerative  disease  of  the  nose,  such  as  syphilis,  struma,  lupus,  etc.,  in 
which  fetor  is  a  prominent  symptom,  and  is  dependent  upon  necrosis  of  bone; 
and  even  then  to  use  the  term  only  with  a  qualifying  adjective,  as  syphilitic 
ozsena,  etc.  The  terms  catarrhus  atrophicns  ozcenicans  and  rhinitis  atrophica, 
it  may  be  mentioned,  have  both  been  suggested  by  foreign  authorities  to 
replace  the  name  ozsena  in  the  nomenclature  of  nasal  diseases. 

E.  FraenkeP  informs  us  that,  up  to  the  present  time,  four  reports  of  accu- 
rate post-mortem  examinations  in  cases  of  rhinitis  atrophica,  or  so-called 
ozsena,  have  been  made,  by  Ilartmann,^  Grottstein,'*  Traenkel,  and  Krause 
these  all  found  large  nasal  cavities,  and  slight  development  of  all  the  turbi- 
nated ^  bones,  and  they  agree  also  in  the  results  of  their  microscopic 
investigations,^  which  showed  connective-tissue  change  in  the  mucous 
membrane,  with  partial  degeneration  of  the  secreting  elements.  Zaufal 
builds  his  theory,  as  to  the  causation  of  the  disease,  on  the  existence 
of  these  large  cavities  (which  he  considers  to  be  congenital),  and  believes 
all  subsequent  changes  in  the  mucous  membrane,  and  the  fetor,  to  be  consecu- 
tive to  their  enlargement  and  to  the  consequent  accumulation  of  the  products 
of  secretion.  In  this  view  he  is  supported  by  Hartmann  and  Martin.^  Fraenkel 
differs  from  this  view,  and  agrees  with  Gottstein  and  Schaffer  in  regarding 


1  Med.  and  Surg.  Reporter,  April  19,  1884. 

2  Virchow's  Archiv,  Bd.  Ixxxvii.  4  Feb.  1882. 
8  Deutsch.  med.  W«ochenschr.,  No.  13,  1878. 

5  Virchow's  Archiv,  Bd.  85.  1881. 


4  Breslau  aerztl.  Zeitschrift.  1879. 
6  De  rOzeiie  vrai.    Paris,  1881. 


DISEASES  OF  THE  NASAL  PASSAGES. 


781 


the  size  of  the  naval  cavities  as  the  result  of  the  last  stage  of  a  diifuse,  at 
first  hyperplastic,  but  subsequently  atrophic,  rhinitis  (see  page  778);  and  the 
results  of  two  post-mortem  examinations  of  his  own  agree  with  those  of 
Gottstein  and  Krause.  He  does  not,  however,  coincide  with  the  latter^  as  to 
the  similarity  of  the  structural  changes  in  oz?ena  with  those  of  xerosis  ol  the 
conjunctiva  and  callous  stricture  of  the  urethra,  in  both  of  which  the  odor  of 
the  secretion,  if  any,  can  be  easily  tested,  and  in  neither  of  winch  has  tctor 
been  found  as  a  symptom.  His  results  lead  him  to  believe  that  atrophy  ot  the 
mucous  membrane  is  necessary  for  the  production  of  the  fetor,  and  that  the 
disappearance  of  Bowman's  glands  is  an  important  factor.  He  adds  that  it 
is  doubtful  whether  the  atrophy  always  follows  hypertrophy,  or  whether,  as 
in  the  granular  kidney,  the  process  is  not  one  in  which  there  is  at  iirst  no 
appreciable  thickening  of  mucous  membrane.  ^.  ,  - 

The  majority  of  authors  thus  agreeing  as  to  the  pathology  of  the  attection, 
two  interesting  points— (1)  as  to  the  immediate  cause  of  the  distinctive,  fetid 
smell  which  has  been  alluded  to,  and  the  views  of  some  authorities  in  regai-d 
to  which  have  been  given,  and  (2)  whether  or  no  the  disease  has  a  consti- 
tutional origin— claim  attention.  Upon  these  points  opinions  vary.  Coz- 
zolino^  believes  that  simple  oziena  may  exist  in  certain  individuals  who  have 
naturally  fetid  secretions,  as  of  the  feet  and  axilh^i ;  Hebdemus,  that  the  fetor 
is  the  result  of  a  gaseous  .exhalation  from  a  mucous  membrane  deprived  of 
secretion;  Krause" finds  a  suflicient  cause  for  it  in  the  fatty  degeneration  of 
the  newly  formed  cell-proliferations,  even  while  they  are  m  intimate  con- 
nection with  their  original  soil  and  before  their  appearance  on  the  surface, 
and  in  the  rapid  change  of  the  fat  into  fatty  acids,  and  consequent  decompo- 
sition, as  proved  by  the  appearance  of  margarin  crystals  in  the  crusts,  these 
fatty  acids  being  the  invariable  products  of  the  decomposition  of  albuminous 
matters ;  Fournie  holds  that  it  is  caused  by  the  constitutional  state  of  the 
individual— a  state  which  excites  a  morbidly  odorous  secretion  in  the  glands 
of  the  Schneiderian  membrane ;  while  Fraenkel's  theory  is^,  that  the  cause  is 
to  be  found  in  suppuration  of  the  mucous  membrane,  and  E.  Fraenkel's,  that 
the  presence  of  micrococci  and  bacteria  is  the  chief  factor  in  its  development. 

Is  atrophic  catarrh  or  ozEena  always  a  constitutional  disease  ?  Fraenkel 
does  not  believe  that  its  existence  proves  any  special  dyscrasia,  but  foremost 
in  the  list  of  constitutional  predispositions  to  which  it  may  be  referred,  he 
would  place  scrofulosis  and  perhaps  syphilis.  Cozzolino  holds  that  it  is  a 
result  of  chronic  rhinitis,  and  never  occurs  but  in  scrofulous  subjects ;  this 
Krause  doubts,  saying  that  there  is  no  ground  for  assuming  that  the^  consti- 
tutional idiosyncrasy,  or  the  constitutional  predisposition^  in  the  individual, 
upon  which  the  disease  depends,  has  any  connection  with  scrofula.  The 
theory  of  a  constitutioual  predisposition  is  also  held  by  Fournid 

The  appearances  of  the  disease,  as  they  are  seen  in  the  nasal  passages,  are 
similar,  though  exaggerated  in  degree,  to  those  described  as  being  incident 
to  atrophic  catarrh.  ... 

Treatment— ThQ  treatment  of  the  affection  will  not  vary,  in  the  main, 
from  that  recommended  for  atrophic  catarrh.  The  essential  point  is  to  insure 
thorough  cleansing  of  the  parts  and  their  subsequent  disinfection  (see  pp.  779, 
780).  The  agents  employed  to  neutralize  the  fetor  are  numerous,  including  anti- 
septics from" permanganate  of  potassium  down  to  iodoform.  Fournie  recom- 
mends boracic  acid  or^salicylate  of  sodium.  The  cotton-wool  tampon  is  generally 
well  spoken  of.  Zaufal  uses  it  to  remedy  the  enlargement  of  the  nasal  cavi- 
ties ;  Gottstein  employs  it  to  stimulate  secretion.  Fournie  believes  that  when 
the  cotton-wool  is  introduced  into  the  nostril,  it  acts  in  a  Listerian  manner, 


1  Loc.  cit. 


2  Rev.  Mens,  de  LaryngoL,  1  Nov.  1881. 


782      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

that  is,  it  prevents  the  germs  from  the  external  air  from  penetrating  into  and 
acting  on  the  mucus,  already  too  prone  to  decompose ;  and  Fraenkel  advises 
astringents  and  the  galvano-cautery  as  the  most  serviceable  means  against  the 
atrophy. 

The  whole  matter  of  treatment  is  summed  up  tersely  by  Kendal  Franks,^ 
to  the  effect  that,  if  the  theory  that  the  disease  is  due  to  atrophy  of  the  mucous 
membrane  is  correct,  there  can  be  as  little  question  of  curing  the  affection  as 
there  would  be  of  causing  the  retrogression  of  a  granular  kidney,  or  of  a  cir- 
rhotic liver.  By  the  application  of  strong  astringents  to  the  already  atro- 
phied mucous  membrane,  nothing  is  to  be  gained,  though  if  w^ewere  able  to 
get  the  disease  in  its  hypertrophic  stage,  theoretically  we  ought  to  be  able 
to  effect  a  return  almost  to  the  normal  condition. 

Rouge^  holds  the  view  that  it  is  impossible  to  have  an  ozsena  without 
some  lesion  of  the  skeleton  of  the  nasal  cavities — a  view  in  which,  as  has 
been  said,  I  do  not  coincide,  although  I  agree  with  the  majority  of  the 
conclusions  upon  which  he  bases  it,  and  hold  that  they  serve  equally  well  to 
corroborate  the  opinion  above  expressed  as  to  the  true  cause  of  the  disease ; 
he  advises  that  the  upper  lip  and  nostrils  should  be  lifted  together  by  first 
freeing  them  by  incisions  through  the  mucous  membrane  of  the  mouth,  and 
dividing  the  cartilages  at  their  attachment  to  the  upper  jaws.  The  anterior 
bony  nares  are  thus  completely  exposed,  and  a  good  view  obtained  of  the 
interior  of  the  nasal  fossae,  together  with  ample  space  for  the  introduction 
of  instruments  and  the  removal  of  diseased  bone. 

Syphilitic  Affections  of  the  I^asal  Passages.^ — Syphilis  may  exhibit 
various  manifestations  in  the  nasal  passages. 

In  the  infant,  the  disease  appears  congenitally^  under  the  form  of  an  acute 
coryza,  with  its  attendant  symptoms  of  swelling  of  the  mucous  membrane, 
obstruction  to  nasal  respiration,  profuse  discharge,  and  hoarse  voice,  together 
with  other  evidences  of  the  disease,  such  as  affections  of  the  skin,  excoriations 
of  the  anus,  etc.  The  evil  effects  of  the  nasal  obstruction,  as  shown  in  the  inef- 
fectual attempts  of  the  child  to  nurse,  and  its  consequent  inanition,  have  been 
elsew^here  detailed  (see  page  766).  The  condition  often  becomes  one  of  grave 
import.  In  addition  to  the  ordinary  constitutional  treatment  of  the  primary 
disease,  it  becomes  requisite,  in  such  cases,  to  thoroughly  clear  the  nasal  pas- 
sages of  all  accumulated  discharges,  by  the  careful  use  of  a  syringe,  with  a 
solution  of  borax,  chlorate  of  potassium,  or  the  like,  in  warm  water.  Sooth- 
ing ointments  may  then  be  applied  with  a  brush,  with  good  effect.  The  dis- 
ease usually  yields  to  this  plan,  without  recourse  being  necessary  to  more 
heroic  measures  or  to  more  active  medication. 

Chancre  of  the  nostril  is  occasionally  met  with;  Watson,'*  Cutter,  and  others 
report  instances  of  its  occurrence. 

The  secondary  stages  of  the  acquired  malady  are  occasionally  characterized 
by  an  acute  and  persistent  coryza,  and,  still  more  rarely,  by  superficial  ulcer- 
ations of  the  mucous  membrane.  Mucous  patches  may  appear  about  the 
orifices  of  the  nostrils.  The  earlier  symptoms  of  the  disease  are  simply 
those  of  an  uncomplicated  nasal  catarrh,  from  which  it  presents  no  points  of 
diagnostic  difference,  and  recourse,  in  attempting  to  establish  its  true  nature, 
must  always  be  had  to  the  clinical  history  of  the  case.  The  ulcerations, 
slight  as  they  are,  are  more  characteristic ;  their  progress  is  slow,  and  they 

»  Dublin  Jour.  Med.  Sci.,  April,  1882. 

2  Nouvelle  M^thode  Cliirurgicale  pour  le  Traiteraent  Chirurgical  de  I'Ozene.    Lausanne,  1873. 

3  See  Scliuster  and  Sanger,  Vierteljahrsschr.  fiir  Derm,  und  Syph.,  Jahrg,  iv.  Heft  i.-ii.  1877; 
and  Mauriac  on  Naso-Pharjngeal  Syphilis.    Paris,  1880. 

*  Med.  Times  and  Gaz.,  April  16,  1881. 


DISEASES  OF  THE  NASAL  PASSAGES. 


783 


are  usually  found  upon  the  cartilaginous  septum.  Rarely  do  they  extend  to 
any  extensive  destruction  of  tissue  or  of  neighboring  parts,  and  never,  if  con- 
trolled by  judicious  treatment. 

The  most  destructive,  the  most  common,  and  the  most  characteristic  of 
the  syphilitic  affections  of  the  nose,  occur  during  the  tertiary  period  of  the 
disease — that  is,  at  a  date  from  five  to  fifteen  years  after  the  primary  infec- 
tion— and,  as  is  the  rule  with  the  severer  lesions  of  sy})hilis,  are  more  apt  to 
appear  in  broken-down,  neglected,  and  strumous  individuals.  The  ulceration, 
commencing  in  a  gummatous  periostitis,  or  in  a  localized  gumnjy  infiltration 
of  the  mucous  meinbrane,  rapidly  becomes  wide-spread  and  destructive,  invad- 
ing and  destroying  both  cartilaginous  and  osseous  structures,  and  eventuating 
in  necrosis  and  discharge;  permanent  deformity,  from  sinking  in  of  the  nose, 
follows,  from  loss  of  its  bony  and  cartilaginous  supports.  iSTo  part  of  the 
interior,  or,  in  certain  rare  cases,  the  exterior  of  the  organ,  is  sacred  from  the 
inroads  of  the  disease.  Vomer,  perpendicular  plate  of  ethmoid,  cartilaginous 
septum,  turbinated  bones,  the  fioor  and  walls  of  the  nose,  yield  in  turn. 
Crusts  and  necrotic  bits  of  bone  accumulate  in  the  passages ;  a  most  intoler- 
able fetor  is  developed  ;  the  discharge  is  stinking,  bloody,  and  purulent;  ab- 
scesses form,  and  may  rupture  externally,  and  the  hard  palate  finally  becomes 
perforated.  In  rare  instances,  serious  consequences  may  still  further  follow 
from  the  extension  of  the  destructive  process  to  the  interior  of  the  cranial 
cavity,  or  from  some  incidental  or  accidental  complication — lodgment  of 
necrosed  pieces  of  bone  in  the  air  passage  or  oesophagus. 

The  diagnosis  of  syphilitic  disease  of  the  nose  is  ordinarily  not  difiicult ; 
the  clinical  history  of  the  case,  the  presence  of  the  syphilitic  cachexia,  the 
appearance  of  the  nasal  ulcerations,  and  especially  the  detection  with  the  probe 
of  necrosed  bone  within  the  passages,  together  with  the  ofi:ensive  odor  and 
discharge,  and  the  existence  of  ulcers  in  the  pharynx  and  fauces,  rarely  leave 
room  for  doubt.  Lupus,  scrofula,  tuberculosis,  cancer,  and  the  ulcers  of  the 
exanthemata,  the  only  other  main  aftections  of  the  nose  giving  rise  to  ulcer- 
ation (see  page  784),  are  readily  eliminated,  in  the  absence  of  their  character- 
istic appearances  and  constitutional  symptoms.  Special  care  must  be  taken 
not  to  confound  cases  of  syphilis,  attended,  as  they  are,  by  an  oz?enic  smell, 
with  cases  of  simple  ozaena,  such  as  have  been  elsewhere  described.  The 
mistake  is  no  unusual  one,  and  the  direful  results  of  want  of  proper  treatment, 
or  the  effects  of  mismanagement,  in  such  instances,  are  well  knoAvn. 

Treatment. — The  importance  of  prompt,  efficient,  and  skilful  treatment, 
both  local  and  general,  cannot  be  overestimated;  the  latter  is  always  essential 
in  controlling  the  disease  ;  the  former,  of  the  utmost  value  in  limiting  its 
destructive  course  and  hastening  its  cure.  Iodide  of  potassium  in  full  doses 
(gr.  x,  XX,  to  XXX,  or  more,  three  or  four  times  daily),  conjoined,  if  the 
necessary  indications  exist,  w^ith  the  administration  of  the  preparations  of 
iron,  cod-liver  oil,  and  the  like,  constitutes  the  sheet  anchor  of  treatment, 
and  its  use  is  often  attended  with  the  most  brilliant  results.  Mercury, 
I  believe  from  experience,  to  be  of  less  value  in  controlling  the  ulcerative 
action  in  this  stage.  The  combined  treatment  may  be  preferred  by  some. 
Locally,  the  indications  are  to  correct  the  offensive  odor,  check  hyper- 
secretion, and  remove  all  the  necrosed  bone,  which  acts  as  a  constant 
irritant.  The  first  step  is  the  thorough  cleansing  of  the  parts  by  means  of  a 
disinfectant  solution  (permanganate  of  potassium,  liq.  sod?e  chlorinat.,  carbolic 
or  salicylic  acid,  borax,  creasote,  etc.),  used  with  the  nasal  douche,  or,  still 
better,  some  form  of  nasal  syringe.  The  nasal  spray-apparatus  is  rarely  forci- 
ble enough  in  the  stream  that  it  throws  to  dislodge  the  thick  and  impacted 
accumulation  of  crusts,  or  to  loosen  necrosed  bits  of  bone ;  indeed,  both  often 
require  direct  extraction  at  the  hands  of  the  surgeon,  aided  by  forceps  and 


784     DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

probe.  This  cleansing  process  thoroughly  accomplished,  the  state  of  cleanli- 
ness thus  obtained  must  be  maintained  by  the  repetition  of  the  syringing,  by. 
either  surgeon  or  patient,  as  often  as  may  be  necessary — certainly,  atthe  out- 
set, each  day.  After  each  cleansing,  powdered  iodoform  may  be  insufflated 
into  both  nostrils,  and  over  all  ulcerated  surfaces,  by  means  of  Smith's  insuf- 
iiating  tube  or  nasal  powder-blower.  Some  prefer  the  immediate  inhala- 
tion of  the  vapor  of  iodine,  or  the  insufflation  of  Trousseau's  mercurial  powder. 
The  first  plan  I  believe  to  be  the  best.  The  importance  of  removing  as  soon 
as  practicable  all  necrosed  bone  will  be  apparent.  It  acts  as  a  foreign  body,- 
keeps  up  ulceration,  and  prevents  reparative  action.  Its  extraction  by  means, 
usually,  of  the  polypus  forceps,  is  a  simple  matter,  and  is  governed  by  ordi' 
nary  surgical  rules.  Goodwillie  has  reported  good  results  in  his  treatment  of 
such  cases  by  grinding  or  cuttting  away  all  dead  bone  with  the  burr  of  the 
dental  engine,  introduced  through  the  nasal  opening,  and  smoothing  away  all 
ragged  and  irregular  surfaces  that  are  left.  The  healing  process  and"  the 
duration  of  the  disease  are  unquestionably  considerably  shortened  by  such  a 
procedure. 

Ulcerative  Diseases  or  the  Mucous  Membrane  of  the  ]^ose.  Aside  from 

syphilis,  which,  as  has  been  shown,  may  in  its  progress  destroy  not  only  the 
mucous  membrane,  but  the  cartilaginous  and  bony  parts  of  the  nose  as  well, 
and  give  rise  to  all  the  symptoms  of  a  marked  ozsena,  other  ulcerative 
diseases  of  the  nasal  mucous  membrane  exist,  the  commoner  ones  compara- 
tively unimportant,  the  more  serious  fortunately  rare.  Both  classes  still 
remain  to  be  considered.  Catarrhal  ulcerations,  as\hey  have  been  termed,  but 
which  are  in  reality  never  more  than  slight  erosions,  are  not  the  rule  in 
uncomplicated  nasal  catarrh,  and  are  but  rarely  met  with.  Contrary  to 
general  assertion,  the  eczematous  form  of  nasal  ulcer,  if  it  may  be  so  termed, 
is  not  uncommon  in  children,  and  may  be  associated  with  eczema  of  the 
upper  lip  and  cheeks.  The  crusts  frequently  form  so  thickly  about  the  nasal 
opening,  that  it  is  occluded  by  them  as  well  as  by  the  attendant  swelling  of  the 
mucous  membrane,  and  much  nasal  obstruction  to  breathing  and  discomfort 
are  thus  caused.   A  deep,  fissure  at  the  low^er  part  of  the  nasal  nieatus 

is  furthermore  no  unusual  result,  if  the  condition  be  neglected.  In  either  case, 
a  constitutional  course  of  treatment  suited  to  the  indications,  and  locally^ 
complete  cleanliness  obtained  by  the  daily  injection  of  an  alkaline  solution' 
and  the  prevention  of  the  re-accumulation  of  the  crusts  by  the  use  of  some 
unirritating  ointment,  such  as  that  of  the  benzoated  oxide  of  zinc,  glycerine  of 
borax, etc.,  will  quickly  relieve  the  affection.  It  is  as  a  rule  not  associated  with 
an  ozaenic  smell,  unless  there  be  considerable  and  prolonged  obstruction  to 
the  exit  of  the  nasal  secretions.  Traumatic  ulcers,  the  result  of  the  mechan- 
ical irritation  caused  by  the  lodgment  or  pressure  of  foreign  bodies  within 
the  nasal  passages,  quickly  heal  when  the  offending  substance  is  once  removed. 
Ulceration  of  the  nasal  mucous  membrane  occurs  among  w^orkmen  in  arsenic 
(paper-hangings),  and  in  those  who  are  exposed  to  the  fumes  of  chromic  acid. 
A  more  serious  form  of  ulceration,  extending  even  to  the  destruction  of  the 
cartilages  and  bones,  occasionally  occurs  among  the  seqiielce  of  certain  fevers 
— measles,  scarlatina,  smallpox,  and  typhus— perhaps  also  in  erysipelas  and 
chronic  pyaemia.  The  local  symptoms  are  marked  and  leave  no  room  for 
question  as  to  the  diagnosis.  Scorbutic  ulcers  of  the  nose  may  occur.  Buzzard^ 
says  that  in  confirmed  scurvy,  the  slightest  pressure  suffices  to  open  the 
skin  and  to  give  rise  to  an  ulcer,  w^hose  edges  are  hard,  thick,  and  shining, 
and  the  surface  fungoid  and  bleeding,  and  that  the  lips  and  nostrils  are 

1  Reynolds's  System  of  Medicine,  vol.  i.  p.  744. 


DISEASES  OF  THE  NASAL  PASSAGES. 


785 


occasionally  the  seat  of  this  form  of  ulceration.  An  intolerably  offensive  odor 
is  emitted,  and  the  exhaustion  attendant  upon  it  is  often  fatal.  Watson 
has  called  attention  to  the  fact  that  in  paresis  of  the  fifth  pair  of  nerves, 
ulceration  of  the  mucous  membrane  of  the  nose  may  occur  as  the  result  of  the 
disturbance  of  nutrition,  associated  with  their  sensorj'  function  {iieuro-paralytic 
ulcers).    He  adds  that  little  can  be  done  in  the  way  of  local  treatment. 

Scrofulous  ulcers^  according  to  Fraenkel,  frequently  occur  in  the  victmis 
of  scrofula,  upon  the  nasal  mucous  membrane.  At  times,  and  as  a  rule, 
small,  at  other  times  they  may  penetrate  deeply,  and  destroy  both  bones  and 
cartilage.  Special  care  is  necessary,  in  order  to  dilferentiate  them  from  similar 
ulcers  of  a  syphilitic  nature. 

Glanders. — The  source  of  glanders  in  the  human  subject  can  almost  uni- 
formly be  traced  to  an  accidental  inoculation  of  the  virus  from  an  animal 
affected  with  the  disease,  for  isolated  instances  only  exist  where  it  has  been 
communicated  from  man  to  man.  The  mucous  membranes,  and  first  that  of 
the  nasal  cavity,  early  manifest  symptoms  of  inflammatory  and  ulcerative 
action.  At  the  outset,  and  following  the  general  lassitude,  pain  in  the  back 
and  limbs,  headache,  and  rigors,  the  discharge  from  the  nose  is  of  thin,  viscid, 
and  light-colored  mucus  only.  Gradually,  however,  there  appears  in  the 
acute  form  of  the  disease,  swelling  and  redness  of  the  organ  anil  its  adjacent 
parts,  accompanied  by  severe  pain  ;  its  upper  portion  is  especially  sensitive  to 
the  touch,  exhibiting  a  difiuse,  erysipelatous  swelling.  The  nasal  discharge 
now  becomes  of  a  thicker  consistence,  more  purulent,  of  a  brownish-yellow 
color,  sanguineous  and  oftensive.  Distinct  tubercles  are  frequently  seen, 
situated  especially  upon  the  al?e,  and  the  formation  of  pustules  and  ulcers 
in  the  mucous  membrane  of  the  nose  may  be  distinguished  in  many  instances 
in  the  more  malignant  forms.  These  terminate  in  involvement  of  the  })eri- 
chondrium  and  perforation  of  the  septum.^  The  constitutional  disturbances 
attendant  upon  these  local  manifestations  are  marked.  Aside  from  those 
already  mentioned,  the  pulse  and  temperature  are  high,  and  the  respiration 
embarrassed  ;  delirium  occurs  early ;  swellings  of  a  red  color  upon  the  legs, 
and  pustules  about  the  face,  follow,  the  original  pustules  assuming  a  purplish 
tint.  Diarrhcjea  and  profuse  sweating,  with  restlessness  and  increased  delirium, 
are  but  the  forerunhers  of  the  end,  exhaustion  and  death  closing  the  scene.^ 

In  chronic  glanders,  the  nasal  lesions  do  not  difi:er  essentially  from  those  in 
the  acute  form  of  the  disease  just  described.  They  run  a  longer  course, 
how^ever,  and  are  soTnetimes  entirely  absent. 

The  treatment  resolves  itself,  practically,  into  that  of  the  general  condition. 
Little  can  be  done  locally,  aside  from  the  injection  of  disinfectant  solutions 
into  the  nasal  cavities  for  the  purposes  of  cleanliness.  Applications  of  tinc- 
ture of  iodine  or  nitrate  of  silver  have  been  advised  by  Bollinger. 

Lupus. — If  lupus  of  the  cutaneous  surface,  especially  of  the  face,  be  not  pre- 
sent, the  diagnosis  of  lupoid  ulcers  within  the  nose  is  a  matter  of  some  difiS.- 
culty,  since  they  are  readily  confounded  with  like  afl:*ections  of  syphilitic 
origin.^  The  points  in  difl:erential  diagnosis  have  been  well  stated  by  Dur- 
ham. Attention  must  be  directed  to  the  history  of  the  case,  to  the  age  of  the 
patient,  to  the  absence  of  other  symptoms  of  syphilis,  and  especially  of  the 
characteristic  cachexia  which  almost  alwa^^s  accompanies  the  more  serious 
syphilitic  attections  of  the  nose,  and  also  to  the  comparative  slowness  with 

^  Consult  the  excellent  article  by  Bollinger,  Ziemssen's  Cyclopaedia,  vol.  ill.  p.  356. 
*  See  Schilling,  Medico-Chirurgical  Transactions,  1830-31. 
'  See  Moiuee,  These  de  Paris,  No.  236.  1877. 


VOL.  IV. — 50 


786      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

which  the  malady  has  progressed,  and  to  the  lateness  of  the  period  at  which 
the  bones  have  become  affected. 

If  the  little  tubercular  infiltrations  of  lupus  can  be  recognized,  and  the  tuber- 
cles present  a  compact,  granular  appearance,  the  diagnosis  is  confirmed  ;  and 
it  is  further  strengthened  if  the  disease  progress  slowly,  and  if  there  be  a 
manifest  disposition  towards  healing,  here  and  there,  even  while  the  ulcer- 
ation is  extending ;  anti-sj^philitic  treatment  may  be  employed  as  a  means  of 
assistance  in  the  diagnosis.  If  an  anterior  rhinoscopic  examination  be  made, 
small,  reddish-looking  tubercles  can  usually  be  seen  early  in  the  disease  to 
stud  the  mucous  membrane ;  these  soon  break  down  in  ulceration,  the  ulcers 
preserving  to  some  extent  their  tubercular  character,  and  the  apices  of  the 
tubercles  being  concealed  by  hard  crusts.  As  the  ulceration  progresses,  the 
cartilages  become  affected,  the  septum  is  perforated,  one  or  both  alse  are  de- 
stroyed, and  the  nasal  bones  are  implicated.  Serious  deformity  may  thus  be 
caused. 

The  treatment  of  lupus  has  elsewhere  been  considered  ;^  it  mduj  be  here  added, 
however,  that  when  possible  to  do  so,  the  lupus-tubercles  in  the  nasal  mucous 
membrane  may  be  destroyed  by  means  of  a  fine  galvano-cautery  point,  or  even 
the  actual  cautery.  Chromic  acid,  caustic  potassa,  and  chloride  of  zinc,  have 
been  recommended  for  the  same  purpose,  but  their  action  is  more  difiicult  to 
control.  Ure  advises  the  use,  as  a  destructive  agent,  of  a  thick  layer  of  a 
paste  composed  of  chloride  of  zinc  with  two  or  three  parts  of  gypsum,  and 
a  little  alcohol.  Following  the  destruction  of  the  tubercular  masses,  the 
resulting  ulcers  and.  the  inflammation  may  be  treated  upon  the  principles 
already  laid  down  elsewhere  in  this  article. 

Tuberculosis  of  the  nasal  mucous  membrane  is  regarded  as  a  rare  afiection, 
and  certainly  is  one  to  which  attention  has  only  been  directed  within  very  re- 
cent years.  The  number  of  cases  as  yet  upon  record  is  too  small  to  furnish 
a  basis  for  definite  conclusions,  or  to  clinically  illustrate  distinctive,  diag- 
nostic appearances  in  the  ulcerations.  The  descriptions  thus  far  given  of  the 
latter  vary  greatly,  and  although  in  many  of  the  reported  instances  a  care- 
ful microscopic  examination  has  established  beyond  doubt  their  true  patho- 
logical nature,  in  others  this  is  open  to  grave  suspicion.  Following  irre- 
gular and  scattered  granulations  in  the  mucous  membrane  of  the  nose,  ulcers 
are  developed  which  are  small,  sometimes  disseminated,  but  at  other  times 
confluent.  They  are  superficial,  with  slightly  thickened  edges,  and  an  irreg- 
ular, unhealthy-looking  base  ;  they  may  occur  at  any  point  in  the  mucous 
membrane  of  the  nasal  passages,  but  are  found  especially  over  that  of  the 
septum,  and  are  only  observed  in  patients  in  whom  physical  examination 
will  show  pulmonary  tuberculosis,  probably  in  an  advanced  stage :  even  in 
such  instances,  their  difEerentiation  from  the  ulcerations  of  lupus,  and  occa- 
sionally of  syphilis,  becomes  a  matter  of  nice  diagnosis. 

The  accessory  cavities  of  the  nose,  the  frontal  sinus,  antrum  of  Highmore, 
and  ethmoidal  cells,  were  never  found  to  be  tuberculous  by  Weichselbaum, 
in  a  careful  post-mortem  examination  of  some  164  tubercular  subjects.^ 

1  See  Vol.  III.,  p.  88. 

2  Fraenkel  (Ziemssen's  Cyclopaedia,  vol.  iv.)  quotes  Willigk's  statistics.  In  the  post-mortem 
examination  of  476  tubercular  patients,  tuberculosis  of  the  nasal  septum  was  seen  but  once. 
Laveran  (L'Union  Medicale,  1877,  Nos.  35  et  36)  gives  two  cases  of  tuberculosis  of  the  nose. 
Riedel  (Deutsch.  Zeitschrift  fiir  Chir.,  Bd.  x.  1878)  gives  cases  of  tuberculosis  of  the  nasal  septum. 
See  also  Thornwaldt,  Deutsch.  Archiv  fiir  klin.  Med.,  Bd.  xxvii.  S.  586;  Weichselbaum,  Allg. 
Wiener  med.  Zeitung,  Nos.  27,  28,  1881.  (The  microscopic  examination  in  two  cases  fully  re^ 
port«d  is  here  given.)    Fraenkel,  Centralblatt  fiir  med.  Wissensch.,  No  27,  1881  (Statistics). 


DISEASES  OF  THE  NASAL  PASSAGES. 


787 


^^"asal  Diphtheria. — It  is  still  an  open  question  whether  diphtheria  of  tlie 
nasal  mucous  membrane  is  ever  a  primary  disease.  Schuller^  believes  that  ii 
may  be,  but  the  case  ottered  in  su})port  of  his  views  is  at  best  but  a  doubtful 
one;  Kohts^  asserts  that  it  sometimes  is,  and  that  its  local  manitestations  may 
either  remain  limited  to  the  nasal  passages,  or,  originating  there,  may  spread 
thence  into  the  upper  pharynx,  pharynx,  and  larynx.  The  converse  is,  beyond 
question,  the  commoner  occurrence,  and  the  local  membranous  evidences  of  the 
attection  must  extend  from  below  upwards,  by  a  process  of  gradual  progres- 
sion, before  they  are  found  within  the  nasal  })assages.  Aside  from  the  consti- 
tutional treatment  of  the  disease,  no  local  measures  are  usually  employed  In 
the  case  of  nasal  involvement,  aside  from  injections  or  sprays  of  alkaline  and 
disinfectant  solutions.  The  relief  that  these  give  to  the  obstruction  in  nasal 
respiration,  caused  by  accumulated  secretion  and  membrane,  and  the  conse- 
quent comfort  of  the  patient,  certainly  indicate  their  use  in  all  cases,  aside 
from  any  direct  influence  that  they  may  liave  upon  the  progress  of  the  disease. 

Pseudo-membranes  in  the  Nasal  Passages. — I  have  on  several  occasions  been 
called  upon  to  remove  tough  membranous  exudations  from  the  nasal  passages, 
where  they  were  giving  rise  to  more  or  less  obstruction  of  the  air  current, 
and  to  the  symptoms  of  a  chronic  coryza.  These  cases  have  occurred  in  young 
patients,  usually  small  children,  free  be3'ond  all  question  from  diphtheritic 
taint.  The  attection  is  purely  a  local  one,  and  the  membranoid  mass  is  the 
result  of  a  collection  of  tough,  inspissated  mucus,  holding  entangled  epithelial 
debris.  The  masses  are  usually  moulded  about  and  over  the  inferior  turbinated 
bones,  to  which  thej^  cling  tightly,  and  the  special  point  of  interest  in  these 
cases  lies  in  their  ditterentiation  from  the  somewhat  similar-looking  produc- 
tions of  diphtheria  in  the  same  locality.  The  absence  of  all  constitutional 
disturbance,  and  of  all  local,  acute  inflammatory  appearances  in  either  nose  or 
throat,  readily  serves  to  stamp  their  true  character. 

Submucous  Inflammation  and  Abscess  of  the  ^Tasal  Cavity. — True  phleg- 
monous inflammation  of  the  nose  can  hardly  exist,  owing  to  the  peculiar  anato- 
mical arrangement  of  its  structures.  Fraenkel  has,  however,  called  attention 
to  a  form  of  acute  inflammation  which,  it  is  true,  occurs  but  rarely,  but 
which  resembles  a  phlegmonous  inflammation  closely  in  its  character,  involves 
the  deeper  structures  and  periosteum,  and  gives  rise  to  all  the  results  of 
phlegmon.  It  is  seen  especially  after  direct  injuries  to  the  nose,  but  may  arise 
without  know^n  or  appreciable  cause.  Its  locality  may  vary.  Usually  one 
nasal  passage  alone  is  attected,and  this  at  some  point  other  than  the  septum. 
As  soon  as  an  abscess  forms  it  should  be  opened.^ 

Pastilles  of  acne  and  small  furuncles  are  not  infrequently  developed  just 
within  the  openings  of  the  nostrils,  and  lead  to  the  formation  of  small,  cir- 
cumscribed abscesses,  attended  with  much  pain  and  the  local  evidences  of 
acute  inflammation.  An  inflamed  hair-bulb  is  a  common  starting-point  for 
the  development  of  furuncle.  Once  incised  w^ith  a  small  tenotomj'-knife,  these 
abscesses  quickly  disappear. 

Cases  of  profuse  watery  discharge  from  one  or  both  nostrils,  without 
appreciable  local  cause,  are  reported  by  Paget,*  Althaus,^  Lingard,^  Tillaux/ 
and  Spiers  f  and  others,  in  w^hich  the  same  condition  was  probably  dependent 

«  Archiv  fur  Kinderheilk.  N.  F.  Bd.  iv.    Jahrg.  1871,  S.  331. 

*  Gerhardt,  Handbucli  der  Kinderkranklieiten,  Bd.  iii.  2te  Halfte,  S.  lb. 

3  See  also  under  Abscess  of  the  Nasal  Septum.  *  Lancet,  voL  ii.  p.  773.  1878. 

5  Brit.  Med.  Journal,  Dec.  7,  1878.  e  Ibid.,  Dec.  21,  1878. 

^  Traite  d'Anatomie  Topograpbique,  p.  56     Paris,  1877. 

8  Lancet,  March  5,  1881. 


788     DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

upon  catarrhal  inflammation  of  the  nose  or  its  accessory  cavities,  by  Carter,- 
Spencer  Watson,  and  Hewan.^  The  discharged  fluid  is  clear  and  colorless, 
free  from  smell  and  taste,  of  a  specific  gravity  of  1004,  and  of  alkaline  reac- 
tion;  it  contains  proteid  matter,  probably  albumen,  chloride  of  sodium,  phos- 
phates, and  a  slight  trace  of  iron,  but  no  grape-sugar.  Its  quantity  varies, 
large  amounts  often  flowing  away  during  the  day,  either  at  intervals,  con- 
tinuously, drop  by  drop,  or  sometimes  so  quickly  as  to  form  a  stream ;  it  is 
increased  by  exertion  or  straining,  or  by  holding  the  head  forwards,  and  its 
duration  has  been,  in  the  reported  instances,  from  nine  to  eighteen  months. 
In  none  of  the  cases  has  there  been  any  evidence  of  general  ill-health,  or 
evidence  of  local  disease  of  the  nose.  In  two,  there  Avas  the  history  of  a  blow 
upon  the  skull,  preceding  for  some  time  the  appearance  of  the  flow.  The 
cause  and  the  source  of  this  large  flow  of  fluid  are  involved  in  some  obscurity. 
Paget  expressed  the  opinion  that  it  might  be  derived  from  either  a  frontal  or 
an  ethmoidal  sinus,  from  the  sub-arachnoid  space,  or  from  the  sac  of  the  arach- 
noid membrane  ;  although  a  subsequent  autopsy  in  the  case  which  he  reported 
showed  its  source  to  be  the  antrum.  Lingard  believed  that  in  his  case  some 
fracture  of  the  cribriform  plate  of  the  ethmoid  might  possibly  have  taken 
place,  and  have  allowed  the  escape  of  cerebro-spinal  fluid  ;  a  suggestion  which 
also  would  cover  the  case  of  Tillaux.  Althaus,  on  the  contrary,  asserts  that 
these  cases  may  be  explained  by  the  withdrawal  of  nervous  force  from  the 
sphere  of  the  trifacial  nerve.  The  nasal  mucous  membrane  receives  its  nervous 
supply  chiefly  from  the  ophthalmic  branch  of  the  trifacial  nerve,  and  from  the 
spheno-palatine  ganglion,  the  secretion  from  the  mucous  membrane  being 
caused  by  the  sympathetic,  and  regulated  and  inhibited  by  the  fibres  of  the 
fifth  nerve.  Remove,  he  says,  this  inhibitor}'  influence  of  the  trifacial,  so  as  to 
allow  the  sympathetic  fibres  to  rule  supreme,  and  hypersecretion  of  liquid  is 
the  result.  Injury  or  inflammation  of  the  nasal  twig  of  the  ophthalmic  branch 
of  the  fifth  nerve  may  then  be  regarded  as  a  cause,  if  not  the  cause,  in  the 
examples  of  the  affection  thus  far  recorded;  and  this  view,  in  regard  to  any 
case,  would  be  still  further  established  if  there  should  be  anaesthesia  of  the 
mucous  membrane  of  the  nose,  or  of  some  portion  of  it,  on  the  side  corres- 
ponding to  the  flow. 

The  treatment  that  has  been  adopted  in  the  few  instances  that  are  reported, 
consisting  mainly  of  astringents  locally,  does  not  appear  to  have  been  atteiided 
with  any  marked  success.  If  the  theory  of  Althaus  be  correct,  the  use  of  the 
constant  voltaic  current  is  indicated,  to  restore  the  function  of  the  trifacial 
nerve  and  thus  check  the  excessive  secretion.  In  one  instance  this  has  suc- 
ceeded. 

Epistaxis. 

Hemorrhage  from  the  nose,  in  which  more  than  a  moderate  amount  of 
blood  is  lost,  is  a  very  infrequent  occurrence;  that  it  may,  however,  give  rise 
to  serious  danger,  and  even  destroy  life,  is  shown  by  the  experience  of  many 
writers.  Rhodius^  relates  an  instance  in  which  eighteen  pounds  of  blood 
were  lost  within  twenty-one  and  a  half  days ;  Martineau*  one  in  which 
twelve  pounds  flowed  away  in  sixty  hours  ;  and  even  seventy -five  pounds  have 
been  known  to  be  lost  within  a  period  of  ten  days.®  Gross^  has  seen  five 
fatal  cases,  in  which  death  was  caused  either  by  imperfect  plugging  of  the 

>  Lancet,  Nov.  30,  1878.  2  ibid. 

»  Obs.  Med.    Francof.,  1576.    (Obs.  xc.) 
*  Morgagni,  De  sed.  et  caus.  morb.,  lib.  i.  epist.  xiv.  23. 
.  *  Act.  Erudit.  p.  205.    Lipsiae,  1688.  ^  gygt.  of  Surgery,  sixth  ed.,  vol.  ii.  page  283. 


EPISTAXIS. 


789 


nostrils,  or  because  the  operation  was  not  performed  until  the  patient  was 
exhausted  by  hemorrhage.  Edwards  reports  likewise  a  fatal  case  of  bleed- 
ing from  the  nose/  and  Parker  Smith^  lost  twelve  out  of  nearly  thirty  cases 
of  diphtheria,  in  which,  on  account  of  the  age  of  the  i)atient,  it  was  impos- 
sible to  tampon  the  posterior  nares.  Epistaxis,  which  it  should  be  borne  in 
mind  is  but  a  symptom,  may  be  either  primari/,  in  other  words,  dei)endent 
upon  some  intra-nasal  lesion,  or  secondary^  the  sequel  of  some  general  con- 
stitutional condition  or  diathesis. 

Primary  Epistaxis. — The  common  variety  usually  occurs  from  one  nostril 
only,  and  is  dependent  upon  direct  violence  or  irritation.  Blows,  ulceration 
of  the  mucous  membrane,  and  the  presence  of  growths,  es[)ecially  when  of 
a  malignant  character,^  constitute  efficient  causes.  Cloquet^  mentions  irritant 
gases  and  powders  as  giving  rise  to  epistaxis,  and  finally  idiosyncrasy,  as 
shown  in  the  peculiar  results  developed  by  the  inhalation  of  certain  odors, 
must  not  be  forgotten.  A  very  common,  but  not  generally  appreciated  cause, 
lies  in  the  existence  of  a  small,  seldom  extensive  erosion  of  the  mucous  mem- 
brane of  the  cartilaginous  septum,  just  above  the  point  of  the  former's  junction 
with  the  skin.  The  term  ulcer  cannot  be  correctly  applied  to  this  lesion — 
certainly  not  in  its  earlier  stages,  and  as  commonly  seen — for  although  there  is 
of  necessity  some  loss  of  substance,  no  marked  excavation  exists  except  in 
extreme  cases.  Catarrhal  conditions  may  or  ma}'  not  coexist ;  they  probably 
will,  but  it  must  be  borne  in  mind  that  neither  erosion  nor  ulceration  is  a 
feature  of  simple  nasal  catarrh.  On  the  contrary,  I  believe  that  these  erosions 
are  always  the  result,  primarily,  of  the  direct  mechanical  irritation  or  injury 
caused  by  the  forcible  and  repeated  removal  of  the  slight  crusts  of  inspissated 
mucus  which  are  formed  in  the  first  instance  by  various  accidental  circum- 
stances at  this  point  (a  slight  concavity  here  is  not  infrequent),  the  finger 
being  the  common  instrument.  The  epithelial  covering  of  the  parts  being 
thus  once  disturbed,  the  subsequent  steps  of  the  process — constant  crust- 
renewal  and  gradually  deepening  ulceration — follow,  until  perforation  of  the 
septum,  no  infrequent  accident,  is  the  result.^ 

Secondary  Epistaxis. — This  variety  may  be  either  active  or  passive.  Under 
the  former  head  may  be  enumerated  those  bleedings  which  occur  when  for 
any  reason  there  is  a  sudden  determination  of  blood  to  the  head.  Mackenzie^ 
discredits  the  old-time  view,  that  the  accident  may  be  produced  by  low 
atmospheric  tension  at  great  heights,  and  Cloquet^  says  that  it  is  possible 
to  ascend  passively  to  a  considerable  height,  as  in  a  balloon,  without  its 
occurrence. 

Passive  epistaxis  is  met  with  in  an  inveterate  and  dangerous  form  in  the 
subjects  of  the  hemorrhagic  diathesis ;  it  also  occurs  in  purpura  hemorrha- 
gica, scurvy,  and  variola  hemorrhagica.  Mosler,^  in  eighty-one  cases  of  leuk- 
aemia, records  sixty-four  examples  of  hemorrhage,  and  in  thirty-five  of  these 
the  bleeding  was  from  the  nose.  In  influenza,  variola,  measles,  and  scarlatina, 
and  in  remittent,  typhoid,  and  relapsing  fever,  it  may  occur  at  the  inception  of 
the  disease,  during  its  course,  or  as  introducing  a  crisis  ;  more  rarely  it  is  seen 
in  acute  tuberculosis,  trichinosis,  and  some  other  similar  conditions.    In  sim- 

'  Transactions  of  the  Mississippi  Medical  Journal  Association,  1881. 
2  Watson,  Diseases  of  the  Nose,  page  51.    London,  1875. 
^  Virchow,  Krankhaften  Geschwiilste,  Bd.  iii.  S.  463. 

*  Osphresiologie,  p.  550.  1821. 

8  Lefferts,  Medical  News,  January  28,  1882  ;  Little,  New  York  Hospital  Gazette,  March  8,  1879. 
6  Lancet,  November  10,  1877.  '  Op.  cit.,  p.  560. 

*  Die  Pathologie  und  Therapie  der  Leukamie.    Berlin,  1872. 


790      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


pie  anaemia  it  is  very  common.  Mackenzie  has  seen  it  occur  as  a  concomitant 
of  a  highly  plethoric  condition  in  children ;  but  more  commonly  in  those  of 
an  ill-nourished,  strumous  constitution.  As  the  result  of  a  gouty  or  arthritic 
diathesis,  in  children,  it  is  not  unknown.^  At  puberty,  especially  in  males, 
it  is  very  frequent.  Furthermore,  any  morbid  condition  which  interferes 
with  the  venous  circulation,  or  increases  the  pressure  within  the  arterial 
system,  alters  the  tension  in  the  bloodvessels  of  the  nose,  and  thus  predis- 
poses to  passive  hemorrhage.  Epistaxis  due  to  emphysema,  heart-disease 
(Durozier),  or  whooping-cough,  is  thus  often  seen,  and  it  may  likewise  depend 
upon  diseases  of  the  ki'dneys,  spleen,  or  liver.  (Boyce.)  Pressure  upon  the 
venous  trunks  by  tumors  of  the  neck  or  chest,  may  also  produce  like  results. 

Those  passive  hemorrhages  from  the  nose  which  have  been  termed  vica- 
rious^ possess  a  peculiar  interest.    Epistaxis  may  appear  vicariously  for  other 

,  customary  hemorrhages,  especially  those  of  a  hemorrhoidal  character,  or  in 
23lace  of  'menstruation,  and  in  both  cases  may  return  at  regular  intervals.'^ 

"  Fricker,^  Obermeier,^  and  Sommer^  all  report  interesting  cases  of  the  latter 
form.  KussmauP  saw  periodical  epistaxis  in  a  woman  having  no  uterus. 
The  deductions  to  be  drawn  from  these  observations  are,  however,  it  must  be 
stated,  denied  by  Puech,^  who  shows,  from  the  statistics  of  one  hundred  cases, 
that  the  nasal  mucous  membrane  is  least  frequently  the  seat  of  a  vicarious 
catamenial  flow. 

Finally,  passive  hemorrhage  from  the  nose  is  said  to  have  sometimes  pre- 
vailed epidemically,^  and  that  habitual  nose-bleed  is  hereditary  in  some 
families,  is  apparently  shown  by  the  observations  of  Babington.® 

Sym])toms  of  Epistaxis. — The  symptoms  of  an  attack  are  evident.  The 
patient  will  complain  of  a  sensation  of  pressure  in  the  head,  sometimes  of  dizzi- 
ness and  a  feeling  of  warmth,  and  of  fulness  and  tickling  in  the  nose.  The  flow 
having  commenced,  may  proceed  from  both  nostrils,  as  in  scurvy,  purpura,  etc., 
or  from  one  only,  as  is  commonly  the  case,  and  its  amount  is  very  variable ; 
usually  it  runs  in  drops,  but  it  may  pour  out  in  the  form  of  a  small  stream. 
Jets  of  blood  are  rarely  seen.  As  a  rule  it  ceases  spontaneously,  or  with 
simple  treatment,  in  a  few  moments,  but,  on  the  other  hand,  it  may  last  for 
hours,  or  even  days,  and  large  quantities  of  blood  may  thus  escape.  Fraenkel 
calls  attention  to  the  fact  that  hemorrhages  dependent  upon  traumatic  causes,  or 
upon  diseases  of  the  nose,  are  much  less  likely  to  be  accompanied  by  an  abun- 
dant flow  than  those  which  are  caused  by  other  conditions.  The  blood  is  of  a 
bright-red  color,  and  coagulates  readily.  Where  the  fllow  is  very  rapid  and 
prolonged,  acute  anaemia,  with  all  its  symptoms,  may  arise,  and  even  death 
may  occur.  The  pulse  and  appearance  of  the  patient  must  then  be  carefully 
watched,  especially  if  fainting  or  other  evidences  of  exsanguination  are  pre- 
sent. 

Diagnosis. — There  is  usually  no  diflaculty  in  arriving  at  a  correct  diagnosis 
as  to  the  source  of  the  bleeding,  especially  if  a  direct  inspection  of  the  nasal 
passage  from  which  it  is  proceeding  be  made.  The  frequency  with  which  it 
arises  from  the  anterior  portion  of  the  nasal  septum  has  been  alluded  to. 
Certain  conditions  may  arise,  however,  to  complicate  the  question  of  its 

»  Guy's  Hospital  Reports,  1868,  p.  39. 

2  Fraenkel,  op.  cit.  (Ziemssen),  vol.  iv.  p.  152. 

3  Wiirtemberg.  med.  Correspond. -Blatt,  No.  21.  1844. 

*  Virchow's  Archiv,  Bd.  liv.  S.  435.  ^  Heidelberger  klinisclie  Annalen.  Bd.  x. 

6  Von  dem  Mangel,  der  Verkiimmerung  und  Verdoppelung  der  Gebarmutter  u.  s.  w.  WiirZi 
burg,  1859. 
?  Gazette  des  Hopitaux,  p.  188.  1863. 

8  Morgagni,  op.  cit.,  lib.  i.  epist.  xiv.  25  ;  Cloquet,  op.  cit.,  p.  557. 
"  Lancet,  vol.  ii.  1865. 


EPISTAXrS. 


701 


origin.  If  the  hemorrhage  be  profuse,  or  if  it  occur  during  sleep,  \yhilc  tlic 
patient  is  in  the  recumbent  position,  the  blood  may  pass  either  into  the 
oesophagus,  and  be  swallowed,  or  into  the  larynx  and  trachea.  In  either  case, 
its  subsequent  removal  can  only  be  accomplished  either  by  vomiting  or  by 
coughing,  and  an  attack  of  h?ematemesis  or  of  luiomoptysis  may  thus  be  closely 
simulated.  Koppe^  relates  the  history  of  a  case  in  which  bleeding  originated  in 
the  transverse  sinus,  and,  there  being  disease  of  the  cavity  of  the  tympanum, 
the  blood  was  discharged  simultaneously  through  the  nose  and  the  external 
auditory  canal.  In  thoia  rare  cases  where  it  originates  in  either  the  tVontal  simis, 
the  antrum,  or  the  ethmoidal  or  sphenoidal  cells,  the  diagnosis  as  to  exact  local- 
ity is  extremely  difficult.  Care  is  also  required  when  the  hemorrhage  is  pro- 
fuse, and  rapidly  fills  not  only  the  atfected  nostril  but  the  pharyngeal  space  aa 
well.  In  this  case  blood  appears  at  the  opposite  nostril,  giving  rise  to  the 
suspicion  that  its  source  is  double,  and  at  the  mouth  also.  Finally,  hemor- 
rhai>:e  from  the  posterior  parts  of  the  nose  is  not  only  more  difficult  to  locate, 
but'lts  symptoms  are  more  liable  to  be  confounded  with  those  of  other  condi- 
tions than  when  it  arises  from  the  anterior  portion.  _  In  any  of  these  very 
exceptional  instances,  careful  observation  and  the  history  of  the  case  will 
generally  serve  to  render  the  diagnosis  clear. 

Prognosis. — This  depends  entirely  upon  the  amount  of  blood  lost  before  the 
patient  is  seen,  the  efficacy  and  promptness  of  treatment,  and  the  nature,  in 
certain  instances,  of  the  cause  which  gives  rise  to  the  epistaxis.^  In  the  great 
majority  of  cases,  as  has  been  stated,  the  accident  is  of  a  trivial  nature,  and 
the  means  available  for  its  arrest  being  effectual,  no  danger  is  to  be  apprehended 
if  they  are  promptly  employed.  Where,  however,  the  epistaxis  is  symptoma- 
tic of  some  disease  of  grave  significance,  the  prognosis  will  be  dependent  upon 
the  nature  of  the  latter,  rather  than  upon  that  of  its  complication  alone. 

Treatment. — The  direct  treatment  of  epistaxis  simply  resolves  itself  into  the 
selection  and  proper  application,  to  the  bleeding  surfaces,  of  some  one  of  a 
long  list  of  either  mechanical  or  medicinal  means  for  the  purpose  of  causing 
coagulation  of  the  blood,  Avhich  then,  in  the  majority  of  instances,  serves  as 
a  tampon  in  the  nasal  cavity,  and  leads  to  occlusion  of  the  bleeding  vessels. 

Unless  the  hemorrhage  be  excessive,  the  simpler  means  may  be  first  em- 
ployed, not  forgetting  here,  as  in  all  instances,  to  reassure  the  patient,  tran- 
quillize his  surroundings,  and  cause  him  to  breathe  quietly  through  the 
mouth,  and  to  abstain  ivom  all  efforts  at  blow^ing  the  nose.  His  position 
should  be  erect,  with  the  head  inclined  forwards.  The  ala  of  the  affected 
nostril  may  now  be  pressed  strongly  against  the  septum,  and  pressure  kept  up 
for  a  few  moments,  or  the  finger  may  be  introduced  into  the  nostril  as  far  as 
possible,  to  act  as  a  tampon.  (Valsalva,  Morgagni.)  During  either  of  these 
procedures,  the  arm  corresponding  to  the  bleeding  side  may  be  raised  above 
the  head  (I^egrier),  and  efforts  made  to  excite  spasm  of  the  nasal  bloodvessels 
through  reflex  action,  by  applying  cold,  in  the  form  of  ice,  to  the  back  of 
the  neck,  or  even  to  the  scrotum,  in  men,  and  to  the  breasts  in  w^omen.  The 
use  of  ice  or  other  cold  applications  to  the  exterior  of  the  nose,  or  to  the  fore- 
head, and  injections,  or  the  pouring  of  cold  water  into  the  nose,  are  some- 
times useful  in  the  lighter  cases,  by  exciting  reflex  spasm  of  the  bloodvessels ; 
but  all  injections  have  the  common  disadvantage,  that  they  w^ash  away  the 
clots  as  fast  as  they  are  formed.  I  have  in  several  instances  used  injections 
of  hot  w^ater  with  good  effect.  Chapman^  recommends  the  w^ater-bag  between 
the  shoulders,  the  water  being  at  a  temperature  of  115°  F.,  on  the  principle 
of  a  derivative.    Finally,  ^Slarin^  states  that,  as  the  blood  in  epistaxis  gene- 


»  Archiv  fiir  Ohrenheilk.,  Bd.  ii.  S.  181. 
»  L'Union  Medicale,  25  Mai,  1872. 


«  Med.  Mirror,  Feb.  1,  1870. 


792     DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

rally  flows  from  one  Dostril  only — and  most  frequently  from  the  anterior  third 
of  one  of  the  nasal  fossse — compressing  the  corresponding  facial  artery  on  the 
superior  maxillary  bone,  near  the  ala  of  the  nose,  will  usually  check  it.  The 
well-known  expedient  of  inserting  a  tight  paper  roll  under  the  upper  lip  will 
be  remembered.  Compression  of  the  common  carotid  artery  upon  the  bleed- 
ing side  is  also  recommended.  If  these  simple  means  fail,  the  nasal  passage 
may  be  tightly  packed  with  small  pledgets  of  lint,  fastened  to  strings  to  facili- 
tate removal,  with  plugs  of  borated  cotton,  or  absorbent  cotton  medicated 
with  various  astringents,  or  with  bibulous  paper.  Leeper^  advises  the  use  of 
soluble  bougies  containing  some  styptic,  and  Thompson  and  Smyly,  the  intro- 
duction of  strips  of  lint  for  the  purpose  of  absorbing  fluid  and  favoring  co- 
agulation ;  Curtin''  sprinkles  these  strips  with  tannin  previous  to  their  intro- 
duction, and  Gilruth^  soaks  them  in  perch loride  of  iron ;  but  Frank  believes 
that  their  efiicacy  depends  upon  the  compression  of  the  parts  w^hich  they 
exercise,  rather  than  upon  their  astringent  qualities,  and  recommends  that 
they  be  twisted  to  a  large  size  previous  to  their  introduction.  The  insuflfla- 
tion  into  the  nares  of  astringent  powders,  and  the  injection  of  solutions  of 
various  astringents,  mineral  or  vegetable,  such  as  alum,  iron,  zinc  sulphate, 
acetate  of  lead,  gallic  or  tannic  acid,  or  decoctions  of  krameria,  have  long 
been  employed.  Crequy^  has  devised  an  excellent  syringe  for  injecting  the 
nostril:  a  canula,  2^  inches  in  length  and  with  a  rounded  extremity,  is  titted 
to  an  ordinary  syringe,  the  canula  being  perforated  its  entire  length  by  a 
series  of  small  holes,  in  spiral  succession,  and  directed  backwards  so  as  to 
emit  small  retrograde  jets.  The  injected  fluid  is  thus  thrown  upon  the 
mucous  surfaces  of  the  passage,  and  does  not  pass  into  the  pharynx.  Injec- 
tions are,  however,  if  carelessly  used,  not  devoid  of  danger.  Malherbe^  re- 
ports an  instance  where  death  from  pulmonary  gangrene  followed  pharyngitis 
and  laryngo-bronchitis,  the  result  of  injections  of  perchloride  of  iron  into  the 
nasal  cavities  ;  and  Gaillard®  details  a  somewhat  similar  case. 

Should  the  means  thus  far  alluded  to  fail  in  checking  the  hemorrhage,  or 
should  it,  for  any  reason,  be  deemed  desirable  not  to  wait  for  their  somewhat 
slow  action,  both  the  posterior  and  anterior  nares  should  be  plugged.  This 
operation  is  readily  effected  by  means  of  a  Belloccj's  canula ;  or,  in  default  of 
this,  a  flexible  catheter,  with  the  stylet  removed  and  a  string  fastened  to  its  eye, 
will  answer  the  same  purpose  and  can  be  used  in  the  same  way.  Bellocq's 
canula,  the  instrument  commonly  employed,  is  undoubtedly  familiar  to  evei^y 
practitioner.  The  canula  having  been  passed  back  into  the  nostril,  as  soon  as 
the  watch-spring  which  it  incloses  has  been  pushed  forwards,  and  its  rounded 
end  appears  behind  the  soft  palate  and  enters  the  pharynx,  the  double  string 
with  which  it  is  threaded  is  seized  and  drawn  out  of  the  mouth.  A  graduated, 
conical  compress  of  lint  is  now  attached  to  the  double  string,  which  is  passed 
through  its  middle,  and  being  guided  in  its  passage  behind  the  soft  palate 
by  the  finger,  is  drawn  tightly  up  into  its  proper  position  in  the  affected 
naris,  by  the  simple  withdrawal  of  the  canula  from  the  nose.  The  anterior 
plug  is  now  introduced,  and  the  two  ends  of  the  string  tied  over  it,  to 
hold  all  snug.  All  possibility  of  further  hemorrhage  is  in  this  way  effectu- 
ally prevented.  These  plugs  should  not  remain  in  position  too  long :  Gross^ 
mentions  that  he  has  seen  several  cases  terminate  fatally  w^ith  low  fever  and 
delirium,  from  systemic  poisoning  produced  by  their  too  long  retention. 
Colles  has  seen  tetanus  follow  from  the  same  cause,  and  Habershon^  pyaemia. 

»  Dub.  Jour.  Med.  Sci.,  Nov.  1873,  p.  364.  2  phila.  Med.  Times,  Aug.  1,  1872. 

5  Lancet,  vol.  ii.  p.  775.  1871.  ^  Dub.  Jour.  Med.  Sci.,  Oct.  1877,  p.  366. 
«  Jour,  de  Med.  de  I'Ouest,  tome  xiv.  p.  108.  1880. 

6  Courrier  Medicale,  tome  xxxi.  p.  238.  1881. 

7  Op.  cit.  8  Lancet,  Feb.  27,  1875. 


EPISTAXIS. 


793 


At  the  expiration  of  forty-eight  hours,  therefore,  they  should  usually  he 
removed,  hy  the  use  of  forceps  and  probe,  and  the  affected  nasal  cavity  should 
be  carefully  syringed  out. 

To  accomplish  the  same  purpose,  but  to  obviate  the  disagreeable  necessity 
of  plugging  the  nares,  as  here  described,  several  devices  have  been  intro- 
duced.^^Kuchenmeister  uses  a  rubber  tube  terminating  in  a  rubber  l)all ;  the 
ball  is  forced  through  the  nostril  into  the  pharynx,  distended  with  water 
injected  through  the  tube  and  retained  by  a  stopcock,  and  then  pulled  for- 
\vards.  Others  use  a  rubber  tampon  distended  with  air.  Englisch  uses  two 
rubber  balls  connected  by  a  tube;  one  ball  remains  at  the  anterior  open- 
ing of  the  nasal  passage  and  occludes  it.^  Frank^  suggests  that  a  bag  of 
hog's  intestine  be  moistened,  passed  into  the  nasal  canal  by  means  of  a  probe, 
and  then  injected  or  inflated ;  and,  finally,  J)i(lay3  extols  the  use  of  a  thin 
caoutchouc  bag,  employed  in  the  same  way.  The  internal  use  of  luiemo- 
statics  is  not  often  called  for  during  an  attack  of  bleeding,  but  it  is  a  com- 
mon practice  to  prescribe  them  if  it  be  at  all  prolonged.  Perchloride  of  iron, 
acetate  of  lead,  gallic  or  sulphuric  acid,  and  opium,  are  thus  employed.  Sul- 
phate of  sodium  is  recommended  by  Heurze,^  one  or  tw^o  drachms  being  given 
every  three  or  four  hours,  the  object  being  to  increase  the  density  of  the 
blood.  For  the  purpose  of  causing  contraction  of  the  arterioles,  ergotine  is 
undoubtedly  the  best  remedy,  used  either  by  the  mouth  or,  if  time  presses, 
subcutaneously.  In  extreme  cases  only  is  transfusion  called  for.  Mosler 
relates  a  case  of  leuk8emic  nose-bleed,  in  which  not  only  the  attack,  but  also 
the  return  of  the  epistaxis,  as  well  as  the  occurrence  of  any  other  hemor- 
rhage, w^as  prevented  by  this  means.  Morton  likewise  details  an  inter- 
esting case  of  the  same  nature.^ 

The  question  may  be  appropriately  raised,  in  many  cases  of  epistaxis, 
whether  or  no  it  is  advisable  to  interfere  at  all  Avith  the  processes  of  nature. 
Peyer  gives  the  following  rule  for  the  guidance  of  the  surgeon  in  such 
instances:^  "Plethoric  youths  in  whom  an  epistaxis  is  aborted  are  prone  to 
be  attacked  by  cephalalgia,  otalgia,  and  various  catarrhal  affections.  Any 
hemorrhage  which  is  accompanied  by  debility,  pallor,  and  coldness,  nuist  be 
considered  as  excessive,  and  in  such  cases  the  active  aid  of  the  physician  is 
demanded."  Mackenzie'  tersely  sums  up  other  contra-indications.  Where 
there  is  great  venous  obstruction,  as  in  cardiac  disease,  emphysema,  cirrhosis 
of  the  liver,  etc. — or  in  lemales  where  the  hemorrhinia  is  of  a  vicarious  char- 
acter there  is  little  demand  for  precipitate  interference  unless  the  bleeding 

has  been  very  persistent.  Examples  exist  in  which  mania,^  epilepsy,^  rheu- 
matism, and  dyspnoea,^^  have  been  cured  or  greatly  alleviated  by  an  attack  of 
epistaxis.  On  the  other  hand,  not  only  are  immediate  and  also  subsequent 
local  treatment  demanded  in  many  instances,  but  constitutional  indications 
are^likewise  to  be  met.  An  example  is  afforded  in  the  habitual  nose-bleed 
of  anaemia,  and  others  will  suggest  themselves. 

1  Allg.  Wien.  med.  Zeitiing,  S.  191.  1875. 

2  Grundsatze  liber  d.  Beliaiidl.  d.  Krank.  d.  Menscheii,  u.  s.  w.,  Bd.  vi.  S.  145.  Mannheim, 
1797. 

3  Weber,  Pitha  und  Billroth's  Handbnch,  Bd.  iii.  1  Abtli.  2  Lief.  S.  187. 
*  Compend.  d.  pract.  Med.,  IV.  Auflage,  S.  94. 

6  Am.  Jour.  Med.  Sci.,  July,  1874. 

«  De  Morbis  Narium.    Basilese,  1766.  ^  Loc.  cit. 

9  Van  Swieten,  Comment,  in  H.  Boerhaave  aphorismos,  1124. 
9  Hoffmann,  De  Epilepsia. 

^  Raymond,  Traite  des  maladies  qu'il  est  dangereux  de  guerir,  p.  255, 


794     DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


Stenosis  of  the  I^asal  Passages.* 

Aside  from  the  causes  which  have  thus  far  been  mentioned,  that  may  lead 
to  the  temporary  or  permanent  occlusion  of  one  or  both  nasal  passages,  nar- 
rowing or  closure  of  these  cavities  is  dependent  upon  a  variety  of  abnormal 
conditions,  some  of  which,  chiefly  those  affecting  the  nasal  septum,  are  now 
to  be  considered.^  Their  general  symptoms,  aside  from  those  which  are  due 
to  the  catarrhal  inflammation  of  the  mucous  membrane,  probably  coexisting, 
and  which  have  elsewhere  been  considered,  are  mainly,  if  not  wholly,  depen- 
dent upon  the  obstruction  to  free  nasal  respiration,  which  may  exist  or  occur 
at  any  portion  of  the  nasal  tract,  and  they  will  consequently  vary  in  their 
gravity  and  persistency,  with  the  grade  and  nature  of  the  occluding  cause. 
They  may  best,  perhaps,  be  studied  collectively  at  this  point.  The  stenosis 
may  vary  from  a  slight  impediment  only  to  the  free  passage  of  air  through 
the  nasal  canals,  producing  in  the  patient  a  sensation  of  uneasiness  and  dis- 
comfort, to  complete  closure,  with  its  attendant  train  of  evils.  Much  will 
likewise  depend  upon  the  fact,  of  whether  one  or  both  nasal  passages  are 
involved,  both  as  regards  the  intensity  of  the  symptoms  and  the  seriousness 
of  the  results.  The  latter  have  been  carefully  studied  by  FraenkeP  and 
others.  Wlien  occlusion  is  complete,  and  in  certain  instances  even  when  it 
IS  only  partial,  oral  breathing  becomes  a  confirmed  habit,  and  the  conditions 
of  respiration  are  thereby  materially  altered  for  the  worse.  The  evil  eflfects 
are  soon  appareut,  not  only  in  disturbances  in  the  respiratory  organs  and 
air-passages  generally,  but  likewise  in  circulatory  derangements,  impaired 
quality  of  the  blood,  and  interference  with  general  nutrition  and  develop- 
ment, the  diminution  of  the  air  supply  to  the  lungs  being,  as  Berkart^  has 
shown,  readily  demonstrated  by  listening  alternately  to  the  chest  of  one  who 
breathes  through  the  mouth  and  to  that  of  one  who  breathes  through  the 
nose.  The  true  function  of  the  nose,  aside  from  the  sense  of  smell,  being 
to  warm,  purify,  and  moisten  the  inspiratory  current  in  its  course  over  the 
turbinated  bones,  and  before  it  reaches  the  deeper  respiratory  passa2:es,  the 
abolition  of  this  function  must  necessarily  charge  the  lungs  with  air  which  is 
not  only  raw  and  unwarmed,^  but  which  likewise  holds  in  suspension  more  or 
less  dust,  and  is  perhaps  loaded  with  irritating  particles.  The  dryness  of  the 
mouth  and  throat,  the  constant  hyperBemia,  and  the  predisposition  to  catarrhal 
inflammation  of  the  mucous  membrane,  bear  witness  to  the  material  disadvan- 
tages and  results  following  upon  nasal  occlusion  and  enforced  oral  respiration. 
Its  effect  upon  the  character  of  the  voice  is  well  known,  and  the  peculiar,  dis- 
agreeable, nasal  intonation,  will  be  recognized  as  a  prominent  symptom  and 
diagnostic  sign  of  the  condition.  Meyer^  has  pointed  out  that  when  obstruc- 
tion IS  complete,  the  letters  "  m"  and  "  n"  become  perverted  into  "  b"  and  "  d"  ; 
and  Lowenberg^  dwells  at  some  length  upon  the  causes  of  this  substitution! 
The  character  of  the  voice  is  thus  altered  for  the  worse  :  its  quality  is  notably 
changed,  its  head-notes  are  abolished,  and  it  becomes  flat  and  nasal.  Toynbee 

I  Consult  also  Lennox  Browne,  On  Obstructions  in  the  Nasal  Fossse  (British  Medical  Journal 
August  24,  1878)  ;  Ziem,  On  partial  or  total  Occlusion  of  the  Nose  (Monatssch.  fiir  Ohrenheilk  ' 
No.  2,  1879)  ;  Ganghofner,  The  Anomalies  and  Narrowings  of  the  Upper  Air-Passages  (Viertel- 
jahrsschrift  fur  pract.  Heilk.,  Bd.  cxli.  1879)  ;  Roser,  On  Deviation  of  the  Nasal  Septum 
(Monatssch.  fur  Ohrenheilk.,  No.  4,  1881)  ;  Pean,  idem  (Centralblatt  fur  Chir.,  No.  46  1880) 
Op.  cit.  (Ziemssen),  vol.  iv.  p.  103.  ' 

3  Asthma,  its  Pathology  and  Treatment.    London,  1878. 

<  Milne  Edwards  has  shown,  by  experiment,  that  it  is  raised  20  in  temperature  when  respired 
through  the  nose. 

6  Med. -Chir.  Transactions,  vol.  liii.  p.  191.  London,  1870. 
8  Les  Tumeurs  adenoides  du  Pharynx  nasal.    Paris,  1879. 


STENOSIS  OF  THE  NASAL  PASSAGES. 


795 


first  demonstrated,  I  believe,  through  a  series  of  carefully  couducted  experi- 
ments, the  altered  condition  of  atmospheric  pressure  m  the  fauces  and  ears 
when  swallowing  with  closed  nostrils;  and  Lucae^  has  called  attention  to 
the  tact,  that,  when  the  nose  is  occluded,  every  act  of  swallowing  repeats 
Toynbee's  experiments.  Both  tympanic  membranes  are  thus  abnormally 
stretched,  and  the  continuance  of  the  process  can  but  lead  to  injurious 
re^mlts  as  regards  the  hearing  power.  The  manner  in  which  these  clianges 
are  produce(f  has  also  been  s^tudied  by  Roe.^  Occlusion,  or  a  stenosed  con- 
dition of  the  nasal  cavities,  when  existing  in  the  infant  at  the  breast  possesses 
a  peculiar  and  pressing  signiticance;  here  even  a  simple  cold  in  the  head, 
with  its  attendant  hypen^mia  and  swelling  of  the  mucous  membrane,  creates 
an  element  of  dan-er.  Both  Billard^  and  Raycr^  have  shown  us  that  under 
these  circumstances  the  proper  nutrition  of  the  infant  becomes  almost  an 
impossibility  ;  every  attempt  to  take  and  hold  the  breast  is  incompatible 
with  the  enforced  oral  respiration ;  the  child,  if  the  attempt  be  persisted  in, 
soon  reaches  a  point  of  suffocation  which  obliges  it  to  desist,  and  use  the 
mouth  for  respiratory  purposes.  -,.  .    .     ^      ^  v. 

In  the  coryza  of  the  new-born,  then,  direct  and  immediate  treatment  be- 
comes a  necessity.  That  by  means  of  astringent  applications  has  already 
been  alluded  to.  Hoppe^  uses  hollow  bougies  as  dilators,  it  the  narrowing 
is  not  extreme,  and  thus  by  admitting  air  to  the  lungs  while  the  mouth  is 
closed  over  the  breast,  renders  nursing  possible;  he  also  recommends 
forcible  distension  of  the  passages  by  means  of  slender  torceps,  a  procedure 
that  will  hardly  meet  with  general  acceptation.  Artificial  feeding  by  means 
of  the  oesoi)hageal  tube,  is  advised  by  Kussmaul  m  extreme  cases,  and 
according  to  Fraenkel  was  successfully  employed  by  Tluersch,  in  the  case 
of  his  own  child.  The  former  author,  also,  after  stating  the  fact,  that  a 
healthy  infant  during  sleep  always  holds  the  mouth  closed,  and  relies  upon 
the  nose  for  purposes  of  respiration,  the  tongue  resting  upon  the  hard  palate, 
shows  tliat,  if  under  these  circumstances  occlusion  of  the  nasal  passages 
takes  place,  asthmatic  attacks  occur  as  soon  as  sleep  overtakes  the  patient 
Asleep  or  awake,  the  vigorous  attempts  at  inspiration,  in  nurslings  attected 
with  coryza,  may  be  followed  by  acute  hyper^emia  of  the  lungs,  and  herein 
also  may  lie  the  explanation  of  the  sudden  suffocative  attacks,  llie  violent 
efforts  at  inspiration,  under  these  circumstances,  have,  moreover,  been  known 
to  produce  urgent  dyspnoea,  through  the  "swallowing  of  the  tongue,  so 
called.  Such  instances  are  reported  by  Cohen  and  Stammer,  and  Bouchut 
has  also  called  attention  to  the  fact.  Hauner^  asserts  that  such  cases  have 
not  only  been  mistaken  for,  but  treated  as,  true  croup.  Paroxysmal  asthma, 
and  even  sudden  attacks  of  asphyxia,  are  not  confined  alone  to  children  the 
subjects  of  nasal  stenosis.  Under  certain  conditions,  the  same  attacks  may 
occur  in  the  adult. 

Roe«  points  out  that  there  are  two  modes  in  which  nasal  disease  may  provoke  an 
attack.  1.  The  most  frequent  form  results  from  a  narrowing  or  occlusion  of  the  nasal 
passa-es  by  hypertrophied  tissue  or  nasal  polypi.  2.  Another  form  is  induced  by  dis- 
ease  of  the  pituitary  mucous  membrane,  unassociated  with  hypertrophy  or  polypi.  1  He 
first,  he  thinks,  is  both  mechanical  and  nerve-reflex  in  its  character,  whilst  the  second 
is  purely  reflex.    It  is  a  noticeable  fact,  that  nasal  polypi  and  hypertrophied  tissue, 

1  Archie  der  Ohrenlieilk.,  Bd.  iv.  S.  188.    1867-8.  «  Medical  Record,  April  30,  1881. 

3  Traite  des  Maladies  des  Enfants  ;  2e  ed.,  p.  480. 

*  Note  sur  le  Coryza  des  Enfants  a  la  Mamelle.    Pans,  1820. 

6  Neue  Zeitung  fiir  Med.,  1850.  , 

6  Traite  prat,  des  Mai.  des  Nouveau-nes,  56  ed.    Pans,  18b ^. 

7  .Tahrbuch  fiir  Kinderheilkunde,  V.  Jahrg.,  S.  73.  1862. 

8  Report  of  Annual  Meeting  of  the  American  Medical  Association,  June,  Lbb6. 


796      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

when  inducing  asthma,  are  almost  invariably  located  on  the  posterior  end  of  the  turbi- 
nated bone,  the  area  that  has  been  likened  by  Dr.  Mackenzie  to  the  sensitive  cough- 
centres  found  in  the  pharynx  and  larynx.  This  fact  explains  the  more  frequent  occur- 
rence of  asthma  at  night  in  those  persons  who  suffer  with  hypertrophic  nasal  catarrh. 
At  the  posterior  end  of  the  inferior  turbinated  bone,  the  cavernous  erectile  tissue  is 
much  thicker  and  more  dilatable  than  at  the  anterior  ;  consequently,  when  in  the  re- 
cumbent position,  the  gravitation  of  fluid  distends  this  portion  of  tissue,  and,  together 
with  the  accumulation  of  secretion,  occludes  the  passage  ;  or  reflex  irritation  of  the 
air-passages  results,  and  the  attack  comes  on.  Dr.  Roe  appends  several  cases  in  which 
treatment  applied  to  the  nose  cured  the  asthma.  He  advocates  removal  of  the  hyper- 
trophied  turbinated  bones  by  the  nasal  bone-scissors,  and  of  the  hypertrophied  tissue  by 
Jarvis's  snare. 

Traube^  relates  two  interesting  cases  in  which  every  inspiration  was  ac- 
companied by  a  pressing  together  of  the  alee  of  the  nose,  instead  of  a  normal 
dilatation,  causing  nasal  stridor  and  difficult  respiration.  This  phenomenon 
he  attributes  to  the  beginning  of  paralysis  of  the  respiratory  nervous  system, 
and  regards  the  condition  as  a  fatal  one,  unless  properly  treated. 

Still  further  but  less  serious  results  affect  the  nasal  organ  directly  when  its 
passages  are  rendered  more  or  less  impermeable.  These  need  but  be  alluded 
to.  The  inspired  current  of  air  is  unable,  in  many  instances,  owing  to  the 
amount  of  obstruction  presented  to  its  entrance,  to  penetrate  to  the  upper 
part  of  the  nasal  cavities  and  reach  the  seat  of  the  distribution  of  the  termi- 
nal expansions  of  the  olfactory  nerve.  The  sense  of  smell  is  thus  blunted  in 
direct  proportion  to  the  amount  of  interference  with  the  entrance  and  passage 
of  the  air  current  charged  with  odoriferous  particles.  The  same  obstructioli, 
again,  by  preventing  or  interfering  with  the  expulsive  force  of  the  expiratory 
current,  prevents  the  removal  of  the  usually  abnormal  amount  of  secretion, 
either  by  blowing  the  nose  or  otherwise ;  its  accumulation  is  in  turn  an 
efficient  factor  in  producing  obstruction ;  and  a  "  vicious  circle,"  as  it  has 
been  termed,  is  thus  established.  The  symptoms,  then,  of  nasal  stenosis  may 
be  thus  summarized :  inability  to  breathe  through  the  nose,  and  consequent 
impairment  of  the  sense  of  smell,  with  its  accompanying  absence  of  the  per- 
ception of  flavors,  hoarseness  and  disturbance  of  speech,  respiratory  obstruc- 
tion, asthma,  sudden  asphyxia,  inability  to  remove  the  nasal  secretions, 
dryness  of  the  pharynx,  a  sense  of  fulness  and  pressure  about  the  nasal  and 
frontal  regions,  more  or  less  persistent  frontal  headache,  weakness  of  the  con- 
junctivae, a  constantly  open  mouth — altering,  in  children,  the  cast  of  the  coun- 
tenance— and,  finally,  a  predisposition  to  catarrhal  inflammation  of  the 
respiratory  mucous  membrane  upon  the  slightest  exposure,  or  on  any  unfa- 
vorable change  in  the  weather.  As  giving  rise  to  the  physical  conditions 
Avhich  produce  the  results  here  described,  a  number  and  variety  of  causes,  as 
has  been  stated,  can  be  enumerated.  Some,  mainly  those  dependent  upon 
the  results  of  catarrhal  inflammation  of  the  nasal  mucous  membrane,  have 
already  been  considered.  Others  still  remain,  of  even  more  serious  import, 
and  will  be  discussed  in  detail. 


Closure  of  the  ^Tostrils. 

Closure  of  the  nostrils  may  be  the  result  of  either  congenital  malforma- 
tion, disease,  or  accident.  The  former  is  rare,  much  rarer  than  like  condi- 
tions in  either  anus  or  vagina.  In  the  reported  instances,  there  has  either  been 
an  adhesion  of  the  ala  of  the  nostril  to  the  septum,  or  it  has  been  drawn  down 


>  Verhandlg.  der  Berliner  med.  Gesellsch.,  Bd.  ii.  S.  141.  1869-71. 


AFFECTIONS  OF  THE  SEPTUM. 


797 


and  attached  to  the  upper  lip;  a  continuation  of  the  normal  integument  has 
covered  in  the  nostril  or  nostrils,  or  the  latter  have  been  blocked  up  by  a  firm 
membrane.  The  effects  of  such  occlusion  are  apparent.  Fortunately,  treat- 
ment is  usually  a  simple  matter,  and  the  earlier  it  is  undertaken  the  better. 
A  simple,  direct  incision  is  often  all  that  is  needed,  the  opening  thus  made 
into  the  nasal  passage  being  kept  open  and  dilated  by  means  of  a  strip  of 
lint,  until  the  healing  process  is  completed.  Where  some_  deformity  of  the 
parts  coexists  with  tlie  occlusion,  a  more  extensive  dissection  of  tissue  may 
be  necessary.  A  like  condition,  the  result  of  accident  or  disease,  is  more  fre- 
quent ;  a  common  cause,  of  which  I  have  seen  and  successfully  treated  two 
instances,  is  the  loss  of  tissue  and  subsequent  cicatricial  contraction  about 
the  nasal  openings  following  smallpox.  Deep  hums  of  the  face  produce  the 
same  result,  ixnd  fractures  of  the  nose,  with  laceration  of  the  soft  parts,  and 
subsequent  contraction  during  the  healing  process,  are  a  like  efhcient  cause. 
As  a  rule,  in  such  instances,  a  small  opening  through  the  adventitious  tissue 
will  be  found  to  exist,  and  may  be  simply  dilated  by  means  of  conii)ressed 
sponge,  laminaria,  or  metallic  bougies.  In  certain  cases  this  treatment  must 
be  supplemented  by  incisions,  the  nature  and  direction  of  which  depend 
upon  the  deformity  in  the  particular  instance  in  which  they  are  undertaken. 
Constant  repetition  of  the  dilating  process  will  always  be  found  necessary  to 
prevent  recontraction. 


Affections  of  the  Septum. 

The  septum  itself  is  liable  to  various  affections,  which  play  an  important 
part  in  producing  either  temporary  or  permanent  stenosis. 

Extravasations  of  blood ^  occur,  as  the  direct  result  of  injury,  beneath  the 
mucous  membrane  on  one  or  both  sides  of  the  cartilaginous  portion  of  the 
septum.  The  resulting  tumor  is  frequently  large,  with  a  broad  base,  and  of  a 
dark,  congested  color  ;  the  surrounding  induration  and  the  tension  are  marked, 
and  often  mask  any  sense  of  fluctuation.  The  rapidity  with  which  the  tumor 
forms  after  the  accident,  and  the  history  of  the  case,  with  direct  inspection 
of  the  parts,  render  the  diagnosis  easy.  Inflammation  and  suppuration  may 
generally  be  prevented,  and  resorption  facilitated,  by  the  adoption  of  strict 
antiphlogistic  measures.  Incisions  are  not  often  required — never  unless  the 
amount  of  extra vasated  blood  be  large  and  the  obstruction  to  nasal  respiration 
great. 

Abscess  of  Septum. — Should  these  measures  fail,  acute  abscess  of  the  septum 
may  result.  Although  this  condition  is  usually  the  direct  result  of  injury, 
and  is  not  preceded"  by  any  marked  extravasation  of  blood — I  have  never 
seen  it  arise  spontaneously,  in  connection,  for  instance,  with  scrofula,  or  sub- 
sequently to  the  exanthemata,  smallpox,  measles,  or  scarlatina — the  atten- 
dant tumefaction  and  inflammation  are  not  always  conflned  to  the  nasal  cav- 
ities, the  whole  nose,  cheeks  and  neighboring  parts  being  not  infrequently 
involved,  especially  at  an  early  stage  of  the  process.  The  tumor  in  the  nose, 
which  is  always— apparently,  at  least — bilateral,  presents  a  smooth,  reddish 
appearance,  is  tender  on  pressure,  and  is  seen  at  the  lower  part  of  the  septum, 
^hadino-  off  above  and  behind  into  the  contiguous  mucous  membrane.  Fluc- 
tuation' is  distinct,  and  is  often  felt  on  .both  sides  of  the  septum,  and 
through  it ;  the  latter  is  always  the  case  if  there  is  perforation  of  the  carti- 


»  Fleming,  Dublin  Quart.  Jour.  Med.  Science,  vol.  iv.  pp.  16-28. 


798      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

lage,  a  not  unusual  result,  especially  if  treatment  has  been  delayed.  I  have 
never  seen  the  inflammation  spread  to  the  frontal  sinus  or  lachrymal  passages. 
With  this  condition  there  is  some  febrile  movement,  and  much  local  pain  and 
distress.  The  treatment  consists  in  opening  the  abscess  by  direct  and  free 
incision,  with  thorough  evacnation  of  its  contents.  The  longer  the  delay,  the 
greater  is  the  risk  of  the  periosteum  or  the  perichondrium  being  involved, 
with  resulting  necrosis.  The  incision,  which  rapidly  closes,  mu'st  be  kept 
open  for  a  few  days  until  tumefaction  has  subsided.  Bad  results  do  not  fol- 
low, even  in  cases  where  the  cartilage  has  been  perforated  ;  the  mucous  mem- 
brane heals  kindly  over  the  small  loss  of  substance  without  leaving  any 
external  deficiency. 

Acute  abscess  complicated  with  a  small  ameitrism  has  been  observed  by  Thudi- 
chum^  in  one  instance.  In  opening  the  abscess  the  aneurism  was  also  opened, 
>     and  the  free  bleeding  could  only  be  checked  by  means  of  the  galvano-cautery. 

Chronic  abscess  of  the  septum^  with  perforation  of  the  cartilage,  may  occur 
in  syphilitic  or  scrofulous  subjects,  and  may  even  exist  without  known  as- 
signable cause.  It  is  unilateral,  its  progress  is  slow  and  insidious,  and  its 
symptoms  slight,  the  patient  often  being  unaware  that  it  exists ;  no  marked 
inflammation  accompanies  it,  and,  externally,  the  nose  gives  no  evidence  of  its 
presence.  The  ulcerative  destruction  of  the  cartilaginous  septum  which  fol- 
lojvs,  is,  however,  serious,  and  one  large  orifice  or  several  small  perforations 
result,  the  former  being  the  rule.  Such  cases  are  not  unfrequently  examined 
long  after  the  subsidence  of  all  of  the  symptoms,  and  when  the  existence  of 
the  perforation  through  the  septum  is  the  only  guide  to  the  surgeon  as  to 
the  nature  of  the  earlier  affection.  Perforation  of  the  nasal  septum,  it  may 
here  be  remarked,  should  not  always  be  regarded  as  syphilitic  in  its  origin, 
the  result  of  the  breaking  down  of  a  gumma.  In  many  instances,  probably, 
the  true  cause  lies  in  the  direct  mechanical  irritation  caused  by  the  patient, 
usually  the  subject  of  nasal  catarrh,  in  constantly  endeavoring  to  remove  hard- 
ened secretions  from  the  anterior  portion  of  the  septum.  Such  cases  are  not  at 
all  uncommon,  and  are  elsewhere  alluded  to  in  this  article.  I  cannot  believe, 
with  Cohen,  that  there  is  even  a  probability  that,  in  a  fair  proportion  of  in- 
stances, the  perforation  has  resulted  during  the  course  of  a  syphilitic  coryza 
which  has  occurred  in  early  infancy.  Still  less  do  I  believe  that  these  perfo- 
rations are  congenital,  even  though  they  be  met  with  independently  of  any 
history  of  local  disease  within  the  patient's  memory. 

Early  incision  of  these  abscesses  is  imperative,  and  a  guarded  prognosis 
should  be  given.  Perforation  of  the  septum  is  the  rule ;  and,  although  no 
external  deformity  of  the  nose  has  ever  followed  in  my  experience,  the  con- 
dition is  one  that,  in  many  respects,  is  disagreeable  in  its  results.  Plastic 
operations  for  the  closure  of  the  deficiency,  although  they  have  been  under- 
taken, are  rarely  if  ever  attended  with  success.  Constitutional  treatment, 
suitable  to  the  indications  presented  in  individual  cases,  is  all-important. 

Syphilitic  induration  of  one  or  commonly  both  sides  of  the  septum,  due 
primarily,  in  all  probability,  to  disease  of  the  perichondrium,  without  any 
marked  inflammatory  symptoms,  and  with  no  evidence  at  any  part  of  its 
course  of  the  formation  of  abscess,  may  exist,  and  may  constitute  an  efiicient 
cause  of  nasal  obstruction.  I  have  met  with  it  in  several  instances.  The 
diagnosis  rests  mainly  upon  the  indurated  character  of  the  swelling,  and  upon 
the  absence  of  all  signs  of  excessive  inflammation.  Its  difterentiation  from 
cartilaginous  outgrowth  of  the  septum,  and  even  from  deflection  of  the  car- 
tilage, should  the  induration  be  unilateral,  demands  some  care.    Its  rapid 


1  Lancet,  April  17,  1880. 


AFFECTIONS  OF  THE  SEPTUM. 


799 


subsidence  under  the  use  of  an  anti-syphilitic  treatment  is  the  rule,  and  (!on- 
■firms  the  diagnosis.  I  have  had  no  experience  in  the  injection  into  the  sub- 
stance of  these  swellings,  of  sohitions  of  iodine  and  iodide  of  potassium, 
ergot,  or  carbolic  acid.    External  applications  are  of  little  avail. 

Submucous  infiltration  of  the  sides  of  the  septum,  to  which  attention 
was  first  called  by  Cohen,^  is  a  not  unusual  conii)lication  in  a  large  proportion 
of  cases  of  chronic  catarrhal  inliainTnation  of  the  nasal  mucous  membrane, 
and,  if  excessive,  produces  in  a  marked  degree  the  symptoms  of  nasal  steno- 
sis. An  examination  with  the  rhinosco[)e  shows  that  a  tumid  mass  exists  on 
either  side  of  the  septum  and  is  confined  to  its  posterior  portion,  of  a  whitish 
color,  that  is  markedly  distinct  from  the  red  color  of  the  adjacent  mucous 
membrane ;  it  does  not  alwaj^s,  as  asserted,  occupy  the  lower  portion  of  the 
septum,  extending  thence  upwards,  the  reverse  being,  to  say  the  least,  very 
commonly  seen.  The  atfection  is  usually  symmetrical ;  the  masses  are  ovoid 
in  outline,  and  much  resemble  nasal  })olypi.  They  appear  to  be  oedematous 
projections  of  the  mucous  membrane  from  accumulation  beneath  it  of  serum, 
sero-mucus,  or  fibrin,  and  are  best  treated,  according  to  Cohen,  by  tearing 
away  portions  of  the  masses  by  forceps  carried  up  behind  the  palate,  or  intro- 
duced through  the  nostril,  as  the  case  may  best  permit,  the  operation  being 
performed  under  the  guidance  of  the  rhinoscopic  mirror.  Hemorrhage  is 
slight.  The  parts,  after  the  operation,  should  be  cauterized.  Sometimes 
puncturing  these  masses  with  a  curved  lancet  sufi5ces.  Finally,  the  galvano- 
cautery  affords  an  appropriate  means  for  their  destruction. 

Deflection  or  deviation  of  the  septum  from  the  normal,  median  line, 
may  be  due  to  an  abnormality,  not  uncommon  in  either  its  bony  or  cartila- 
ginous portions,  or  may  occur  as  the  result  of  a  fracture  or  displacement  of  the 
septum,  the  effect  of  direct  violence.^  In  such  cases,  the  cartilaginous  septum 
is  that  which  is  most  frequently  displaced,  and  usually  at  the  point  of  its 
articulation  with  the  bony  septum ;  next  in  point  of  frequency,  the  perpen- 
dicular nasal  plate  is  broken,  and  especially  where  it  approaches  the  vomer. 
The  force  of  the  concussion  rarely  reaches  the  latter,  the  perpendicular  plate 
giving  away  first  and  easily.  Proportionate  to  the  amount  of  displacement 
will  be  the  degree  of  obstruction  to  the  nasal  passages ;  a  depression  of  the 
cartilage  forming  the  ridge  of  the  nose  is  necessarily  accompanied  with  a 
corresponding  degree  of  lateral  displacement,  with  or  w^ithout  fracture  of  its 
perpendicular  portion,  and  produces  therefore  not  only  great  deformity,  but 
sometimes  complete  flattening  of  the  end  of  the  nose,  aside  from  complete 
obstruction  of  the  nostrils.^  The  results  of  such  fracture  and  displacement 
must  not,  however,  be  confounded  with  a  deflected  septum  the  result  of  con- 
genital or  acquired  abnormality.  The  clinical  history  will  assist  in  making 
the  differential  diagnosis.  As  a  matter  of  fact,  the  nasal  septum  is  rarely 
found  perfectly  straight,  but  exhibits  a  slight  inclination  either  to  one  side  or 
the  other,  usually  the  left.  Owing  to  its  composite  nature,  its  errors  of  posi- 
tion are  furthermore  not  of  one  kind  ;  thus,  deviations  occur  in  the  perpendicu- 
lar plate  of  the  ethmoid  bone,  at  the  ethmo-vomerine  suture,  and  in  the  supe- 
rior maxilla;  and  in  the  living  subject  they  are  also  seen,  and  very  commonly, 
in  the  triangular  cartilage.  All  of  the  above-mentioned  forms  may  exist 
separately,  or  together.  The  frequency  of  these  deviations  from  the  normal 
standard  is  shown  in  a  study  by  Allen^  of  58  adult  crania;  of  these,  only  18 
exhibited  normal  nasal  cavities,  w^hile  in  the  remaining  40,  19  were  found  in 


^  Diseases  of  the  Throat,  2d  edition.  2  gee  page  801,  infra. 

^  Hamilton,  Fractures  and  Dislocations,  3d  ed.  1866.         ^  Am.  Jour.  Med.  Sci.,  Jan.  1880. 


800      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

which  the  curvature  was  so  great  as  to  cause  the  septum  to  lie  in  contact 
with  the  superior  and  middle  turbinated  bones ;  and  Semeleder,  in  an  exami- 
nation of  49  skulls,  found  that  the  septum  was  straight  in  only  10,  bent 
towards  the  left  in  20,  towards  the  right  in  15,  and  in  4  was  so  twisted  that 
it  resembled  the  letter  S  in  shape. 

_  As  a  rule,  the  deflected  part  will  be  found  to  affect  principally  the  cartila- 
ginous septum,  and  to  exist  at  the  anterior  portion  of  the  latter.  Such 
deviations,  however  great  they  may  be,  but  rarely  deform  the  external 
contour  of  the  nose.  When  excessive,  as  the  patient  develops,  the  abnormal- 
ity in  the  position  of  the  septum  turns  the  nose  to  one  side,  and  narrows  or 
occludes  one  or  both  nostrils.  Although  probably,  m  the  majority  of 
instances,  the  conditions  here  described  are  congenital,  there  can  be  no 
question  but  that,  in  certain  cases,  deflection  or  deformity  is  produced  by 
the  common  practice  of  pressing  more  firmly  on  one  side  than  the  other  in 
blowing  the  nose.  Beclard  explains  it  by  the  habit  of  wiping  the  nose  with 
the  right  hand,  the  deflection  being  more  often  to  the  left  than  to  the  right. 
Be  the  cause  as  it  may,  the  condition  is  an  exceedingly  common  one,  and  if 
excessive,  it  produces  such  an  amount  of  nasal  obstruction,  and  gives  rise  to 
such  distressing  symptoms,  that  surgical  treatment  for  its  relief  is  always 
indicated.  ^  Diagnosis  is  not  difiicult ;  the  appearance  of  the  occluding  mass 
and  its  feeling  to  the  touch  establish  its  nature,  and  this  is  further  shown  by 
an  inspection  of  the  unaftected  cavity  of  the  nose,  which  will  show  a  concavity 
corresponding  to  the  convexity  upon  the  narrowed  side.  The  cure  of  the 
condition  is  attained  by  various  means,  all  having  however  for  their  object 
the  replacement  of  the  cartilaginous  septum  in  the  median  line,  and  its  reten- 
tion there,  or  the  removal  of  the  oftending  portion. 

Chassaignac^  resorted  to  subperiosteal  resection  of  the  deviated  portion. 
An  incision  was  made  through  the  mucous  membrane  in  an  antero-posterior 
direction,  low  down  towards  the  floor  of  the  nostril  on  the  aftected  side ;  the 
membrane  was  raised  from  the  cartilage  by  means  of  a  small  spatula,  and  the 
convexity  of  the  cartilage  then  cut  away  in  slices  until  sufiiciently  thinned  to 
allow  of  its  being  pushed  back  into  its  normal  position ;  the  mucous  mem- 
brane was  then  replaced,  and  the  cartilage  held  in  its  new  position  by  a  sponge 
inserted  in  the  nostril.  Eupprecht,^  when  the  deviation  is  caused  by  an 
abrupt  curve  or  bulging,  uses  a  sharp  pair  of  forceps  with  blades  so  arranged 
as  to  cut  out  the  affected  portion  of  the  septum ;  a  communication  is  thus 
established  between  the  two  sides  of  the  nasal  cavity,  and,  according  to  the 
inventor,  the  permeability  of  the  closed  side  is  also  restored.  Blandin^  per- 
forates the  septum  in  the  deflected  portion  with  a  like  punch.  Steele*  makes 
a  stellated  division  of  the  mucous  membrane  and  cartilage,  then  forcibly 
replaces  the  divided  septum,  and  retains  it  in  position  by  ivory  or  wooden 
plugs  introduced  into  the  nostrils.  The  division  of  the  cartilage  destroys  in 
a  great  measure  its  resiliency,  and  the  plugs  are  more  to  give  support  than  to 
exert  pressure.  The  instrument  by  means  of  which  this  is  efl'ected  is  a  stout 
forceps,  shod  on  one  blade  with  knives  set  in  stellar  form;  the  two  blades 
are  united  after  the  manner  of  obstetrical  forceps,  to  facilitate  introduction 
and  withdrawal.  The  great  advantage  of  the  latter  operation  is,  that  it 
takes  no  portion  of  the  septum  away,  as  is  the  case  in  both  of  the  former ; 
and  though  deformity  of  the  nose  never  follows  the  removal  in  these 
instances  of  a  small  portion  of  the  septum,  the  effects  of  the  resulting  arti- 
ficial perforation  are  disagreeable  in  numerous  ways  (whistling  noise  during 

»  Gaz.  Hebdom.,  11  Juin,  1869.  2  Wien.  med.  Wochenschc,  S.  1157.  1868. 

3  Diet.  Ency eloped,  des  Sciences  Med.,  art.  Nez. 
*  Archives  of  Laryngology,  vol.  iii.  No.  1. 


AFFECTIONS  OF  THE  SEPTUM. 


801 


respiration  through  the  nose,  constant  collection  and  drying  of  the  secretions 
upon  the  edges  of  the  perforation,  tendency  to  superticial  ulceration,  etc.), 
and  should  therefore  be  avoided  if  possible.  Pancoast  has  separated  the  car- 
tilaginous from  the  bony  portion  of  the  septum  by  subcutaneous  division 
with  a  tenotome,  and  then  replaced  it  in  its  normal  position,  pulling  tlie  nose 
to  the  opposite  side  and  holding  it  with  adhesive  stri})s.  Other  suro'eons 
have  divided  the  nose  in  the  median  line  and  resected  tlie  septum.  The  indi- 
cations  presented  in  individual  cases  must  guide  the  operator  in  his  selection 
from  these  means. 

If  the  obstruction  is  due  to  a  deflection  or  displacement  of  the  cartilaginous 
septum,  involving  its  whole  or  nearly  whole  length,  the  most  successful  ope- 
ration for  correcting  it  is  probably  that  proposed  by  Adams.^  In  this  method, 
the  bent  portion  is  forcibly  broken  or  straightened  by  means  of  powerful  for- 
ceps with  parallel  blades,  one  of  which  is  introduced  into  each  nostril ;  and 
when  the  nasal  bones  are  displaced  laterally  and  likewise  depressed,  these  are 
raised  also  by  carrying  the  blades  of  the  forceps  directly  upwards.  After  the 
nose  and  its  cartilage  have  thus  been  straightened,  a  retentive  apparatus  is 
employed,  consisting  of  a  steel  screw-compressor,  applied  so  as  to  support  the 
septum ;  and,  subsequently,  ivory  plugs  are  used  to  keep  the  nostrils  moder- 
ately distended  and  to  give  support  "to  the  cartilaginous  septum,  not  only 
during  the  healing  process,  but  likewise  for  a  time  afterwards. 

In  conclusion,  certain  less  heroic  measures  need  but  be  alluded  to:  the 
simple  insertion  of  metallic  tubes  in  the  nasal  passages,  thus  exercising  gentle 
dilatation  and  some  compression,  and  the  use  of  sponge  tents,  or  of  laminaria 
hougies,  may,  if  their  use  be  persisted  in,  especially  in  young  subjects,  bring 
forth  good  results,  provided  that  the  amount  of  deviation  is  not  excessive. 

Fractures  and  Dislocations  of  the  ^^'asal  Septum.— The  treatment  of 
these  injuries  is  usually  discouraging,  as  they  are  commonly  followed  by  per- 
manent deformity,  which  is,  however,  rarely  great.  Hamilton  doubts  whether 
a  partition  so  thin  and  unsupported,  can  ever'be  well  adjusted  and  maintained 
by  artificial  means,  but  advises  that  each  nostril  should  be  plugged  carefully 
and  equally  with  pledgets  of  lint,  and  the  outside  of  the  nose  then  covered 
completely  with  a  nicely-moulded  gutta-percha  splint  or  case,  which  ought  to 
be  made  to  press  snugly  upon  the  sides ;  these  dressings  should  be  permitted 
to  remain  for  several  weeks,  or  until  the  cure  is  completed.  This  mode  of 
procedure  must  be  modified  and  varied  to  suit  individual  indications. 

Fracture  of  the  nasal  septum,  if  extensive,  and  unless  carefully  treated  at 
the  time  of  the  accident,  may  by  its  displacement  and  subsequent  deformity 
seriously  occlude  the  nasal  passages.  A  common  form  of  the  lesion  is  the 
tearing  away  and  lateral  displacement  of  the  cartilaginous  septum  from  the 
bony,  at  their  point  of  junction.  The  treatment  must  consist  in  the  accurate 
readjustment  of  the  displaced  parts  by  intra-nasal  and  extra-nasal  manipula- 
tion, and  their  retention  by  means  of  mechanical  supports,  probably  within 
the  nasal  passages.  If  the  septum  be  broken  into  several  pieces,  as  is  some- 
times the  case,  their  immediate  removal  is  indicated  ;  and  under  any  circum- 
stances, if  reposition  cannot  be  effected,  and  if  the  subsequent  deformity  be 
sufficient  to  occasion  occlusion,  the  offending  parts  may  be  cut  away. 

Tumors  of  the  septum,  aside  from  the  osseous  and  cartilaginous  outgrowths 
which  not  infrequently  affect  it,  are  rare.  The  former  are  the  least  common, 
and  are  only  met  with  far  back  in  the  nasal  passage,  over  the  bony  portion 
of  the  septum.   They  are  more  or  less  linear  in  shape,  stretching  in  an  antero- 

»  British  Med.  Jour.,  Oct.  2,  1875. 

VOL.  IV. — 51 


802      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


posterior  direction,  sometimes  with  a  sharp  exterior  edge,  at  other  times 
more  flattened  ;  upon  their  size  depends  the  amount  of  nasal  obstruction  that 
they  cause,  and  their  true  nature  may  usually  be  at  once  appreciated  from 
their  density  and  their  location.^  The  cartilaginous  outgrowths  or  thicken- 
ingsyon  the  other  hand,  occur  anteriorly  in  the  nasal  fossae,  and,  for  the  most 
part,  are  attached  by  broad  bases  to  the  septum  and  adjoining  parts  of  the 
floor  of  the  nose.  Their  removal,  if  indicated,  is  readily  accomplished.  I 
have  been  in  the  habit  of  slicing  them  oft',  as  it  were,  from  the  septum,  by 
means  of  a  long,  strong,  probe-pointed  knife  ;  the  incision  is  easily  made  ;  the 
removal,  if  the  knife  is  kept  parallel  to  the  septum,  is  thorough,  and  the 
result  good  ;  the  wound  of  the  mucous  membrane  heals  over  kindly.  When 
an  exostosis  or  spiculum  of  bone  projects  from  the  side  of  the  vomer,  it  must 
be  of  necessity  removed  by  means  of  a  small  chisel,  the  patient  being  anaes- 
thetized, or  by  the  small,  double  gouge-forceps  devised  by  Weir.^  Goodwillie^ 
recommends  for  the  same  purpose,  the  use  of  the  surgical  or  dental  engine, 
drilling  away  the  bony  mass  by  the  revolving  multiple-knife  inclosed 
within  a  sheath.  Cohen  has  reported  a  case  of  exostosis  from  the  palatine 
ridge  of  the  superior  maxilla  and  vomer,  occluding  the  right  nostril,  which 
he  removed  with  the  burr  of  the  dental  engine^  and  Pomeroy^  gives  a  simi- 
lar instance.  Of  the  other  forms  of  tumor,  pajnlloma  is,  perhaps,  the  most 
frequently  encountered.^  The  growths  generally  occur  just  above  the  orifice 
of  the  nostrils,  and  spring  from  the  mucous  membrane  of  the  septum  at  this 
point.  In  five  instances  that  I  have  met  with,  the  tumors  have  been  small, 
and  always  unilateral,  and  have  occurred  in  young  persons,  giving  rise 
to  some  obstruction  of  the  nasal  passage,  but  notably  to  recurrent  attacks 
of  epistaxis.  In  a  sixth  case,  recently  seen,  the  tumor  grew  from  the  anterior 
extremity  of  the  right  inferior  turbinated ,  bone ;  it  is  the  only  one  that  I 
have  ever  seen  in  this  locality.  The  general  resemblance  of  these  tumors  to 
papillomata  of  the  mucous  membrafie  of  other  parts,  renders  their  recognition 
easy,  and  as  they  may  be  easily  and  effectually  removed  by  the  knife,  snare, 
or  scissors,  their  occurrence  is  a  matter  of  more  interest  than  importance. 
Gelatinous  j)olypi^  true  myxomata,  are  occasionally  encountered  springing 
from  the  side  of  the  septum. 

Cohen  is  authority  for  the  statement  that  cystomata  sometimes  occur  in  the 
same  situation.  The  treatment  consists  in  evacuation  of  the  colloid  contents 
of  the  sac,  by  incision,  and  in  local  medication  of  its  walls  so  as  to  excite  adhe- 
sive inflammation.  Van  Yadja''  has  seen  a  case  of  sarcoma  of  the  nasal  sep- 
tum in  a  male  syphilitic  subject,  and  Mason^  one  of  myeloid  tumor. 

Congenital  occlusion  of  the  posterior  nares  is  a  rare  affection.  Its  sub- 
jects are,  as  a  rule,  very  young  children,  and  the  obstruction  to  nasal  respira- 
tion makes  itself  manifest  soon  after  birth,  upon  attempts  being  made  to 
suckle  the  infant.  The  attendant  symptoms— diflicult  respiration,  frequent 
suftbcative  attacks,  and  mucous  discharge— persist,  should  the  child  survive, 
into  later  years.  Several  cases  are  reported  in  medical  literature.  In  Em- 
mert's^  patient,  a  boy  of  seven,  the  nose  was  well  formed,  but  the  choanse  were 
closed  by  a  bony  wall.  He  had  never  breathed  through  the  nose,  and  had  been 
nourished  as  an  infant  only  with  the  greatest  diflGlculty.    FraenkeP^^  demon- 

1  See  Michel,  Gaz.  Hebdom.,  1873.  2  Medical  Record,  March  13,  1880. 

3  New  York  Medical  Gazette,  July  31,  1880. 

4  Medical  and  Surgical  Reporter,  .July  13,  1878.  ^  Medical  Record,  June  11,  1881. 

6  See  Fere,  Bull.  Soc.  Anat.  de  Paris,  tome  iv.  p.  587.  1880  ;  Maiocchi,  Gaz.  Med.  di  Roma, 
t.  iv.  p.  265.    1878  ;  Delavan,  Archives  of  Laryngology,  vol.  iii.  No.  2. 

7  Wien.  med.  Presse,  18  Marz,  1877.  *  Lancet,  April  29,  1876. 

8  Lehrbuch  der  Chirurgie,  Bd.  ii.  S.  355.    Stuttgart,  1853. 
^  Ziemssen's  Cyclopaedia,  vol.  iv.  p.  113. 


AFFECTIONS  OF  THE  SEPTUM. 


803 


strated  in  a  like  case,  in  a  young  man,  the  existence  of  a  smooth  and  solid  bony 
wall,  covered  on  both  sides  witTi  mucous  membrane,  occluding  the  right  naris 
posteriorly.  Cohen^  does  not  state  the  nature  of  the  obstruction  in  the  case 
of  an  infant  which  he  successfully  treated.  Voltolini  operated  with  the 
galvano-cautery  upon  a  total  occlusion  of  the  right  i)Osterior  naris,  due  appar- 
ently to  congenital  adhesions,  and  long  mistaken  for  nasal  tumor.  Bitot^  has 
seen  an  instance,  in  a  ftjetus  of  seven  months,  in  which  the  atresia  or  obtura- 
tion of  the  posterior  orifices  of  the  nasal  passages  was  due  to  the  presence  of 
two  triangular  bones,  articulating  above  with  the  sphenoid,  below  with  the 
horizontal  plates  of  the  palatine  bones,  to  the  outside  with  the  lesser  wings  of 
the  pterygoid  processes,  and  impinging  on  each  other  interiorly.  An  equally 
reliable  and  close  post-mortem  observation  has  been  made  by  Luschka^on  the 
cadaver  of  a  girl  who  died  soon  after  birth.  Here  the  bony  framework  was 
formed  by  the  palatal  bones  on  both  sides.  The  posterior,  normally  free  and 
concave  border  of  the  horizontal  plate  was  continued  in  a  somewhat  oblique 
direction  upward  and  backward,  to  the  lower  surface  of  the  body  of  the 
sphenoid  bone,  being  attached  to  the  latter  by  a  serrated  edge.  Laterally,  the 
bony  plate  reached  tlie  inner  side  of  the  lamina  interna  of' the  pterygoid  pro- 
cess. In  the  median  line,  the  lamella  joined  its  fellow  at  the  point  where  the 
posterior  nasal  spine  usually  arises,  while  the  two,  in  their  further  progress 
upwards,  were  separated  by  a  very  narrow  slit,  into  which  the  lower  ex- 
tremity of  the  rudimentary  vomer  had  penetrated.  More  recently,  instances 
of  congenital  occlusion  have  been  reported  by  Gosselin,^  Morton,^  Brandeis,* 
Wilkinson,^  and  Ronaldson,^  the  cause  in  the  last  surgeon's  case  having  been 
a^  thick,  tirm  membrane.  Koch  reports  a  curious  case,  which  may  be  men- 
tioned here,  viz.,  one  of  cicatricial  closure  of  the  right  posterior  naris,  follow- 
ing a  scrofulous  pharyngo-laryngitis  f  and,  finally,  Mackenzie^"  relates  the 
following  case : — 

The  naso-pharynx  was  separated  into  two  lateral  halves  by  a  thin  bony  partition, 
continuous  anteriorly  with  the  posterior  edge  of  the  vomer,  and  inserted  posteriorly 
into  the  posterior  pharyngeal  wall.  Superiorly  it  became  fused  with  the  pharyngeal 
vault.  The  septum  narium  was  slightly  deflected  to  the  left  from  before  backward ; 
the  bony  lamella  had  a  similar  inclination,  and  seemed  to  be  in  fact  a  backward  pro- 
longation of  the  vomer.  Its  inferior  edge  was  more  or  less  sharp,  clearly  defined,  and 
curved  from  before  backwards  and  upwards,  presenting  a  very  marked  resemblance  to 
the  normal  posterior  curve  of  the  nasal  septum.  Its  insertion  into  the  pharyngeal  wall 
was  on  a  higher  plane  than  that  of  its  origin,  which  corresponded  with  the  inferior  edge 
•of  the  septum.    Attempts  were  made  to  dislocate  it,  but  without  success. 

The  indication  for  treatment  lies  in  establishing,  by  surgical  means,  an  open- 
ing through  the  affected  nasal  passages,  at  as  early  a  date  as  possible.  In  the 
case  of  membranoid  occlusion,  this  may  easily  be  accomplished  by  means  of 
the  knife  and  subsequent  use  of  bougies,  to  dilate  and  keep  open  the  artificial 
perforation.  In  Cohen's  case  the  occluding  structures  were  bored  through 
with  a  knife  and  steel  probe,  and  the  passage  kept  open  and  enlarged,  from 
time  to  time,  by  the  insertion  of  a  sound,  and  subsequently  of  small  bits  of 
sponge  fastened  to  a  holder.  When  the  occlusion  is  of  a  dense  and  bony 
nature,  the  employment  of  the  burr  of  the  dental-engine,  elsewhere  alluded  to, 
suggests  itself  as  the  best,  quickest,  and  safest  means  of  perforation. 

•  Diseases  of  the  Throat,  p.  385.    1879.  2  Archives  de  Tocologie.    Sept.  1876. 

3  Der  Schluiid-kopf,  S  27.    Tubingen,  1868.  4  Gazette  Med.  de  Paris,  No.  36.  1877. 

5  Surgery  in  the  Pennsylvania  Hospital,  p.  333.    Phila.,  1880. 

6  London  Med.  Record,  April  15,  1882. 

7  North  Carolina  Med.  Journal,  vol.  ix.  page  305.  1882. 

8  Edinburgh  Medical  Journal,  vol.  xxvi.  page  1035.  1880-1 
9 "Ann.  des  mal.  de  I'oreille  et  du  larynx.  No.  4,  1878. 

^0  Archives  of  Laryngology,  vol.  iv.  No.  3. 


804      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

Bifid  Septum. — A  curious  abnormality  of  the  posterior  nares,  of  which  I 
am  aware  of  but  two  instances,  those  reported  by  Schroetter^  and  myself,^ 
is  as  follows:  The  posterior  edge  of  the  septum  narium,  from  its  point  of 
mergence  into  the  parts  making  up  the  vault  of  the  pharynx  to  one-half  way 
in  its  course  from  the  floor  of  the  nares,  is  divided  vertically  into  two  dis- 
tinct halves,  inclosing  between  them  a  small  space  ;  this  space  is  more  or  less 
triangular  in  shajDe,  its  base  lying  above,  and  is  lined  apparently  with  normal 
mucous  membrane.  This  description  applies  to  both  of  the  instances  men- 
tioned. In  neither  was  there  any  history  of  injury  or  disease ;  the  condition 
gave  rise  to  no  symptoms,  and  was  discovered  only  by  accident,  during  rhi- 
noscopic  examination. 

Foreign  Bodies  in  the  ^^'asal  Passages. 

Articles  of  the  most  varied  character,  form,  size,  and  description,  are  not 
infrequently  found  lodged  within  the  nasal  fossse,  either  as  the  result  of  acci- 
dent or  design  ;  especially  is  the  latter  the  case  in  children.  Fraenkel,  more- 
over, calls  attention  to  the  fact  that  foreign  bodies  may  originate  within 
the  organism,  having  their  source,  in  such  cases,  first,  within  the  nose  or 
neighboring  cavities— as  for  instance,  in  the  detachment  of  necrosed  bits  of 
bone — or  second,  originating  elsewhere  in  the  body,  carried  into  the  nasal 
cavities,  and  lodged  there :  as  examples  may  be  quoted,  the  entrance  of  part 
of  the  contents  of  the  stomach  through  the  posterior  nares  into  the  nostrils, 
in  violent  attacks  of  vomiting,  and  the  occasional  presence  of  the  ascaris 
lumbricoides  within  these  or  the  contiguous  cavities.  Thiedemann^  has 
collected  a  number  of  cases  in  which  the  lumbrici,  having  reached  the 
stomach,  passed  out  of  the  body  by  the  nose  instead  of  the  mouth,  or  even 
remained  for  some  time  in  the  former,  causing  by  their  presence  great  local 
disturbance. 

If  the  foreign  body  come  from  without,  it  has  but  three  points  of  entrance : 
first,  and  most  commonly,  through  the  anterior  nares ;  second,  but  rarely ^ 
through  the  posterior  nares  ;  and  finally,  infrequently,  through  the  soft  parts 
of  the  face,  as  is  seen  in  gunshot  wounds,  accidents  of  various  kinds,  stab- 
wounds,  etc.^  The  latter  two  classes,  from  their  infrequency,  need  but  pass- 
ing mention.  Lowndes^  reports  the  case  of  a  ring — too  large  to  have  passed 
in  through  the  anterior  nares — as  having  been  lodged  in  the  post-nasal  cavity^ 
where  its  presence  could  only  be  accounted  for  by  its  having  been  swallowed 
and  passed  into  the  nose  from  the  lower  pharynx;  and  Noyes  has  removed 
the  entire  breech-pin  of  an  exploded  gun  from  the  nasal  cavity,  where  it  had 
long  lain  undiscovered,  the  patient  having  applied  to  Dr.  I^oyes  for  treatment 
of  his  eyes.^  The  catalogue  of  the  foreign  bodies  introduced  into  the  nostril 
through  its  anterior  opening,  forms  an  interesting  and  curious,  but  illimitable 
list.  Buttons  and  glass  beads  are  favorite  articles  with  children.  I  have 
removed  carpet-tacts,  nuts,  small  pebbles,  copper  rivets,  bits  of  wood,  pieces 
of  coal,  shot,  pins,  and  beans ;  in  the  case  of  the  latter,  germination  is  possi- 
Ijle,  although  I  have  never  seen  it. 

The  foreign  body  once  introduced,  if  discovered  by  the  attendant,  or  its  in- 
troduction acknowledged  by  the  patient,  is  usually  quickly  removed,  if  efforts 
looking  towards  that  end  are  at  onc^e  made  by  the  surgeon  ;  on  the  other  hand,  if 
forgotten  and  undisturbed,  it  not  unfrequently  remains  in  situ  for  years,  covered 

'  Laryngologische  Mittheilungen.    Wien,  ISTf).  *  Med.  News,  Jan.  7,  1882. 

3  Von  lebenden  Wurmen  und  Insekten  in  den  Geruchs-organen  des  Menschen.  1844. 

*  Cloquet,  Ospliresiologie.    Weimar,  1824. 

5  British  Medical  Journal,  September,  1867.  ^  See  also  Lancet,  May  3,  1884. 


FOREIGN  BODIES  IN  THE  NASAL  PASSAGES. 


805 


probably  witb  phospbatic  deposits,  keeping  up  a  constant  irritation,  muco- 
purulent discbarge,  and  oftensive  smell,  and  not  very  rarely  being  mistaken 
for  carious  bone,  tbe  result  of  struma  or  sypbilis.  Two  sucb  instances  bave 
come  under  my  observation.  In  one,  tbe  foreign  body,  a  sboe  button,  tbickly 
covered  witb  calcareous  matter,  bad  lam  undisturbed  for  some  eigbteen 
years,  baving  been  introduced  by  tbe  patient  wben  a  cbild,  a  fact  distinctly 
remembered  wben  its  presence  was  demonstrated.  In  tbe  second,  a  bean, 
likewise  encrusted,  was  removed  after  a  sojourn  of  some  fifteen  years.  In 
both  cases,  all  tbe  symptoms  of  fetid  catarrh  were  present.  Tbe  presence 
of  a  foreign  body  bad  been  demonstrated,  and,  through  tbe  su})position  that 
this  was  necrosed  bone,  both  patients  had  been  for  some  ^time  under  anti- 
syphilitic  treatment.  N'o  attempt  at  tbe  removal  of  the  foreign  body  had 
been  made  in  eitlier  instance. 

The  symptoms  caused  by  the  presence  of  a  foreign  body  within  the  nose, 
vary  naturally  according  to  the  duration  of  its  stay,  as  well  as  upon  its  irri- 
tating or  non-irritating  nature  and  form.  If  the  latter  be  sharp,  irregular, 
or  pointed  in  character,  considerable  mflammatorj^  reaction  will  follow 
its  entrance  into,  and  impingement  upon,  the  nasal  mucous  membrane,  while 
a  smooth,  rounded  body,  on  the  contrary,  will  give  rise  to  little  or  no  local 
disturbance.  As  a  rule,  tbe  symptoms  in  recent  cases  are  simply  those  of  an 
ordinary  chronic  coryza,  with  abundant  purulent  discbarge,  and  the  results 
of  the  occlusion  of  a  nasal  passage.  Should,  however,  the  foreign  body  be  of 
sucb  a  nature  that  it  imbibes  moisture  from  the  nasal  walls,  and  swells 
within  tbe  bony  inclosure  in  which  it  lies,  to  these  symptoms  must  be  added 
those  due  to  the  pressure  and  tension  that  it  causes,  viz.,  pain,  severe  head- 
ache, and  distortion  of  the  nose.  Sbould  its  sojourn  be  one  of  months  or 
years,  all  the  symptoms  of  a  fetid  catarrh  will  probably  be  developed,  as  in 
the  instances  above  reported ;  and  in  cases  where  the  foreign  body  is  sharp 
and  irregular,  ulceration  of  the  mucous  membrane  at  its  point  of  lodgment, 
with  bloody  discbarge  at  times,  and  increased  pain,  will  be  the  rule,  and  will 
still  further  complicate  the  existing  conditions. 

The  diagvosis  of  a  foreign  body  within  the  nostril  is  greatly  assisted  by 
tbe  statement  of  the  patient,  if  this  can  be  obtained  ;  in  default  of  it,  it  must 
rest  upon  the  results  of  inspection  and  palpation.  The  foreign  body  being 
usually  obscured  by  a  thick  coating  of  mucus,  a  thorough  washing  out  of  the 
affected  nostril  will  be  found  desirable  as  a  preliminary  to  the  use  of  tbe 
probe  Much  valuable  information  may  thus  be  obtained  as  to  its  nature, 
form,  and  method  of  lodgment  The  probe,  carefully  used,  establishes  the 
fact  of  its  existence.  It  can  be  but  confounded  with  one  condition,  viz., 
necrosed  bone.  The  mobility  of  the  object,  the  character  of  its  surface,  and 
tbe  peculiar  sensation  conveyed  to  the  linger  by  the  probe  on  touching  it, 
w^ill  always  serve  to  differentiate  the  substances.  It  is  hardly  necessary  to 
add,  that  in  default  of  a  clear  clinical  history  of  the  presence  of  a  foreign 
body,  a  careful  examination  should  be  instituted  in  eveiy  case  of  offensive 
discbarge  from  the  nares,  attended  by  symptoms  of  occlusion,  both  by  an- 
terior inspection  and  by  the  use  of  the  rhmoscopic  mirror 

The  treatment  of  a  foreign  body  within  the  nares  lies  in  its  removal  at  as 
«arh^  a  date  as  possible  after  its  entrance.  To  do  this  will  often  tax  the  mven- 
tive  ingenuity  of  tbe  surgeon.  Small,  loose  bodies  may  sometimes  be  quickly 
expelled  by  exciting  sneezing  in  the  patient ;  blowing  strongly  into  the  un- 
affected nostril,  is  also  said  to  expel  tbe  offending  substance  from  the  other 
King  gives  an  instance  of  the  expulsion  of  a  cherry-stone  from  the  nose  during 
the  action  of  an  emetic,  the  mouth  being  held  closed  at  tbe  moment  of  emesis. 
Success  may  be  obtained  by  the  injection  of  a  powerful  stream  of  water 
through  tbe  nares,  either  anteriorly,  by  means  of  a  large  syringe  held  to  the 


806      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

unocclacled  nostril — the  best  method — or  by  the  use  of  the  nasal  douche,  the 
can  being  well  elevated  to  render  the  pressure  strong ;  or  the  posterior  nasal 
syringe  may  sometimes  succeed  in  driving  out  the  foreign  body,  if  it  be  not 
firmly  impacted,  by  the  mere  mechanical  force  of  the  stream  of  water.  Cohen 
recommends  that  curved  bougies  or  probes  be  passed  up  behind  the  velum  into 
the  , occluded  nostril,  and  the  foreign  body  thus  pushed  forwards.  He  also 
alludes  to  the  method  pursued  by  aurists  to  remove  bodies  impacted  in  the 
external  auditory  meatus — by  placing  a  brush,  loaded  with  glue  or  other  adhe- 
sive fluid,  in  contact  with  it,  and  allowing  it  to  remain  until  firmly  adherent,, 
so  that  the  brush  can  be  used  as  a  tractor — as  applicable  in  the  removal  of  cer- 
tain classes  of  foreign  bodies  from  the  nose.  When  the  foreign  body  is  large, 
and  perhaps  firmly  imbedded  in  the  soft  parts,  it  must  be  seized  directly  by 
means  of  the  fenestrated  scoop,  slender  hook,  curved  probe,  or  small,  slender 
forceps,  made  in  two  distinct  portions  which  may  be  introduced  separately, 
one  on  each  side  of  the  foreign  body,  and  afterwards  locked  together  lik«  mid- 
wifery forceps. 

Some  care,  and  a  little  attention  devoted  to  the  peculiarities  of  each  case 
that  may  be  treated,  will  render  easy  the  choice  of  the  special  instrument  best 
adapted  to  the  extraction  of  the  foreign  body.  For  instance,  I  have  on  a  few 
occasions  been  able  to  hook  a  small  probe  into  the  eye  of  a  button  firmly  fixed 
in  the  nostril,  and  thus  readily  remove  it.  The  forceps  would  have  but  pushed 
it  further  into  the  nasal  passage.  The  latter  is  a  not  unfrequent  occurrence, 
which  renders  subsequent  efibrts  at  removal  anteriorly  even  more  difiicult. 
Even  with  care,  it  is  sometimes  not  to  be  avoided,  and  the  question  arises, 
w^hen,  from  its  location,  size,  and  impaction,  a  foreign  body  cannot  by  any 
gentle  means  be  removed  through  the  anterior  nares,  whether  it  should  not 
be  pushed  backwards  into  the  pharynx,  either  there  to  be  caught  and  extracted, 
or,  as  is  commonly  the  case,  to  be  swallowed  and  afterwards  discharged  by 
the  rectum.  My  own  experience  is,  that  when  necessary  (I  do  not  hold  that 
it  is  desirable)  this  may  be  done  with  impunity.  I  have  never  met  with  the 
danger  so  forcibly  alluded  to  by  some  writers,  viz.,  that  of  the  foreign  body 
falling  into  the  larynx ;  nor  have  I  found  it  necessary  to  follow^  their  advice 
and  protect  the  entrance  to  this  organ.  The  results  where  I  have  followed  out 
this  plan  of  treatment,  unsurgical  I  admit,  have  been  favorable.  In  a  case 
reported  by  Morrman,  a  foreign  body,  lodged  far  back  in  the  nasal  passage, 
was  pushed  forwards  within  reach  of  the  forceps  by  closing  the  mouth  with 
the  hand,  so  as  to  cause  the  patient  to  breath  alone  through  the  nose.  In  rare 
instances,  where  extraction  is  impossible  by  any  of  the  above  means,  it  may 
be  necessary  to  gain  direct  access  to  the  point  of  impaction  by  means  of  some 
form  of  external  excision.  The  operations  that  have  been  employed  are:  the 
division  of  the  wing  of  the  nose  (Yidal);  division  in  the  median  line  (Dieffen- 
bach);  and  raising  the  Avhole  nose  by  means  of  an  incision  through  the  gingival 
margin  of  the  upper  lip,  and  thence  dissecting  upwards  (Rouge).  Finally,  to 
proceed  to  the  other  extreme,  Watson  alludes  to  the  possibility  of  leaving 
the  foreign  body  to  be  extracted,  partly  by  nature's  efforts  and  partly  by  the 
assistance  of  art.  In  process  of  time  ulceration  will  take  place  around  it,  and 
this  will  have  the  effect  of  loosening  it  from  the  bed  in  which  it  has  been 
so  tightly  wedged  ;  then,  by  using  the  douche  apparatus  through  the  opposite 
nostril,  it  may  be  dislodged  and  expelled. 


Nasal  Calculi,  or  Ehinolites. 


Calcareous  concretions  are  occasionally  encountered  in  the  nasal  foss8e,  their 
origin,  probably,  being  always  due  to  hard  foreign  bodies  which  have  been 


NASAL  CALCULI,  OR  RHINOLITES. 


807 


forced  into  these  passages  at  dates  long  antecedent  to  their  discovery,  and 
which  have  in  process  of  time  become  nuclei  for  deposits  consisting,  accord- 
ing to  Demarquay,^  of  phosphates  of  lime  and  magnesium,  chloride  of 
sodium,  and  tlu3  carbonates  of  lime,  magnesium,  and  sodium — in  other  words, 
essentially  the  sediments  of  the  saline" portion  of  the  serum  of  the  blood. 
Numerous  cases  may  be  found  scattered  through  medical^  literature,  in  some 
of  which  the  calculns  has  attained  an  extraordinary  size,  even  that  of  a 
pigeon's  egg,  weighing  three  or  four  drachms.  Many  of  the  earlier  cases 
are  cited  by  Demanpiay,  in  his  elaborate  work.  Bartholin,  quoted  by  Clo- 
quet,2  relates  the  instaiice  of  a  young  woman,  who,  after  suffering  a  long 
time  from  headache,  passed  from  her  nose  several  calculi,  which,  in  size  and 
and  shape,  resembled  date-stones.  Clauder  witnessed  the  case  of  a  woman, 
who  expelled  from  her  nose,  a  very  hard,  round  concretion,  as  large  as  a 
hazel-nut.  Khern  mentions  several  pisiform  calculi  which  had  escape(l  fnmi 
the  nostrils  of  a  young  person  sutfering  from  a  violent  headache.  Riedlin, 
D'Ulm,  Buchner,  Plater,  Watson,  and  others,  add  similar  instances.  Savialles 
informs  us  of  a  case  of  the  same  kind,  which  had  for  its  nucleus  a  foreign  body 
introduced  into  the  nose  from  without.  Some  remarkable  cases  are  to^  be 
found  in  the  Contributions  to  Pathology  and  Surgery^  of  Mr.  Hawkins. 
Roe^  reports  an  instance  occurring  in  a  young  woman,  in  which  the  rhinolite 
weighed,  after  removal,  forty  grains.  Two^instances  of  my  own  have  been 
alluded  to  above.  Although  in  all  of  these  cases,  as  has  been  stated,  some 
foreign  body  introduced  froin  without  has  probably  formed  the  nucleus  of  the 
concretion,  and  although  this  is  the  common  cause  of  the  formation,  Watson* 
holds  that  it  is  possible  that  the  crusts  formed  in  fetid  catarrh  or  oz^ena,  may, 
when  retained  for  a  lengthened  period,  become  consolidated,  and  subsequently 
encrusted  with  the  carbonates  and  phosphates  of  lime ;  but  he  admits  that 
such  instances  must  be  rare.  Two  cases  which  he  records  seem  to  bear  out 
this  view. 

i^"asal  calculi  may  be  formed  in  any  of  the  various  passages  of  the  nose ; 
they  may  even  originate  in  the  frontal  or  maxillary  sinuses,  and  pass  thence 
into  the  nasal  canal,  or  be  formed  beneath  the  pituitary  membrane,  lying 
imbedded  in  the  tissues ;  as  a  rule,  however,  they  are  formed  in,  and  will 
be  found  lying  in,  the  inferior  meatus  of  the  affected  cavity,  and  their 
exact  position  will  be  determined  by  the  method  and  direction  of  their  intro- 
duction. The  reason  of  their  forniation  is  not  so  clear.  Grafe  argues  in  favor 
of  a  gouty  dyscrasia,  as  favoring  their  production.  Durham,  with  more  pro- 
bability, holds  that  chronic  inflammation  of  the  nasal  fossa  and  lachrymal 
gland,  may  give  rise  to  such  alterations  in  the  secretions  that,  a  foreign  body 
being  present,  the  deposition  of  calcareous  matter  around  it  can  readily  be 
explained.  Such  deposition  is  also  favored  by  various  anatomical  abnormali- 
ties, preventing  the  free  exit  of  secretions.  Brown^  reports  such  an  example, 
in  which  cicatricial  closure  of  the  nostril,  following  smallpox,  gave  rise  to 
the  formation  of  a  calculus  weighing  three  and  one-half  drachms,  which  was 
removed  by  incising  the  occluding  membrane. 

After  what  has  been  said,  it  can  readily  be  understood  that  nasal  calculi 
may  constantly  increase  in  size  through  the  deposition  of  successive  layers, 
that  their  contour  must  depend  upon  the  shape  of  the  cavity  in  which 
they  are  formed,  and  that  they  may  be  either  hard  and  firm,  or  soft  and 
friable,  in  their  nature.  The  Symptoms  to  which  they  give  rise  have  in 
great  measure  been  detailed  in  speaking  of  other  causes  of  nasal  obstruc- 

1  Meraoire  sur  les  Calcules  nasaux.    Arch.  G^n.  de  Med.  1845. 

•2  Op.  cit.  ^  Vol.  i.  p.  225. 

<  Archives  of  Laryngology,  vol.  i.  p.  149.  ^  Diseases  of  the  Nose. 

6  Edinburgh  Med.  Jour.,  vol.  v.  p.  50.- 


808      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

tion,  and  of  foreign  bodies.  Pain  is  a  more  constant  symptom,  however  ;  and 
periodical  hemicrania,  terminating  by  the  evacuation  of  a  nasal  calculus,  has 
more  than  once  been  reported.^  An  ichorous  or  muco-purulent  discharge — 
sometimes  stained  with  blood,  and  of  an  offensive  character — is  never  want- 
ing. The  very  character  of  this  discharge  may  lead  to  the  mistaken  diag- 
nosis of  oz8ena,  or  fetid  catarrh,  especially  in  those  cases  of  calculi  in  which  the 
mass  is  encysted  beneath  the  mucous  membrane,  or  located  so  far  posteriorly 
that  it  cannot  be  seen.  The  peculiar,  characteristic  click  of  the  probe  against 
it  will,  in  the  latter  instance,  however,  render^the  matter  clear.  The  dilata- 
tion of  the  nostril  and  the  obstruction  to  respiration  will  still  further  com- 
plicate the  differential  diagnosis  between  calculus  and  nasal  polypus  f  and  the 
deformity  and  accompanying  suppuration,  that  between  the  same  condition  and 
necrosis  of  the  nasal  bones  ;  but  with  care,  direct  inspection,  and  thorough  prob- 
ing, the  difficulty  is  easily  overcome.  The  latter  is  the  mistake  commonly 
made  ;  instances  are  probably  familiar  to  many  of  us.  In  a  reported  case,  the 
calculus  was  a  large  one,  and  was  removed  by  lithotrity  in  four  sittings  ;  it  had 
been  mistaken  for  necrosis  of  the  malar  bone.  Fraenkel,  finally,  calls  attention 
to  the  danger  of  confounding  nasal  calculi  with  calcareous  degeneration  of  the 
mucous  membrane  itself.  The  latter  is  sometimes  found  in  the  nose,  especially 
in  the  old,  but  occasionally  likewise  in  the  young,  in  consequence  of  the  ossific 
diathesis  ;  the  membrane  covering  the  turbinated  bones  may  develop,  first,  fine 
granular  points,  and  afterwards,  plates  of  calcareous  matter.  The  condition  is, 
however,  a  rare  one.  The  diagnosis  having  been  made,  the  removal  of  the  cal- 
culus may  be  at  once  undertaken  by  the  same  methods  as  were  detailed  in 
treating  of  the  removal  of  foreign  bodies  from  the  nasal  passages.  Granted 
that  it  be  not  too  large,  nor  too  firmly  imbedded,  and  that  it  is  accessible,  the 
scoop  or  forceps  will  be  all-efficient  means  of  removal.  In  cases  where  the  rhi- 
nolite  is  located  beneath  the  mucous  membrane,  it  will  be  necessary  to  incise 
this  down  to  the  stone,  to  allow  of  its  extraction.  Erichsen^  mentions  two 
cases  of  this  kind  as  occurring  in  children.  When  the  calculus  is  too  large 
to  permit  of  extraction  by  the  natural  nasal  opening,  it  must  of  necessity,  in 
order  to  lessen  the  danger  of  laceration  of  the  soft  tissues,  be  crushed  up  by 
a  strong  pair  of  forceps,  or  drilled  through,  and  the  debris  washed  out  by  the 
syringe  introduced  into  the  unaffected  passage.  Cohen  recommends  that  in 
some  instances  the  point  of  a  knife  should  be  passed  under  the  edge  of  the  cal- 
culus, a  short  distance  into  the  soft  parts,  and  that  it  should  then  be  pried  out, 
in  part,  by  some  blunt  instrument.  The  subsequent  treatment,  after  the  removal 
of  the  concretion,  will  be  the  thorough  cleansing  of  the  nasal  cavities,  and  the 
application  of  such  astringent  remedies  as  may  tend  to  allay  inflammation, 
reduce  inflammatory  thickening,  and  heal  superficial  ulceration.  These 
results — with  a  subsidence  of  all  subjective  and  objective  symptoms — usually 
follow  very  quickly  the  removal  of  the  oflending  body. 


Parasites  of  the  ^^asal  Cavity. 

The  entrance  of  living  creatures  into  the  nasal  cavities  is  always  more  or 
less  a  matter  of  chance,  and  the  occurrence  a  rare  one,  although  the  older 
writers,  manifestly  wrong,  ascribed  all  cases  of  ozsena  attended  with  severe 
frontal  headache  to  the  presence  of  insects  or  their  larvse  in  that  situation, 
^^"umerous  cases  are  not  wanting,  however,  in  modern  times,  in  which  the 

'  Axmann,  Arch.  Gren.  de  Med.,  Mai,  1829. 

2  Voltoliiii  narrates  the  history  of  such  a  case.  Die  Anwendung  der  Gralvano-kaustik,  S.  240, 
Zweite  Auflage.  1872. 

^  Science  and  Art  of  Surgery,  vol.  ii.  p.  390. 


PARASITES  OF  THE  NASAL  CAVITY. 


809 


diagnosis  has  been  established  by  ocular  demonstration,  and  the  possibility  of 
the  occurrence  thus  shown.  Tliiedeinann^  has  collected  proof  of  the  existence 
within  the  nose  of  centipedes  (Scolopendnx?),  ear-wigs  (Forficula  auricularia), 
and  the  larvje  of  the  bacon-beetle  (Derniestes  lardarius).  The  occasional 
presence  of  the  Ascaris  lunibricoides  has  already  been  alluded  to.  Urbanck 
reports  such  an  instance  ;2  i*ackard,  one  of  the  accidental  entrance  of  a 
centipede  into  the  nostril  ;^  and  Buchanan,  a  case  of  the  de})Osition  of  the 
ova  of  the  fly  in  the  nasal  fossi^.''  Leeches  have  been  known  to  effect  an 
entrance,  and  to  have  been  dislodged  with  great  dilticulty,  from  these 
cavities.  The  larva?  of  the  dipterous  insects,  also,  are  of  even  more  frequent 
occurrence.  CoquereP  reports  five  cases  in  which  these  larvae,  lodged  in  the  fron- 
tal sinuses  and  nasal  passages,  produced  violent  symptoms,  which  in  three  of  the 
cases  were  followed  by  death.  In  most  of  them,  several  hundred  larva}  were 
evacuated  by  ulceration  and  necrosis  of  parts  investing  the  cavities.  Coquerel 
also  quotes  in  his  article  several  analogous  cases  from  authors  who  had  observed 
similar  occurrences  in  Europe.  Cloquet^  reports  a  somewhat  similar  case. 
An  excellent  summary  of  our  present  information  on  the  subject  is  given  by 
Fraenkel.  Attracted  by  the  odor  emanating  from  an  ozsena,  flies  are  found 
(Musca  vomitoria  and  Musca  carnaria)  which  deposit  their  eggs  in  the  vicin- 
ity of  the  nostrils,  the  young  being  nourished,  when  hatched,  by  the  decom- 
posing organic  matters.  Maggots  likewise  are  occasionally  seen  in  cases  of 
oziiena,  as  in  any  other  purulent  and  fetid  surface  or  cavity  of  the  human 
body.  According  to  Von  Frantzius,  this  occurrence  is  a  frequent  one  in  the 
tropics.^  Weber^  tells  us  that  in  the  same  locality,  especially  in  Cayeime  and 
Mexico,  there  is  a  fly  (Lucilia  hominivora)  which  sometimes  forces  its  way 
even  into  healthy  noses  and  lays  its  eggs  there ;  the  larvae,  measuring  one- 
half  inch  in  length,  are  developed  at  the  end  of  fourteen  days.  Finally,  the 
larvse  of  the  gad-fly  (Oestrus)  are  rarely  found  in  the  human  nose. 

It  has  been  stated  that  centipedes  may  remain  for  years  in  the  frontal  sinus. 
Other  parasites  make  of  necessity  but  a  temporary  sojourn  in  the  nose. 
Upon  the  duration  of  their  stay,  then,  will  depend  in  great  measure  the  in- 
tensity and  seriousness  of  the  symptoms.  These  are  never  unimportant,  and 
the  attendant  pain  and  distress,  amounting  in  many  instances  to  agony,  lead- 
ing to  psychical  disturbance, delirium, and  even  death, are  graphically  described 
by  several  authors.  All  the  evidences  of  general  as  well  as  local  inflamma- 
tion, with  high  fever,  are  present ;  the  face  and  fauces  become  swollen ;  the 
nasal  discharge  becomes  fetid  and  bloody ;  and  ulceration  and  perforation, 
especially  of  the  palate,  may  occur.  The  prognosis  of  such  cases  must 
always,  then,  be  a  guarded  one,  and  frequentlj'  unfavorable. 

Treatment^  if  we  may  judge  from  the  reported  instances,  is  not  always 
attended  with  success.  If  the  parasites  be  large  and  easily  reached,  they  may 
be  extracted  with  forceps  ;  if  they  are  numerous,  careful  syringing  with  carbo- 
lized  solutions,  or,  as  has  been  recommended,  with  solutions  of  corrosive  sub- 
limate, with  decoctions  of  bitter  herbs  or  tobacco,  or  with  turpentine,  may 
succeed  in  dislodging  them.  The  inhalation  of  chloroform  has  been  highly 
spoken  of  as  an  efficient  means  of  accomplishing  the  latter  result. 

•  Op.  cit.,  S.  11.  2  Wiener  med.  Presse,  No.  7,  1878. 

8  Med.  and  Sur^.  Rep.,  Aug.  3,  1878.  *  Phila.  Med.  Times,  Oct.  30,  1876. 

6  Arch.  Gen.  de  Med.,  Mai,  1858.  6  Am.  .lour.  Med.  Sci.,  May,  1828. 
^  Virchow's  Archiv,  Bd.  xliii.  S.  98. 

8  Recherclies  sur  la  Mouclie  Antliropage  du  Mexique.  Rec.  de  M6m.  de  Med.  etc.  Mil.,  Fev. 
1867,  p.  158. 


810     DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


Tumors  of  the  J^ose. 

External  Tumors. — Tumors  located  externally  upon  the  nasal  organ,  are  of 
very  rare  occurrence,  and  among  them  the  sebaceous  growth  hardly  deserves  the 
name  of  tumor.  It  is  usually  small,  painless,  and  of  slow  growth,  and  its  soft, 
compressible  consistence  serves  to  readily  distinguish  it  from  other  varieties  of 
neoplasm.  Once  extirpated,  it  does  not  recur.  The  fibroid  tumor  generally 
springs  from  the  surface  of  the  fibro-cartilage  of  the  nose  lying  immediately 
below  the  perichondrium,  and  exhibits  the  same  structure  as  similar  growths 
in  other  parts  of  the  body.  (Gross.)  An  important  fact  in  connection  with  it 
is  its  tendency  to  recurrence  after  removal.  Lijmnatons  tumors,  the  only 
other  variety  of  growth  met  with  externally,  consist  of  an  accumulation  of 
the  subcutaneous  adipose  tissue,  usually  associated  with  marked  hypertrophy 
of  the  overlying  integument,  and  increased  vascularity  with  distension  of  the 
sebaceous  crypts.  Lipoma  occurs  in  elderly  subjects,  and  is  easily  recogni- 
zable by  its  lobulated  appearance,  pendulous  character,  and  soft  consistency. 
The  remedy  for  the  disease  lies  in  its  excision,  care  being  taken  to  preserve 
the  nasal  cartilages  intact. 

Tumors  of  the  ^Tasal  Passages. — Tumors  of  varied  pathological  nature 
affect  the  nasal  passages,  arising  either  primarily  within  them,  or  involving 
them  secondarily  by  a  process  of  gradual  extension  from  the  neighboring 
and  communicating  sinuses  and  cavities.  The  commonest  form  is  unques- 
tionably the  mucous  or  gelatinoid,  jpolypus^  while  the  more  serious,  such  as 
the  fibrosis  or  naso-pharyngeal  jpolypiis^  the  osseous  or  cartilaginous  growths, 
as  well  as  the  semi-malignailt  sarcoma  and  malignant  carcinoma^  are  fortu- 
nately rare.  Other  forms  of  tumor  are  but  infrequently  seen,  and  need  but 
passing  consideration  ;  they  are  the  adenoma^  papilloma^  neuroma^  and  finally 
cystic  growths. 

General  Symptoms. — The  earliest  symptoms,  due  to  the  presence  of  any 
tumor  within  the  nasal  passage,  being  in  all  cases  nearly  identical — certainly 
in  the  incipient  stages  of  its  formation — and,  as  Mackenzie  remarks,  beuig 
neither  distinctive  with  respect  to  the  different  classes  of  growth,  nor,  in  fact, 
distinguishable  subjectively  from  those  of  chronic  rhinitis,  it  may  be  well  to 
consider  them  here  collectively,  laying  special  stress  upon  those  of  a  later 
date  which  in  certain  forms  of  neoplasm  have  a  diagnostic  significance. 
Hypersecretion,  sensation  of  fulness,  and  constant  desire  to  clear  the  nose  and 
throat,  with  perhaps  frontal  headache  and  some  nasal  obstruction  to  respira- 
tion—in short,  the  symptoms  of  a  chronic  coryza — are  the  first  to  attract  the 
patient's  attention,  and  become  so  gradually  pronounced  that  the  surgeon's 
attention  is  rarely  called  to  the  affection  in  this  stage.  As  the  tumor  devel- 
ops, however,  all  the  symptoms  and  attendant  discomfort,  due  mainly  to 
obstruction  of  one  or  both  nasal  passages,  are  decided.  The  patient  then 
breathes  partially,  perhaps  wholly,  through  the  open  mouth,  the  senses  of 
taste  and  smell  become  blunted,  and  the  voice  acquires  the  characteristic, 
nasal  intonation.  The  direction  of  the  growth  of  the  tumor  determines  the 
development  of  further  conditions:  if  it  be  backwards,  it  presses  upon  the 
pharyngeal  orifice  of  the  Eustachian  tube,  and  impairment  of  hearing  fol- 
lows ;  if  upwards  and  forwards,  it  presses  upon  the  outlet  of  the  nasal  duct, 
and  lachrymal  abscess,  epiphora,  or  mucocele  of  the  lachrymal  sac  are  not 
unusual  results;  if  backwards  and  downwards,  it  encroaches  upon  the  soft 
palate,  and  limits  its  movements  in  deglutition ;  and  finally,  by  blockins;  up 
the  outlet  of  the  antrum  of  Ilighmore,  it  may  induce  the  development  there  of 
a  cystic  or  other  growth.    Mucous  j)olypi  being  often  pedunculated,  give  rise 


TUMORS  OF  THE  NOSE. 


811 


to  aji  uneasy  sensation  by  moving  backwards  and  forwards  in  the  respiratory 
current  through  the  nose ;  and,  being  likewise  hygroscopic,  or  ready  absorb- 
ents of  moisture,  their  size,  and  the  consequent  degree  of  occlusion  which 
they  cause,  vary  greatly  with  changing  atmospheric  conditions.  .  Even  when 
they  are  multiple^  or  their  size  excessive,  they  rarely  cause  any  distortion  of  the 
neighboring  parts,  the  soft  growth  or  growths  adai)ting  themselves  to  the  con- 
tour of  the"surrounding  nasal  walls.  The  libroid  growth,  on  the  contrary, 
displaces  all  in  its  growth,  pushes  aside  the  septum,  absorbs  bone  or  separates 
connecting  sutures,  and  penetrates  and  develops  in  all  directions,  producing  the 
characteristic  deformity  known  as  "frog  face"  when  it  invades  and  dis[»laces 
the  antrum  on  either  side ;  in  the  latter  case  the  attencUmt  nasal  discharge, 
usually  of  a  thin,  watery  nature  only,  becomes  purulent  and  even  fetid,  and 
frequent  attacks  of  epistaxis  occur. 

Pain  is  a  frequent  symptom  in  this  class  of  growth  likewise,  as  well  as  in 
the  osseous,  cartilaginous,  and  malignant  varieties,  and  may  be  excessive. 
Not  only  does  characteristic  deformity  of  the  nose  attend  all  of  these  forms, 
but  displacement  of  the  eyes,  strabismus,  inability  to  close  the  lids,  chemosis, 
conjunctivitis,  distortions  of  the  internal  parts  of  the  mouth,  and  the  like,  are 
no  unusual  results.  With  sarcoma  and  carcinoma  must  be  added,  softening 
and  ulceration  of  the  tumor,  with  their  sequeh\?,  fungoid  granulations,  hemor- 
rha2:es  and  fetid  discharges.  Constitutional  cachexia  and  infiltration  of  the 
neighboring  lymphatics^ are  absent  in  sarcoma,  present  in  carcinoma;  with 
both  there  is  excessive  pain,  and  a  tendency  to  penetrate  into  the  cavity  of  tlie 
orbit  or  brain,  or  destroy  in  their  onward  march  the  tissues  and  soft  parts  of 
the  nose  and  cheeks,  and  appear  externally  upon  the  face  as  a  fungoid,  bleed- 
ing mass. 

One  complication  or  result  of  the  nasal  obstruction  caused  by  polypi,  or 
even  by  the  hypertrophy  of  the  tissue  over  the  turbinated  bones,  in  certain 
instances,  is  of  sufficient  interest  to  demand  special  mention.  I  allude  to 
their  direct  influence  in  the  causation  of  bronchial  asthma.  Thudichum^ 
asserts  that  there  is  no  more  common  complication  of  nasal  diseases,  par- 
ticularly polypus ;  and  since  the  first  observation  was  put  upon  record  hj 
Voltolini,^  numerous  cases  have  been  detailed,  and  the  subject  carefully  studied 
by  several  authors — Porter,^  Fraenkel,*  Haensisch,^  Daly,®  Hartmann,  Spen- 
ser, Rumbold,  Todd,  MuUhall,  and  Schafier.  JoaP  details  eleven  cases  of  his 
own,  m  all  of  which  the  asthmatic  attacks  immediately  disappeared  after  the 
removal  of  the  polypus,  though  in  some  instances  only  to  return  as  soon  as 
the  nasal  respiration  became  afi:ected  by  the  recurrence  of  the  growth.  All  of 
the  patients  were  of  marked  gouty  constitution.  He  shows  us  that  mucous 
polypi,  which  may  be  innocent  in  some  individuals,  in  others  play  a  part — 
occasional,  without  doubt,  but  powerful — in  the  causation  of  nervous  respi- 
ratory troubles  All  of  the  above  observations  show  then,  beyond  question, 
that  not  only  may  the  reflected  irritation  from  nasal  obstruction  be  the  ex- 
citino-  cause  of  asthma,  but  that,  if  the  cause  be  prolonged,  local  bronchial 
lesions  may  be  the  result  (Thudichum) ;  and  that  to  cure  the  condition, 
the  removal  of  the  cause  of  the  reflex  irritation  is  requisite,  and  usually 
promptly  succeeds.  The  irritation  of  the  pneumogastric  nerve,  which  in- 
duces the  spasmodic  contraction  of  the  bronchial  muscles,  and  thus  approxi- 
mates the  cartilaginous  rings  of  the  bronchi  (Bert,  Traube),  is  probably 
excited  by  reflected  impressions  received  through  the  medium  of  the  fifth 

1  Lancet,  April  17,  1880.  2  Galvanokaustik,  S.  246,  312.  1871. 

3  Med.  Record,  Oct.  11,  1879,  and  Archives  of  Laryngology,  vol.  iii.  No.  2. 

4  Berlin  klin  Wochensclir.,  Nos.  16,  17.  1881  ;  and  Ziemssen's  Cyclopaedia,  vol.  iv.  p.  107. 
6  Berlin  klin.  Wochensclir.,  S.  503.  1874.  ^  Archives  of  Laryngology,  vol.  ii.  1880. 
^  Archives  Gen.  de  Medecine,  tome  i.  1882. 


812      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

nerve.  (Other  less  tenable  theories,  it  may  be  here  stated,  are  advanced.)  It 
has  been  objected  that  this  implies  peripheral  irritation  producing  central  dis- 
turbance, thence  reflected  to  the  nerve  of  supj^ly  and  to  the  part  aSected — that 
is,  an  impression  conveyed  from  the  origin  of  the  fifth  nerve  to  the  origin  of 
the  pneumogastric.  But  Porter  remarks,  that  even  were  this  true  it  would 
not  disprove  the  theory ;  and  he  adds,  that  there  is  a  more  direct  line  of  com- 
munication. The  pneumogastric,  though  in  its  origin  a  sensory  nerve,  receives 
motor  filaments  from  the  seventh,  or  portio  dura  (to  auricular  branch),  from  the 
spinal  accessory  (to  ganglion  of  the  root),  from  the  hypoglossal  (to  ganglion  of 
the  trunk),  and  from  the  first  and  second  cervical  nerves.  As  the  Contiguity  of 
the  origin  of  the  cranial  nerves  is  now  demonstrated,  it  is  reasonable  "to  sup- 
pose that  impressions  may  be  conveyed  from  the  origin  of  the  fifth  nerve 
directly  to  the  origin  of  any  of  these,  and  thence  by  a  continuous  motor-tract 
to  the  pneumogastric. 

The  original  and  direct  cause  of  the  irritation  does  not  arise  in  the  polypus 
itself,  in  cases  where  it  is  present;  this  is  impossible,- as  the  ordinary  gelatinous 
polypi  are  destitute  of  nerves,  and  can  therefore,  as  J.  J^.  Mackenzie  justly 
observes,*  only  awaken  reflex  phenomena  in  an  indirect  or  mechanical  man- 
ner. They  do  so  then  only  when  they  spring  from,  or,  much  more  commonly, 
by  their  position,  form,  etc.,  are  brought  in  contact  with,  the  erectile  tissue 
covering  the  inferior  turbinated  bones,  and  especially  their  posterior  extremi- 
ties. By  acting  here  as  a  mechanical  irritant,  they  cause  engorgement  of 
the  mucous  membrane  and  erectile  cells,  and  thereby  excite  the  chain  of 
reflex  action  described  above. 

Aside  from  asthma,  reflex  cough  has  recently  been  recognized  as  a  symp- 
tom of  a  number  of  pathological  conditions,  affecting  especially  the  erectile 
tissue  covering  the  posterior  extremities  of  the  turbinated  bones,  but  J.  is'. 
Mackenzie^  has  called  attention  to  the  direct  influence  of  nasal  polypi  in  its 
production.  The  cough  is  only  present,  he  tells  us,  when  the  growths  are 
brought  in  contact  with  the  erectile  area  alluded  to  above,  and  thus  excite 
reflex  action  and  produce  explosive  cough.  The  probability  of  cough  excita- 
tion will  mainly  depend  therefore,  other  things  being  equal,'^upon  the  position 
of  the  growth.  In  regard  to  the  mechanism  of  the  reflex,  two  explanations 
are  given :  either  the  assumption  of  the  correlation  of  the  nasal  erectile  area 
and  the  inter-arytenoid  space  (laryngeal  cough  centre),  by  virtue  of  which 
irritation  and  vascular  engorgement  of  the  former  may  lead  to  hypersemia  of 
the  latter  through  the  medium  of  the  vaso-dilator  nerves,  through  the  supe- 
rior cervical  ganglion,  and  to  the  consequent  production  of  a  laryngeal  cough  ; 
or  the  direct  transmission  of  the  irritation  through  the  spheno-palathie  nerves 
to  the  medulla,  and  its  immediate  reflection  outwards  to  the  muscles  con- 
cerned in  the  expiratory  act.^ 

As  has  been  said,  the  removal  of  the  polypus,  or  other  occluding  cause, 
from  the  nasal  passage,  has,  in  the  majority  of  instances  reported,  been  effec- 
tual in  curing  the  asthmatic  complications  and  the  cough,  without  recourse 
being  had  to  further  measures.  It  is  advisable  that  this  should  be  done  at 
an  early  date,  to  prevent  any  possible  change  in  the  texture  of  the  lung  tissue, 
or  the  occurrence  of  chronic  hypereemia. 

General  Diagnosis. — By  means  of  a  skilful  anterior  and  posterior  rhino- 
scopic  examination,  the  observer  is  almost  always  in  a  position  not  only  to  diag- 
nosticate accurately  the  fact  of  the  presence  of  a  growth  within  the  nasal 
passage,  but  likewise  to  determine  its  location,  extent,  and  not  unfrequently 
the  nature  of  its  attachment,  and,  from  its  appearances  alone,  its  pathological 


1  Medical  Record,  May  3,  1884. 

*  See  section  on  Nasal  Cough,  p.  830. 


2  Loc.  cit. 


TUMORS  OF  THE  NOSE. 


813 


nature  ;  exceptions  exist,  it  is  true,  especially  in  the  case  of  multiple  growths, 
and  those  of  great  size,  which  involve  neighboring  cavities;  here  much 
care  and  repeated  examinations  are  necessary  to  establish  a  correct  diagnosis. 
Certain  facts,  if  borne  in  mind,  will  serve  to  elucidate^  the  problem,  and 
these  are  so  clearly  stated  in  the  valuable  essay  of  Mackenzie,*  that  I  here  take 
the  liberty  of  presenting  them  in  part,  in  a  condensed  form,  and  with  certain 
additions. 

The  softness,  elasticity,  mobility,  and  pale  translucent  appearance  of  mu- 
cous polypi  contrast  strongly  with  the  hardness,  opacity,  fixedness,  and 
deeper  red  color  of  other  tumors.  Fibroid,  sarcomatous  and  malignant  for- 
mations usually  bleed,  even  when  gently  touched.  Cartilaginous  and  osseous 
growths  are  heavy  and  dense,  and  ofter  such  a  sense  of  resistance  to  the 
probe  that  their  real  nature  is  at  once  apparent.  The  probe  will  also  enable 
the  surgeon  to  distinguish  the  chronic  thickening  of  the  mucous  membrane 
covering  the  inferior  turbinated  bone,  met  with  in  hypertrophic  nasal  catarrh, 
from  polypus.  In  the  former  case,  the  absence  of  a  pedicle,  the  consistence, 
and  the  gradual  blending  of  the  outgrowth  with  the  structures  around  the 
base,  assist  the  differential  diagnosis.  The  possibility  of  the  existence  of  a 
deflected  septum,  and  of  the  blood  tumors  and  abscess  of  the  latter,  elsewhere 
described,  must  not  be  forgotten,  as  they  are  perhaps  calculated  to  deceive 
the  inexperienced  observer.  Mucous  distension  of  the  ethmoidal  cells  is 
mentioned  likewise  by  Watson^  as  a  possible  source  of  diagnostic  error. 
Fibromata  may  be  distinguished  from  mucous  polypi,  not  only  by  the  cha- 
racteristics of  both,  mentioned  above,  but  also  by  their  lack  of  the  hygro- 
metric  quality.  They  are  generally  harder,  slower  in  growth,  and  more 
distinctly  pedunculated  than  sarcomatous  and  cancerous  growths.  The 
absence  of  cachexia,  and  of  involvement  of  the  lymphatic  glands,  serves 
also  to  differentiate  them  from  the  last.  Cartilaginous  growths  are  never 
pedunculated,  seldom  ulcerated,  and  present  more  smoothness  of  surface, 
with  symmetrical,  globular  outline,  than  other  forms  of  tumor.  The  touch 
alone  is  sufficient  to  establish  the  nature  of  an  osseous  tumor ;  while  sarcoma 
can  only  be  confounded  w^ith  carcinoma.  Mackenzie  says  that  in  the  nose 
it  is  much  more  frequent  than  the  latter,  and  can  generally  be  recognized 
by  its  occurring  at  an  earlier  age,  and  by  its  displaying  a  much  milder  type 
of  malignancy.  Finally,  in  regard  to  cancer — for  the  other  growths  alluded 
to  as  occurring  in  the  nose,  but  not  here  mentioned,  occur  so  very  rarely  that, 
practically,  they  are  of  but  little  importance  in  relation  to  differential 
diagnosis — there  is,  unfortunately,  no  room  for  doubt  when  the  disease  has 
once  commenced  to  progress ;  its  rapid  growth  and  equally  rapid  ulceration, 
and  the  widespread  destruction  which  it  causes,  tell  the  true  story  of  the 
distinctive  malignancy  of  this  form  of  neoplasm. 

Mucous  Polypus  or  Myxoma. — The  gelatinoid  or  mucous  polypus  is  by  far 
the  most  frequent  variety  of  tumor  encountered  in  the  nasal  passages,  occur- 
ring more  frequently  than  all  of  the  other  forms  combined.^  Views  as  to  its 
causation  varyc  An  enlargement  of  the  acinous  glands,  with  attendant  hy- 
pertrophy of  the  submucous  tissues  and  covering  mucous  membrane,  with 
serous  infiltration,  so  that  the  membrane  is  pushed  or  drawn  out  by  the 
gradual  increase  of  the  growth  into  a  narrow  pedicle,  and  this  as  the  result 
of  repeated  mflammatory  attacks,  or  chronic  nasal  catarrh,  is  probably  the 
common  cause ;  in  other  words,  it  may  be  regarded  as  a  localized  hypertro- 
phy.   An  adenomatous  variety  is  not  unusual.    Gruner  and  Pott  attribute 


»  Lectures  on  Diseases  of  the  Nose.  Lancet,  July  28,  Aug.  25,  Nov.  10,  1877. 
*  Diseases  of  the  Nose,  p.  72.    London.  1875. 


814     DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

the  origin  of  mucous  polypi  to  such  influences  as  heredity,  struma,  syphilis, 
miasma,  suppressed  menstruation,  and  the  like  (Mackenzie),  while  instances 
exist  in  which  the  local  irritation  of  a  foreign  body  has  determined  their 
deyelopment.  The  polypus,  of  a  dingy,  bluish-white  color,  with  a  smooth, 
shining,  elastic  surface  covered  by  ciliated  epithelium,  devoid  of  sensibility 
and  breaking  easily  under  pressure,  almost  bloodless,  of  variable  size  and  con- 
flguration^ — the  latter  being  determined  by  the  gravitation  of  the  contents  of 
the  polypus  downwards,  and  by  the  shape  of  the  nasal  foss^ — is  single  or 
multiple,  and  attached,  as  a  rule,  to  the  superior  turbinated  bone,  more  rarely 
to  the  middle,  and  only  very  occasionally  to  the  septum  ;2  it  may  spring  from 
the  roof  of  the  nose,  or  may  extend  into  that  organ  from  the  frontal  or  ethmoi- 
dal cells,  though  this  occurs  but  rarely.  A  single  polypus  may  even  be  attached 
at  several  points  to  the  surrounding  nasal  parts,3but  such  roots  are  always  to 
be  regarded  as  the  result,  in  the  first  instance,  of  pi^essure  and  friction,  with 
subsequent  ulceration  and  cicatricial  adhesion,  and  not  as  true  points  of 
origin.  Occasionally  polypi  contain  fibro-cartilaginous  concretions,  or  have 
small  osseous  formations  upon  their  surface.  Polypi  are  more  frequent  in 
adults  than  in  children,  and  are  found  rather  in  males  than  in  females.  Once 
carefully  removed,  close  to  their  attachment,  the  prognosis  as  regards  their 
re-formation  is  favorable.  Mackenzie*  says  that  only  one  in  seven  recurs, 
hut  he  calls  attention  also  to  the  important  fact  that,  as  in  the  case  of  recur- 
rent growths,  there  is  always  a  possibility  of  malignancy,  proportionate  to  the 
rapidity  with  which  they  increase  in  size.  The  prognosis  must  be  a  guarded 
one,  until  lapse  of  time  has  established  facts  in  respect  to  the  question  of 
recurrence  or  non-recurrence. 

Treatment — The  surgeon  called  upon  to  undertake  the  removal  of  nasal 
polypi  has  a  wide  choice  as  to  means.  The  inventive  ingenuity  of  the  pro- 
fession has  for  years  expended  itself  upon  this  subject,  if  I  may  judge  from  its 
literature.  But  here,  as  in  other  like  conditions,  the  simplest  surgical  means 
consistent  with  the  indications  have  proved  the  best.  The  application  of 
various  drugs  has  been,  and  is  to-day,  extolled  by  observers  whose  ranks  from 
time  to  time  receive  additions.  Unquestionably,  a  gelatinoid  polypus  is  occa- 
sionally amenable  to  local  remedies,  but  cures  thus  obtained  are  not  the  rule  ; 
these  means  may  be  summarized  as  follows  :  Primus,^  the  repeated  local  appli- 
cation of  saffronized  tincture  of  opium  (Pr.  Phar.) ;  Bryant,^  that  of  iodine  ; 
Mackenzie,^  perchloride  of  iron,  mixed  with  sufficient  water  to  form  a  thick 
paste  (also  Peeder) ;  other  authorities,  oxy sulphate  of  antimony  with  sugar, 
gallic  acid,  tannin  alone  or  in  combination  with  burnt  alum,  borax,  sugar,  or 
camphor  (Cohen),  alcohol,  strong  astringent  solutions,  sulphate  or  chloride  of 
zinc  (Erichsen),  or  copper,  and  the  like,  lime-water,  calomel,  bichromate  of 
potassium,  nitrate  of  silver  (Felaton),  and  pulverized  blood-root  (Gross)  as  a 
snuff. 

Injections.— Key no\^^^  and  others  recommend  the  injection  of  the  polypus 
by  means  of  a  hypodermic  syringe  with  various  solutions  ;  among  the  remedies 
used,  carbolic  acid,  glacial  acetic  acid,  Lugol's  solution,  and  tincture  of  the 
chloride  of  iron  (Reeder),  occupy  a  prominent  place. 

Evulsion  is  probably  the  method  most  widely  employed,  and,  though 
condemned  in  unmeasured  terms  by  Yoltolini,  Michel,  and  Zaufal,  when 
forceps  are  used,  in  good  surgical  hands,  they  can  be  productive  of  no  harm, 

•  Billroth,  Ueber  den  Bau  der  Schleimpolypen.    Berlin,  1855. 

2  Davies  Colley,  Brit.  Med.  Jour.,  June  30,  1877,  p.  810. 

3  Meckel,  Path.  Anat.,  pp.  304,  311,  313. 

*  Lectures  on  Diseases  of  the  Nose.    Lancet,  July  28,  Aug.  25,  Nov.  10,  1877. 

6  Am.  .Jour.  Med.  Sci.,  vol.  ii.  p.  219.  6  Lancet,  Feb.  23  and  Aug.'  24,  1867. 

»  Lancet,  July  28,  1877.  8  Med.  Record,  Oct.  1,  1881. 


TUMORS  OF  THE  NOSE. 


815 


not  even  excessive  hemorrhage.  In  sini[»licity  and  certainty  this  method 
surpasses  all  others,  and  though  it  is  more  })aint"ul,  it  is  much  more  rai)id. 
The  operation  is  performed  either  with  forceps,  or  with  some  one  of  the 
various  forms  of  wire  ecraseur.  The  forceps  should  be  a  lightly  made 
instrument,  either  straight  or  with  a  blight  curve  in  its  shank,  so  that 
the  handles  will  not  obstruct  the  operator's  view,  and  with  a  firm,  close 
bite,  and  well-serrated  blades.  The  nostril  having  been  well  dilated  by 
means  of  a  nasal  speculum — Fraenkel's  or  any  of  the  ordinary  wire  specula 
will  answer  the  purpose — and  the  polypus,  the  precise  location  and  attach- 
ments of  which  should  have  been  previously  well  studied,  brought  inta 
view,  its  pedicle  or  base  may  be  seized,  well  twisted,  and  the  growth  then 
torn  out.  When  the  growth  is  located  far  back  in  the  nasal  i>assage,  so  that 
it  caimot  be  seen  during  the  introduction  of  the  forceps,  the  operator  nmst 
rely  in  great  measure  upon  his  tactus  eruditus,  in  his  efforts  to  seize  it.  Occa- 
sionally, a  tumor  thus  located  can  be  pushed  forwards  into  view  by  the  finger 
carried  up  behind  the  soft  palate.  When  the  growth  is  very  large  and  has 
numerous  attachments,  it  is  ordinarily  extracted  piecemeal.  Stoker  has 
invented  a  forceps  for  carrying  out  evulsion  very  perfectly.  A  fine  forceps 
is  fixed  to  a  ^vooden  handle  at  an  angle  of  45°.  The  growth  being  seized  at 
its  base,  the  horizontal  portion  of  the  instrument  is  retracted  from  the  groove 
in  which  it  lies,  and  is  then  rotated,  while  the  handle  remains  firm.  The 
forceps  on  the  pattern  of  the  midwifery  forceps  occasionally  answers  a  better 
purpose  than  the  above  instruments ;  one  blade  at  a  time  is  adjusted  in 
position,  then  both  are  locked,  and  a  firm  hold  on  the  tumor  is  thus  obtained. 
(Schreger,  Ri elite r.)  Dzondi  recommends  that  the  growth  be  drawn  foi'wards 
with  one  pair  of  forceps  to  put  its  pedicle  upon  the  stretch,  and  that  the 
latter  should  then  be  caught  by  a  second  forceps,  and  crushed  through,  as 
close  as  possible  to  its  attachment.  It  is  possible  that,  when  the  exceedingly 
friable  nature  of  the  gelatinoid  polypus,  and  the  readiness  with  wdiich  it  tears 
into  bits  in  the  grasp  of  the  forceps,  render  its  extirpation  difficult,  this  pro- 
cedure may  be  of  benefit.  A  polypus  frequently  breaks  up,  and  a  firm  hold 
upon  it,  and  thorough  eradication,  root  and  branch,  are  impossible,  with  one 
introduction  of  the  forceps  ;  in  such  cases  a  repetition  of  the  procedure  should 
be  undertaken,  the  blood  being  syringed  away,  and  frequent  halts  being  made 
for  visual  inspection,  until  the  operator  is  assured  that  the  result  for  which 
Ms  operation  was  undertaken,  viz.,  entire  extirpation  of  the  polypus  or  of  the 
polypi,  has  been  thoroughly  accomplished. 

The  tendency  to  the  reproduction  of  these  tumors  may,  to  a  certain  extent, 
be  controlled  by  the  topical  use  of  astringents  and  even  caustics ;  but  upon 
each  reappearance,  a  repetition  of  the  above  procedures,  or  some  one  of  them, 
becomes  necessary.  A  case  is  cited,  in  the  literature  of  this  subject,  of  an 
individual  who  was  obliged  to  submit  to  an  operation  of  this  kind  every 
month  for  forty  consecutive  years.  In  cases  where  this  tendency  to  repro- 
duction of  the  polypus  exists  to  an  excessive  degree,  Gross  recommends  that 
half  or  even  more  of  the  implicated  turbinated  bone  shall  be  removed  by 
the  forceps,  in  addition  to  the  polypus,  following  in  this  advice  the  example 
of  Fergusson  and  Pirogoff'  Mackenzie  even  asserts  that  there  are  some 
polypi  which,  from  their  anatomical  situation,  cannot  be  removed  miless  a 
portion  of  the  turbinated  bone  be  previously  taken  away,  or  uidess  the  bone 
be  removed  with  the  growth ;  and  to  do  this  he  recommends  that  an  instru- 
ment be  used  wdiich  consists  of  a  fine  hollow  forceps,  having  toothed  edges 
on  one  side  and  smooth  edges  on  the  other,  while  between  the  two  a  sharp 
cutting  blade  can  be  rammed  down. 


»  Klin.  Chir.,  Heft  iii.  S.  74.    Leipzig,  1854. 


816      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

Evulsion  hy  means  of  the  loii^e-snare  is  preferred  to  other  methods  by  many 
operators,  who,  through  practice,  have  become  expeditiouss  and  skilful  in 
applying  the  wire  over  the  polypus,  and  pressing  it  up  well  towards  its  attach- 
ment— sometimes  a  small,  blunt  fork,  passed  into  the  nostril,  assists  this  step 
of  the  procedure — and  it  is  claimed  by  many  that  the  method  is  less  painful 
and  more  thorough,  and  that  there  is  less  hemorrhage  and  danger  of  laceration, 
than  if  the  forceps  is  used.  (Durham.)  Among  the  many  different  forms  of 
wire-snare,  or  ecraseiir^  that  of  Hilton,  modified  by  Blake,  and  the  snare  of 
Jarvis,  are  perhaps  the  best.  The  wire  is  passed  about  the  growth,  and  as 
near  as  possible  about  its  pedicle,  and  then  drawn  home,  by  sliding  back  with 
the  fingers  the  cross-piece  on  the  bar  of  the  instrument  to  which  the  ends  of 
the  w^ire  are  attached.  Thus  securely  fastened  about  the  tumor,  this 
is  torn  away  by  withdrawing  the  instrument  from  the  nose.  This  procedure 
answers  for  growths  situated  anteriorly,  and  easily  accessible ;  but  wdien  they  are 
located  far  back  in  the  nasal  passage,  and,  perhaps,  hanging  into  the  cavity  of 
the  pharynx,  they  must  b0  encircled  by  a  loop  of  w^ire  passed  through  the 
nose  into  the  mouth,  the  tumor  being  controlled  by  a  strong  thread  previously 
passed  through  it,  if  possible,  and  coming  out  of  the  mouth.  The  loop  of 
wire  having  reached  into  the  pharynx,  or  around  the  velum  into  the  mouth, 
is  guided  over  the  growth  by  the  fingers  of  the  operator,  passed  behind  the 
soft  palate.  A  double  canula  is  now  sometimes  passed  over  the  ends  of  the 
wire,  through  the  nose,  and  the  latter  is  then  drawn  home  so  as  to  strangulate 
and  thus  cut  away  the  growth.  I  can  see  no  object  in  prolonging  this  process  of 
strangulation  through  several  days,  until  the  growth  drops  ofl*  from  its  attach- 
ment, as  is  sometimes  done.  Bellocq's  canula  is  sometimes  of  assistance  in 
passing  the  wire  about  the  polypus  in  the  above  procedure,  as  well  as  the 
tying  forwards  of  the  soft  palate,  as  recommended  by  Wales,  by  means  of  tapes 
or  elastic  cords  passed  through  the  nose,  brought  out  through  the  mouth,  and 
fastened  over  the  upper  lip.  Much  space  is  thus  gained  in  the  pharynx,  in 
which  to  carry  out  the  requisite  manipulations.  Much  depends,  however,  in 
any  instance,  upon  the  skill  and  ingenuity  of  the  operator,  and  the  particular 
methods  of  attaining  success  must  be  suited  to  the  indications  presented  by  each 
individual  case.  Gross  succeeded  in  one  instance  in  breaking  ofi"  a  polypus 
hanging  down  into  the  fauces,  by  simply  introducing  the  index  finger  into 
the  mouth,  and  carrying  it  around  the  soft  palate ;  and  it  is  true  that  polypi 
may  occasionally  be  removed  by  the  fingers  alone — one  being  thrust  into  and 
through  the  posterior  naris,  the  other  through  the  anterior,  and  the  growth, 
grasped  between  them,  being  pushed  backwards  and  forwards  until  its  attach- 
ment is  torn  through.  (Morand  and  Sabatier.)  McRuer,  reviving  the  procedure 
recommended  by  Hippocrates,  passed  a  piece  of  catgut  through  the  afiected 
nostril,  and,  after  it  had  reached  into  the  pharynx,  tied  a  piece  of  sponge  to  it; 
the  latter  was  then  forcibly  drawn  through  the  nose,  tearing  away  in  its 
course  the  adventitious  growths.  This  method,  or  a  modification  of  it,  has 
recently  been  advocated  also  by  Yoltolini.^  In  any  case,  care  must  be  taken 
to  secure  the  tumor  previous  to  its  division  from  its  attachment,  to  prevent 
its  falling  upon,  or  into,  the  larynx.  Knives  and  scissors  are  rarely  used  to 
excise  polypi,  unless  these  be  situated  in  the  anterior  nares,  and  thus  easily 
accessible.  The  toothed  scissors  of  Richardson  would  here  play  a  useful  part. 
Anaesthetics  may  be  required  in  any  of  the  above  operations,  but  are  a  decided 
disadvantage,  and  their  use  should  be  avoided  if  possible,  and  the  intelligent 
co-operation  of  the  patient  thus  secured.  Tamponing  the  posterior  nares,  on 
account  of  hemorrhage,  will  be  rarely  requisite. 

The  galvano-cautery^  which  was  first  used  in  the  removal  of  polypi  by 


«  Monatsschr.  fiir  Ohreiili«ilk.,  No.  1.  1882. 


TUMORS  OF  THE  NOSE. 


817 


Middledorpf,  and  subsequently  warmly  advocated  by  Yoltolini,  is  applied 
either  by  means  of  the  wire  loop,  or  with  various  electrodes.  In  the  former 
case,  a  platinum  wire  is  passed  about  the  growth,  as  above  described,  drawn 
home  through  a  double  tube  introduced  through  the  nose,  and  attached  to  a 
suitable  handle,  which  is  in  connection  witli  a  powerful  galvanic  battery.  As 
soon  as  constriction  of  the  mass  is  effected,  the  connection  is  closed,  and  the 
s^rowth  burnt  through.  The  disadvantage  of  this  operation,  aside  from  the 
pain,  is,  that  the  wire  can  rarely  be  accurately  adjusted  to  the  pedicle  of  the 
tumor,  and  that,  as  no  traction  upon  the  roots  is  made,  the  growth  is  not 
thoroughly  extirpated.  Thudichum'  is  at  present  the  warmest  advocate  of 
this  instrument,  but  even  in  one  of  his  own  cases  the  operation  had  to  be 
repeated  some  tifty-five  times. 

Enlargement  of  the  Outlets  of  the  Nasal  Cavity. — Such  an  operation  may,  in 
rare  instances,  be  requisite  when  the  tumor  is  of  such  a  size,  or  so  placed,  as 
not  to  be  easily  reached  and  extracted  through  the  natural  openings.  The 
simplest  method  consists  in  the  dilatation  of  the  nostril  by  laminaria  tents, 
as  proposed  by  Thudichum,  or  by  the  blades  of  strong  forceps.  Should, 
however,  more  room  be  necessary,  the  choice  lies  between  the  method  of 
Dietfenbach,^  by  cutting  the  wing  of  the  nostril  to  the  edge  of  the  nasal  bone — 
or,  if  both  al?e  are  freed,  the  septum  is  also  divided,  and  the  nose  turned  upwards 
upon  the  face — or  that  of  Maune  (modilied  by  Maisonneuve  by  leaving  the 
uvula  intact,  and  called  the  "  buttonhole"  opening),  by  incising  the  soft  palate 
throughout  its  whole  extent  in  the  median  line.  The  latter  method  is  specially 
applicable  to  those  cases  in  which  the  growth  is  located  well  back  in  the  nasal 
passage  ;  the  polypus  is  encircled  by  the  wire  loop  passed  through  the  open- 
ing thus  made,  and  is  removed  by  crushing. 

After  any  of  the  above  operations,  careful  cleanliness  of  the  affected  nasal 
passage  must  be  insisted  upon  ;  and  Durham  asserts  that,  in  some  cases,  the 
insufflation  of  tannin  or  other  astringent  powder  is  of  great  sej'vice,  either 
in  retarding  the  re-development  of  the  growth,  or  in  aiding  the  destruction 
of  such  portions  as  may  have  had  their  vitality  impaired  by  the  operation. 

Fibrous  Polypus. — This  ma}^  occur  at  any  period  of  life.  Gross  has  seen 
it  in  children  under  fourteen  years  of  age,  as  well  as  in  adults  and  in  old 
persons  ;  but,  originating  in  the  nasal  cavity,  such  a  growth  is  very  rare.  It 
may  grow  from  any  part  of  the  walls  of  the  nasal  foss^,  springing  from  the 
aponeurotic  covering  of  the  bones,  or  from  the  periosteum,  with  which,  as 
well  as  with  the  subjacent  bone,  it  is  closely  connected ;  but  it  is  ordinarily 
attached  by  a  broad  base  to  the  superior  turbinated  bone,  or  to  the  roof  of 
the  nose,  and  so  far  back  that  it  is  not  readily  seen  in  an  anterior  examina- 
tion of  the  nasal  passage.  Rogers^  removed  such  a  polypus  from  the  vomer. 
Other  cases  are  reported  where  the  growths  sprang  from  the  floor  of  the  nasal 
fossge,  and  even  from  the  external  lateral  walls  of  the  nose  ;  furthermore,  they 
may  originate  in  the  antrum,  and  extend  thence  into  the  nose.  The  exact 
point  of  origin  is  often  very  difficult  to  determine,  owing  to  the  tendency  of 
the  growth  to  acquire  secondary  attachments. 

Its  substance  is  made  up  of  hard,  white  fibres,  or  connective  tissue,  inter- 
spersed richly  with  bloodvessels ;  occasionally,  round  and  fusiform  cells  are 
present,  but  rarely  in  large  numbers ;  its  color  is  a  dark  red  or  purple. 
The  surface  of  the  tumor,  when  denuded  of  its  epithelium,  bleeds  readily  on 

*  On  Polypus  of  the  Nose  and  Ozaena.    London,  1869. 

2  Surgical  Observations  on  the  Restoration  of  the  Nose  and  the  Removal  of  Polypi,  London, 
1833. 

3  N.  Y.  Jour.  Med.,  vol.  i.  p.  323.  1851. 

VOL.  IV. — 52 


818      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


slight  irritation,  and  is  not  infrequently  ulcerated  at  several  points.  Calca- 
reous deposits^  sometimes  occur  within  it,  and  cartilaginous  and  osseous 
degenerations^  of  the  growth  are  not  unknown.  Allowed  to  pursue  its  course,, 
unrelieved  by  operation,  it  often  attains  an  enormous  size,  and  displaces, 
distorts,  and  destroys  all  parts  in  its  immediate  neighborhood,  giving  rise  to 
the  most  hideous  deformity,  and  to  imminent  danger  from  compression  of  the 
brain  or  other  cerebral  complication. 

A  tumor  possessing  the  same  general  characteristics,  and  of  the  same  nature, 
springs  usually  from  the  basilar  process  of  the  occipital  bone  and  the  adja- 
cent part  of  the  body  of  the  sphenoid,  and  is  more  common  than  the  first- 
mentioned  form.  It  is  distinguished  b}'  its  origin,  rapid  growth,  and  serious 
results,  and  is  known  as  the  naso-j^haryngeal  polypus. 

Naso-j)haryngeal  jpolypus^^  aside  from  a  point  of  origin  as  above,  may 
arise  from  the  ptery go-maxillary  fossa ;  as  it  enlarges  it  may  extend  thence 
outwards  into  the  zygomatic  and  temporal  fossse,  and  inwards  through  the 
spheno-palatine  foramen  into  the  pharynx ;  but  Sands'*  correctly  remarks 
that  tumors  thus  arising  form  a  special  group,  and  should  be  distinguished 
both  anatomically  and  clinicalh"  from  that  which  has  been  mentioned  above, 
which  embraces  the  fibrous  growths  most  often  met  with  in  this  neighbor- 
hood, and  to  which  the  name  of  naso-pharyngeal  polypus  has  been  correctly 
applied.  The  latter,  according  to  some  writers,  always  springs  from  the  site 
first  given  above,  but  cases  exist  where  it  has  been  found  to  have  had  its 
point  of  attachment  to  the  following  parts :  the  antrum,  the  upper  part  of 
the  pterygoid  fossa,  the  internal  pterygoid  plate,  the  greater  wing  of  the 
sphenoid,  the  apex  of  the  petrous  portion  of  the  temporal  bone,  and  lastly, 
the  edges  of  the  posterior  nares ;  occasionally  it  springs  apparently  from 
the  upper  part  of  the  spinal  column.  (Michaux,  Robert,  and  others.)  What- 
ever its  site,  the  tumor  extends,  in  its  gradual  growth,  downwards,  or  for- 
wards, until  it  blocks  up  the  entire  upper  and  middle  pharynx,  involves 
both  the  mouth  and  nasal  passages,  and,  after  having  displaced  or  caused  the 
absorption,  perforation,  or  destruction,  of  all  parts  opposed  to  its  irresistible 
onward  march,  appears  at  the  anterior  nares  with  great  distortion  of  the 
external  nose,  or  in  the  middle  pharynx  with  protrusion  forwards  of  the 
soft  palate.  Masse  records  instances  in  which  naso-pharyngeal  polypi  pene- 
trated the  pterygo-maxillary  fissure,  and  passed  through  the  pterygoidean 
space,  between  the  muscles,  towards  the  face.  Extensions  are  not  infre- 
quently found  into  the  antrum,  and  the  frontal  and  sphenoidal  sinuses,  and 
prolongations  reach  through  the  spheno-maxillary  fissure  into  the  orbit,  and 
displace  the  eyeball.^  Robert  asserts  that  these  growths  spring  from  the 
foramen  lacerum  anterius.  The  polypi  are  usually  pedunculated,  and  not 
infrequently  form  firm  attachments  to  the  various  points  upon  which  they 
press,  thus  rendering  their  exact  point  of  origin  doubtful.  Their  growth 
is  rapid,  and  extirpation  is  apt  to  be  followed  by  recurrence.  Spontaneous- 
cure  by  sloughing  rarely  occurs.  (Johnson,  Birkett,  Bonnet,  Vincent,  and 
others.)  A  marked  tendency  to  undergo  sarcomatous  degeneration  is  ex- 
hibited,^ and  a  special  tendency  to  penetrate  the  cavity  of  the  orbit,  or  that 
of  the  cranium,  although,  according  to  some  authorities,  the  latter  occur- 

'  Bourdilliat,  Fibrome  calcifie.    Gaz.  Med.,  1868  :  and  H.  Cloquet,  op.  cit.,  p.  688. 

2  Virchow,  Die  krankhaften  Greschwiilste,  Bd.  i.  S.  185. 

3  Consult  Girald6s  ;  Masse,  Des  polypes  naso-pharyngiens.  Paris,  1864 ;  D'Ornellas,  Anat. 
path,  et  traitement  des  polypes  fibreux  de  la  base  du  crane,  etc.  Paris,  1854  ;  Brevet,  Des  polypes 
naso-pharyngiens.    Paris,  1855. 

*  On  Naso-pharyngeal  Polypi.  Archives  of  Scientific  and  Pract.  Med.,  No.  6,  June,  1873. 
(Reprint.) 

^  Spence,  Edinburgh  Med.  Jour.,  vol.  ix.  p.  996. 

6  Weber,  Billroth  und  Pitha's  Handbuch,  Bd.  ilL  Abth.  i.  S.  207. 


TUMORS  OF  THE  NOSE. 


819 


rence  is  a  rare  one.  Gross^  states  that  these  tumors  are  hy  tar  most  common 
in  young  subjects,  between  the  fit'teentli  and  twenty-lit'tli  years,  and  tliat 
neither  his  own  experience  nor  recorded  instances  present  any  example 
in  the  female.  To  this  latter  statement,  I  must  except  that"^  Marjolin^ 
reports  the  case  of  a  girl,  aged  two,  who  died  from  the  extension  of  such 
a  growth,  and  Lincoln,  eight  additional  cases  in  females  ;3  and  one  instance 
at  least  is  known  of  the  growth  occurring  in  a  patient  of  tifty-tive.  Winter'* 
reports  an  instance  in  a  foetus  of  seven  months.  Sands  remarks  that  the  dis- 
covery of  a  polypoid  growth  at  either  extreme  of  age  would  be  presumptive 
evidence  of  its  malignancy.  ^s"aso-pharyngeal  poly[)i  are  much  more  fre- 
quent in  males  than  in  females  (in  58  cases,"48  were  males,  8  females,  2  not 
state*!),  and  the  precise  causes  of  their  origin  are  involved  in  complete  ob- 
scurit}'. 

The  main  points  in  the  diagnosis  of  these  growths  have  elsewhere  been 
touched  upon.  It  will  be  sufficient  to  add  here  that  malignant  tumors  of 
similar  origin,  intra-nasal  tibrous  polypi,  and  even  syphilitic  nodes  and  scrofu- 
lous abscesses,  may,  when  located  in  the  pharynx,  simulate  true  naso-pha- 
ryngeal  tumors.  Cruveilhier  reports  a  case  in  which  a  portion  of  the  dura 
mater,  thickened,  exhibiting  a  fungous  appearance,  and  containing  parts  of 
the  arachnoid  and  jna  mater,  with  cerebral  substance  and  pus,  formed  a 
hernia  through  the  cribriform  plate  of  the  ethmoid  bone ;  and  Yirchow  a 
like  one,  in  wdiich  the  tumor  penetrated  the  palate  and  protruded  through 
the  mouth.  Such  cases,  though  rare,  may  complicate  the  diagnosis.  An 
important  point  to  bear  in  mind  is,  that  the  region  in  which  true  naso-pharyn- 
geal  polypi  can  originate  is  one  of  narrow  limits,  corresponding  with  the 
margins  of  the  posterior  nares  and  the  summit  of  the  pharynx.  (Sands.) 

Treat7nenL--Yor  the  removal  of  the  smaller  fibrous  polypi,  any  of  the 
methods  detailed  when  speaking  of  the  treatment  of  the  gelatinoid  variety, 
are  applicable ;  but  when  the  growth  is  large,  and  has  invaded  or  displaced, 
not  alone  the  nasal  cavities,  but  likewise  those  in  connection  with  them, 
more  extensive  operative  procedures  become  necessary.  In  certain  rare 
instances,  naso-pharyngeal  polypi  have  spontaneously  sloughed  away,  or  have 
separated  f  rom  their  attachments  and  been  expelled.  Such  cases  are  reported 
by  Johnspn,^  Birkett,^  Saviard,^  Bonnet,  Yimont,^  and  others.^ 

Operative  interference,  by  complete  and  radical  extirpation  of  the  growth, 
with  its  underlying  parts  and  all  extensions,  is  the  only  treatment  upon 
which  absolute  reliance  can  be  placed,  certainly  in  extreme  cases.  It  may 
here  be  briefly  stated  that  the  judgment  of  modern  surgery  is  against  recourse 
to  the  use  of  avulsion,  ligature,  and  caustics,  as  means  of  eradicating  these 
growths  ;  the  reasons,  based  on  experience,  are  apparent  to  those  familiar  with 
the  literature  of  the  subject.  The  first  method  {avulsion)  is  advocated  by  Schuh,'^ 
who  has  had  one  successful  case.  Dupuytren,  attempting  the  same  proce- 
dure, lost  his  patient  from  hemorrhage.  Cooper  Forster"  has  seen  it  attended 
by  fracture  of  the  cribriform  plate  of  the  frontal  bone,  and  death  from  general 
arachnitis  and  limited  sloughing  of  the  brain.  Guerin's^^  pj^^^  seerns  no 
better,  although  it  w^as  attended  by  success  in  one  case.  The  tumor  was  steadied 
by  the  left  fore  finger  introduced  behind  the  soft  palate,  and  then  torn  tVom 
its  base  by  means  of  a  bone  scraper  introduced  through  the  nose.  Forster 

•  System  of  Surgery,  vol.  ii.  p.  372,  2  (jaz.  des  Hop.,  2.5  Mai,  1861. 

3  Arch,  of  Laryngology,  vol.  iv.  No.  iv.  *  (xiinther,  Operationen  am  Halse,  S.  311. 

6  Brit.  Med.  Jour.,  vol.  i.  p.  61.    1858.  6  Brit.  Med.  Jour.,  vol.  i.  p.  119.  1858. 

'  Recueil  d'obs.  chir.,  p.  112.    Paris,  1784. 

s  Quoted  by  Brevet,  op.  cit..  p.  16.    Paris,  1855. 

9  Masse,  D'Ornellas,  Durham.  10  Wiener  med.  Wochenschr.,  S.  99.  1865. 

"  Trans.  Clin.  Soc.  Lond.,  vol.  iv.  1871.  ^  Gazette  des  Hop.,  p.  144.  1865. 


820      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


in  one  case  tore  the  tumor  from  its  attachments  by  the  lingers  alone.  The 
ligature  has  also,  it  is  true,  been  successfully  employed  in  a  few  cases.    It  is, 
however,  impracticable  when  the  tumor  is  large,  has  numerous  attachments, 
or  is  wide  spread.    The  method  of  applying  the  ligature  lias  elsewhere 
been  described.^    ^Nlichaux^  reports  an  apparently  successful  case  of  its  use. 
Gunther^  lost  a  patient  by  the  tumor  having  fallen,  after  separation  from  its 
attachment,  upon  the  laryngeal  aperture,  thus  causing  suffocation.  Other 
deaths  are  reported  from  pyaemia — a  result  to  be  anticipated  from  the  presence 
of  the  large,  sloughing  mass  in  the  pharynx — and  from  laryngeal  complications. 
But  passing  mention  need  be  made,  and  that  in  condemnation,  in  the  present 
state  of  our  surgical  knowledge,  of  the  chain-saw  (Deroubaix),  and  of  the 
ecraseur  (Chassaignac),  although  Durham  and  Bryant  report  successful  cases  of 
the'  use  of  the  latter.    Caustics^  such  as  the  actual  cautery,  caustic  potassa, 
chloride  of  zinc,  and  the  like,  are,  in  the  great  majority  of  cases,  not  only 
ahsolutely  inapplicable,  but  seem  in  all  instances  to  stimulate  increased 
growth.    The  increase  of  the  tumor  thus  defies  the  energetic  attempts  made 
for  its  destruction.    The  galvano-caustic  ligature,  first  employed  by  Middel- 
dorpf  in  1853,  has  a  number  of  successful  cases  to  be  placed  to  its  credit — 
notably,  three  reported  by  Lincoln* — but  is  open  to  many  of  the  objections 
already  alluded  to.   As  in  Dr.  Lincoln's  cases,  it  may  be  radical  and  complete  in 
its  work  of  extirpation,  but  on  the  other  hand  it  often  fails,  and  quick  re- 
production from  the  undestroyed  base  of  the  tumor  is  the  result.    The  size, 
location,  method  of  attachment,  prolongations,  and  involvement  of  neighbor- 
ing parts  by  the  tumor,  must  determine  the  indications  for  its  use  over  more 
severe  surgical  procedures.    It  is  certainly  less  open  to  objection  than  the 
means  thus  far  alluded  to.    Electrolysis  has  answered  its  destructive  purpose 
in  a  few  reported  cases,^  and  though  the  process  is  slow,  may  prove  satisfac- 
tory in  the  removal  of  small  tumors,  especially  those  of  an  erectile  nature. 
That  it  is  a  means  of  anything  like  general  application,  is  out  of  the  question.® 
i!^"othing  in  the  above  remarks  is  to  be  construed  as  against  the  use  of  the 
actual  or  galvano-cautery,  as  a  means  of  destruction  of  the  base  of  a  growth 
after  the  more  radical  procedures  for  its  extirj^ation  that  are  now  to  be  con- 
sidered ;  nor  as  a  method  of  reaching  parts  inaccessible  to  the  knife,  even  after 
the  cavity  of  the  pharynx  has  been  opened  from  w^ithout.    In  both  such 
instances  they  serve  a  useful  purpose,  and  indeed  are  indicated,  to  destroy  all 
possible  remains  of  the  tumor. 

The  methods  of  operating  for  the  purpose  of  first  rendering  these  tumors 
directly  accessible,  and,  this^being  accomplished,  of  extirpating  them,  remain 
now  to  be  considered.  I  shall  merely  allude  to  the  methods  of  procedure, 
which  are  many  and  varied,  and  to  their  originators.  A  special  description  of 
the  operative  steps  requisite  in  each  method,  is  not  necessary  here,  and  is 
impossible  in  the  space  allotted  for  this  article.  The  subject  is  treated  of  in 
the  majority  of  works  on  general  surgery,  and  in  other  portions  of  this  work.^ 
In  preparing  the  following  summary,  I  have  received  much  assistance  from 
the  valuable  brochure  of  Sands  already  quoted,  and  to  it  I  can  confidently  refer 
the  reader  for  a  succinct  description  of  the  operative  procedures,  illustrated 
wnth  wood-cuts  showing  the  lines  of  the  various  incisions  through  either 
mouth  or  face,  by  means  of  which  direct  access  is  gahied  to  the  pharynx^. 

«  See  section  on  nasal  polypi.  2  Schmidt's  Jalirbucher,  Bd.  cxxxiv.  S.  311. 

3  Operationen  am  Halse,  S.  313. 

<  This  paper  contains  a  record  of  74  operations  for  naso-pharyngeal  polypi  in  58  patients, 
tabulated  with  the  result  of  the  operative  treatment.  The  series  embraces  all  cases  published 
from  1867  to  date  of  publication.    Archives  of  Laryngotomy,  vol.  iv.  No.  iv.  1883. 

6  Nelaton,  Med.  Times  and  Gaz.,  March  16,  1867. 

6  See  Althaus-on  the  Electrolytic  Treatment  of  Tumors. 

7  See  Vol.  III.,  pp.  569-573,  and  pp.  935,  936,  infra. 


TUMORS  OF  THE  NOSE. 


821 


I.  Operations  through  the  3Iouth. — Of  ancient  origin,  this  method  was  revived 
by  Maune,  and  still  more  recently  by  Xelaton.^  It  consists  in  exposing  the 
polypus,  either  through  an  incision  in  the  median  line  of  the  soft  palate, 
dividing  it  completely  or  extending  only  to  the  base  of  the  uvula,  or  by 
combining  this  incision  with  exsection  of  part  or  all  of  the  hard  palate. 
Masse-^  quotes  twenty-six  cases,  in  thirteen  of  which  the  results?  were  favorable. 

II.  Operations  through  the  Face. — This  method  embraces  resections  of  some 
one  or  more  of  the  bones  of  the  face.  The  resection  may  be  temporary  or 
permanent ;  in  the  former  case,  the  excised  portion  of  the  bone  is  replaced,  after 
the  extirpation  of  the  tumor.  Tliis  operation  receives  the  specific  name  of  "  osteo- 
plastic resection."  The  facial  methods  of  operating,  then,  embrace  1st,  Exci- 
sion, partial  or  total,  of  the  upper  jaw  ;  and  2d,  Various  osteo-plastic  operations. 

Total  excision  of  the  upper  Jaw  w^as  first  advised  for  this  purpose  by 
Whateley,  and  practised,  unsuccessfully,  by  Syme^  in  1832,  by  Flaubert  in 
1840,"*  by  YerneuiP  in  1860,  and  since  that  date  by  Michaux  and  many  other 
operators.^ 

Partial  excision  of  the  upper  jaiv^  for  the  removal  of  naso-pharyngeal  poly- 
pus, was  first  performed  by  Maisonneuve^  in  1860,  and  since  that  date  has 
been  repeated  by  many  operators.    It  is  the  operation  commonly  selected. 

Osteo-plastic  Operations. — Those  best  known  are  five  in  number,  viz.,  the  two 
inethods  devised  by  Langenbeck,^  and  those  of  Iluguier,^  Roux,'®  and  Cheever.*^ 
Full  details  as  to  the  necessary  procedures  will  be  found  in  the  monograph  of 
Sands.  This  surgeon  sums  up  the  respective  merits  and  relative  value  of  all 
of  these  preliminary  operations  for  the  extirpation  of  naso-pharyngeal  polypi, 
as  follows  (I  take  the  liberty  of  condensing  his  remarks  slightly) : — 

Operations  through  the  mouth  have  the  advantage  of  avoiding  mutilation  of 
the  face,  the  features  being  left  untouched.  Nor  can  it  be  denied  that  such 
operations  have  sometimes  been  done  with  gratifying  success.  If  the  pedicle 
be  narrow,  and  the  situation  of  attachment  central,  it  may  be  dealt  with 
thoroughly  after  simple  section  of  the  soft  palate,  and,  its  attachment  having 
been  destroyed,  the  wound  in  the  palate  may  be  closed  at  once  by  sutures, 
with  every  probability  of  securing  primary  union.  But  it  must  be  confessed 
that  the  operation  can  rarely  be  conducted  in  the  manner  described,  and  the 
published  cases  prove  that  it  has  generally  been  found  impracticable  to 
destroy  the  pedicle  so  completely  as  to  warrant  the  immediate  closure  of  the 
wound  in  the  soft  palate.  Accordingly,  it  is  the  practice  of  many  surgeons 
to  leave  the  wound  open  until  the  pedicle  has  been  removed  by  some  sub- 
sequent procedure,  and  afterwards  to  restore  the  palate  by  staphyloraphy. 
These  facts  alone  prove  that  the  method  now  under  consideration  does  not 
afford  the  space  requisite  for  the  removal  of  a  tumor  having  extensive  attach- 
ments, and  that  in  this  respect  it  must  be  rejected  as  defective ;  moreover,  it 
is  by  no  means  easy  to  destroy  the  pedicle  afterwards,  and  for  similar  reasons. 
The  actual  cautery  and  various  caustic  applications  have  been  employed  for 
this  purpose.  In  many  instances,  the  pedicle  has  continued  to  increase  in 
size,  in  spite  of  treatment,  and  the  surgeon  has  been  finally  driven  to  the 
alternative  of  excision  of  the  jaw  to  gain  the  desired  end.  Fatal  results  have 
more  frequently  follow^ed  operations  through  the  mouth  than  those  of  appa- 
rently greater  magnitude,  so  that  the  former  operations  cannot,  as  a  rule,  be 

'  Bull,  de  la  Soc.  de  Chir.,  tome  i.  p.  159.  Op.  cit. 

3  Edinburgh  Med.  .Jour.,  vol.  xxxviii.  p.  322.         *  Schmidt's  Jahrbucher,  Bd.  xxx.  S.  63. 

5  Mem.  de  la  Soc.  de  Chir.    Paris,  1860.  ^  s;^^  Masse  (op.  cit.),  for  details. 

7  Gaz.  des  Hop.  1860. 

8  Deutsch.  Klinik,  S.  281.  1861  ;  and  Schmidt's  .Jahrb.  Bd.  cxii.  S.  195. 

9  Bull,  de  I'Acad.  de  Med.,  p.  783.    1860  ;  and  Gaz.  des  H6p.,  p.  337.  1861. 

10  Gaz.  des  Hop.,  p.  354.  1861. 

"  Med.  and  Surg.  Reports  of  the  Boston  City  Hospital,  p.  156.  1870. 


822      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

recommended  either  for  their  safety  or  certainty — they  avoid  disfigurement, 
but  do  not  guarantee  success. 

Osteo-plastic  resections  cause  less  deformity  than  ordinary  excisions.  Lan- 
genheck's  first  method,  namely,  that  which  consists  in  resection  of  the  nasal 
bones,  has  been  performed  several  times  with  success,  and  is  adapted  espe- 
cially to  those  cases  in  which  the  tumor  occupies  the  nasal  cavity,  rather  than 
the  pharynx,  and  in  which  the  attachments  are  well  forwards.  It  certainly 
would  not  afford  the  requisite  facility  for  reaching  tumors  which  occupy  the 
usual  situation,  as  an  examination  of  the  cadaver  alone  will  show.  Lav  gen- 
heck's  second  operation,  in  which  portions  of  the  malar  and  superior  maxillary 
bones  are  temporarily  displaced,  is  admirabl}'  adapted  to  the  removal  of  those 
polypi  which  originate  in  the  ptery go-maxillary  fossa,  and  it  is  for  this  pur- 
pose that  it  was  originally  designed.  But  though  it  has  been  also  done  success- 
fully for  naso-pharyngeal  polypi,  it  is  inferior  to  several  other  procedures  for 
this  purpose.  The  operation  itself  is  difficult  of  execution,  unless  the  spheno- 
palatine foramen  is  abnormally  dilated  ;  and  the  pharynx  is  very  imperfectly 
exposed,  owing  to  the  presence  of  the  pterygoid  process.  These  objections 
will  prevent  the  operation  from  being  extensively  adopted. 

Hugider's  ojyeration  has  been  performed  by  its  inventor,  and,  with  slight 
modifications,  by  Cheever.  Both  patients  recovered.  The  liability  to  recur- 
rence of  the  disease  after  removal  offers  a  strong  argument  against  osteo- 
plastic operations  generally. 

Roux's  operation  involves  great  mutilation  of  the  facial  bones,  and  does  not 
afford  satisfactory  access  to  the  pharynx.  To  expose  a  tumor  having  broad 
attachments,  it  would  be  necessary  to  displace  the  maxillary  and  malar  bones 
on  both  sides  of  the  face,  thereb}'  greatly  increasing  the  risks  of  the  operation. 

Cheever's  operation  [which  involved  both  upper  jaws]  is  ingenious,  and, 
although  it  terminated  fatally  in  the  first  instance  in  which  it  was  per- 
formed, Sands  agrees  with  its  originator  in  thinking  that  there  is  no  danger 
inherent  in  the  operation  itself  that  ought  to  prevent  its  repetition.  [A  suc- 
cessful case  has  since  been  reported  by  Tiffany.] 

The  objections  that  apply  to  partial  or  toted,  excisions  of  the  upper  jaw,  as  a 
preliminary  operation,  are  mainly  owing  to  the  disfigurement  which  they 
produce;  in  partial  excision  this  is  but  slight.  Sands  remarks  that  these 
operations  as  a  class,  are  remarkably  successful.  Lincoln,^  that  the  result  of 
a  study  of  the  table  of  cases^  accompanying  his  paper,  suggests  a  doubt  as  to 
the  propriety  of  this  conclusion.  It  will  be  found  that  among  28  cases  treated 
by  a  section  of  the  bones  of  the  face,  in  several  instances  the  growths  returned, 
necessitating  a  repetition  of  the  operation  or  the  substitution  of  some  other; 
and  also  that  in  8  cases,  or  more  than  28  per  cent.,  death  followed . immedi- 
ately, or  in  a  few  days. 

Excision  of  the  jaw  certainly  affords  easier  access  to  the  pharynx  than  any 
of  the  other  methods,  and  thus  enables  the  operator  to  attack  the  pedicle 
with  the  maximum  chances  of  success ;  accoi'dingly,  the  probability  of  a  recur- 
rence will  be  correspondingly  diminished.  Xeither  the  procedures  through 
the  mouth,  nor  any  of  the  osteo-plastic  procedures  w^hich  have  been  described, 
permit  that  satisfactory  exposure  of  the  base  of  the  skull  which  is  afforded 
either  by  partial  or  total  resection  of  the  superior  maxilla.  From  what  has 
elsewhere  been  said,  it  must  be  evident  that  ample  space  is  necessary,  both  for 
the  extirpation  of  the  tumor  and  for  the  prompt  arrest  of  the  hemorrhage  that 
so  often  accompanies  its  removal.  Another  advantage  of  ordinary  excision 
is,  that  a  wide  gap  is  left  after  the  operation,  through  w^hich  the  disease,  should 
it  recur,  can  be  readily  recognized  and  treated. 


*  Op.  cit. 


2  This  table  is  reproduced  on  page  823. 


TUMORS  OF  THE  NOSE. 


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824      DISEASES  AlUB  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

Partial  excision  of  the  jaw,  according  to  the  plan  of  Maisonneuve,  will  in 
most  cases  fulfil  all  the  indications  presented.  Partial  excision  affords  an 
excellent  view  of  the  pharynx,  and  leaves  the  patient  with  very  slight  external 
disfigurement.  The  orbital  plate  and  malar  tuberosity  being  left  intact,  the 
eyeball  does  not  descend  from  its  normal  position,  and  the  prominence  of  the 
cheek  remains — which  is  not  the  case  after  complete  excision.  The  skill  of 
the  dentist  can  readily  imitate  the  lost  portion  of  bone,  and  the  gap  in  the 
palate  can  be  closed,  partly  by  staphyloraphy,  and  partly  by  an  obturator 
made  of  hard  rubber. 

Of  all  the  operations  mentioned,  then,  which  are  applicable  to  grave  cases, 
Dr.  Sands  gives  the  preference  to  partial  excision  of  the  upper  jaw,  as  the 
one  which  is  adapted  to  favor  the  most  complete  removal  of  the  tumor  with 
the  least  practical  disfigurement.  In  this  view  he  is  in  accord  Avith  the 
majority  of  surgeons  of  the  day. 

Cartilaginous  growths  have  elsewhere  been  alluded  to  (page  801)  as 
occurring  not  infrequently  upon  the  septum,  more  in  the  form  of  general 
thickening  of  its  cartilaginous  portion  than  as  distinct  tumors,  and  often  asso- 
ciated with  deviation  of  the  cartilage.  Large  cartilaginous  tumors  springing 
from  either  the  ethmoidal  cells  or  frontal  sinuses  are  very  uncommon,  and 
but  few  instances  are  upon  record.^  They  usually  affect  young  persons, 
cause  frightful  deformity,  and  lead  to  the  early  death  of  the  patient.  When 
small,  they  may  perhaps  be  removed  by  means  of  the  knife,  gouge,  or  chisel, 
through  tifie  nasal  opening  ;  but  if  large,  with  deep  attachments  to  the  base  of 
the  cranium,  or,  perhaps,  lying  in  contact  with  the  under  surface  of  the  brain, 
as  is  usually  the  case,  operative  interference  is  out  of  the  question. 

Osseous  Growths. — Bony  formations  of  various  classes  are  found  within 
the  nasal  passages.  First,  exostoses,  developed  from  the  bony  portion  of  the 
nasal  septum  or  floor  of  the  nostril,  which  are  common ;  likewise  tumors 
springing  from  some  neighboring  bone  and  invading  secondarily  the  nose  ;  or 
growths  which  may  be  the  result  of  strumous  or  syphilitic  disease  of  the 
osseous  framework  of  the  nasal  cavity,  and  into  the  formation  of  which  car- 
tilage may  enter  in  variable  proportion  and  disposition.^  Second,  ossified 
cartilaginous  or  sarcomatous  growths.  (Mackenzie.)  And  third,  a  remarkable 
form  which  is  to  be  carefully  distinguished  from  the  true  exostoses,  whether 
cancellated,  compact,  or  eburnated,  and  from  the  mixed  bony  and  cartilagi- 
nous growths  just  alluded  to  ;  instances  of  this  form  are  reported  by  Legouest, 
Duka,^  Michon,*  and  Dolbeau,^  and  the  whole  subject  is  elaborately  treated  of 
by  Ollivier.^  In  all  such  cases  the  bony  growth  is  developed  from  between 
the  layers  of  the  nasal  mucous  membrane  or  periosteum  which  lines  the 
cavities,  independently  of  any  apparent  disease  of  the  parts  which  envelop 
it,  and  always  remains  free  and  movable ;  it  may  take  its  origin  in  the 
frontal  sinuses  or  in  the  nasal  fossae,  and  by  slow  growth  may  attain  a  consider- 
able size.  It  has  been  suggested  that  these  growths  may  be  analogous  in  their 
mode  of  development  and  subsequent  separation  to  the  antlers  of  the  CervidcE. 
(Durham.)  Thudichum^  adds  that  exostosis  of  the  turbinated  bones  is  an 
occasional  complication  of  nasal  polypus. 

1  See  Ure,  Stanley,  and  Prochaska  (Disquisit.  Anat.-physiol.  Organismi.  Corp.  Human.,  p.  172. 
Viennse,  1812)  ;  also.  Cooper's  Surgical  Dictionary. 

2  Trelat  and  Dolbeau,  Bull,  de  la  Soc.  de  Chir.,  1862,  p.  261;  and  Morgan,  Guy's  Hosp. 
Reports,  series  i.,  vol.  i.  p.  403  ;  sequel,  series  i.,  vol.  vii.  p.  491. 

Path.  Trans.,  vol.  xviii.  p.  256  ;  vol.  xix.  p.  311,  another  case. 
*  M6m.  de  la  Soc.  de  Chir.  de  Paris,  tome  ii. 
5  Bull,  de  I'Acad.  de  Med.,  tome  xxxi.  p.  107. 

«  Sur  les  Tumeurs  osseuses  des  Fosses  nasales.    Paris,  1869.  '  Lancet,  Sept.  1868. 


f 


TUMORS  OF  THE  NOSE.  825 

Bony  tumors  vary  somewhat  in  their  character  and  formation  ;  some  have 
a  hard,  ivory-like  density  ;  others  are  soft  and  friahle ;  they  are  often  inter- 
spersed with  small  cavities,  occupied  with  gelatinoid,  fibrous,  or  cartilaginous 
matter;  but  whether  compact  or  cancellated,  they  always  present  the  character- 
istic arrangement  of  the  Haversian  canals.  Their  removal  is  ctl'ected  by  cut- 
ting otf  their  attachments  with  the  knife,  saw,  pliers,  or  chisel,  either  through 
the  nose,  or,  if  the  mass  be  very  bulky,  by  an  opening  through  the  face.  (Gross^ 
Mott.^)  OUivier  suggests  that  the  cancellated  variety  may  be  crushed  up, 
and  then  extracted  without  enlarging  the  natural  opening  of  tlie  nose.  Cohen,* 
in  a  case  of  exostosis  developed  from  the  palatine  ridge  of  the  superior  max- 
illa, and  in  the  vomer,  ground  the  offending  mass  away  through  the  natural 
passage  with  the  burr  of  the  dental  engine,  the  parts  being  exposed  by  detach- 
ing the  overlying  mucous  membrane  and  periosteum,  which  were  replaced 
after  the  exposed  surfaces  had  been  carefully  polished  by  the  corundum 
wheel.    Similar  cases  have  been  reported  to  me  by  Clinton  Wagner. 

The  curious  "  osseous  tumors"  above  referred  to,  require  free  and  complete 
exposure  of  the  cavities  in  which  they  lie,  and  may  then  be  turned  out 
without  difficulty.  (Legouest.^)  If  allowed  to  remaiti  in  situ^  they  finally  cut 
off  their  own  nourishment  by  pressure,  and  slough  out  through  the  tissues 
which  envelop  them.  (Hilton.'*) 

Sarcomatous  Growths.— The  tendency  which  fibroid  polypi,  cartilaginous 
tumors,  and  even  simple  gelatinoid  growths,  occasionally  exhibit  to  degene- 
rate into  sarcomata,  has  been  alluded  to;  but  aside  from  these  sources,  sarcoma 
may  develop  primarily,  with  all  the  characteristics  belonging  to  its  class. 
Its  differential  diagnosis  from  carcinoma  is  difficult:  both  present  in  the 
nasal  cavities  many  appearances,  and  give  rise  to  many  symptoms,  that  are 
in  common.  The  main  points  in  differentiation  have  already  been  touched 
upon  (page  813). 

Sarcoma  usually  shows  itself,  in  the  nasal  passages,  as  a  dark-red,  fleshy- 
looking,  lobulated  mass,  with  prolongations  and  attachments  stretching  in 
different  directions ;  its  consistence  varies,  being  either  of  a  dense  hardness, 
or  with  a  soft  and  fluctuating  feel.  It  is  exceedingly  vascular,  and  its  growth 
rapid,  especially  in  children,  where  the  adjacent  cavities,  particularly  the 
cranium,  orbit,  and  pharynx,  are  often  invaded  almost  simultaneously. 

It  is  unquestionably  the  surgeon's  duty,  especially  in  the  earlier  stages  of 
the  affection,  to  attempt  the  extirpation  of  the  neoplasm  by  some  one  of 
the  operative  procedures  which  have  been  described.  This  extirpation  must, 
however,  be  radical,  and  must  be  successful  and  complete  at  tlie  first  attempt, 
or  disaster  is  sure  to  follow ;  recurrence  of  the  tumor  is  always  attended  with 
increased  rapidity  of  growth,  and  w^th  marked  access  of  malignancy. 

Carcinoma. — The  rarity  of  true  cancer  originating  within  the  nasal  pass- 
ages, is  conceded  by  all  writers.  Watson*  holds  that  the  recorded  instances 
are,  for  the  most  part,  either  examples  of  fibrous  or  sarcomatous  tumors 
that  have  undergone  softening  and  degeneration,  with  perhaps  fungous 
protrusion,  or  cases  of  encephaloid  disease  which  has  originated  in  the 
meninges  or  cranial  bones,  and  which  has  made  its  way  through  the  ethmoid 
and  sphenoid  bones,  into  the  orbit  and  nostril.^    The  disease  occurs  either  in 

1  American  Journal  of  the  Medical  Sciences,  January,  1857,  p.  35. 

2  Op.  cit.,  p.  400.  ^  Mdm.  de  I'Acad.  de  Med.,  1865-G(),  p.  147. 
*  Guy's  Hosp.  Reports,  series  i.,  vol.i.  p.  495.        »  Op.  cit.,  p.  286. 

6  Out  of  fifty-one  cases  of  meningeal  cancer  analyzed  by  Velpeau,  seven  presented  themselves 
in  the  orbito-nasal  region,  and  in  several  of  these  the  tumor  appeared  in  the  nostril,  and  caused 
symptoms  commonly  referred  to  malignant  polypus. 


826       DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

young  children,  or  in  those  past  middle  life.  Its  destructive  inroads  are 
widespread  and  terrible,  and,  as  it  is  necessarily  fatal,  palliative  measures 
alone  can  be  adopted ;  all  experience  deprecates  any  recourse  to  operative 
interference. 

The  remaining  varieties  of  tumor  that  may  occur  in  the  nasal  passages, 
are  very  infrequent,  and  demand  but  passing  notice. 

Adenoma  is  developed  from  the  glands  of  the  mucous  membrane,  and  may 
not  only  attain  a  great  size,  but  may  reach  from  the  nasal  passages  into  all 
the  adjacent  cavities. 

Neuroma.— A  case  is  reported  by  Gerdy,i  in  which  a  neurilemmatous  tumor, 
connected  with  the  second  branch  of  the  fifth  pair  of  nerves,  made  its  way 
into  the  nostril  through  the  spheno-palatine  foramen.  Attempts  at  evulsion, 
the  growth  having  been  mistaken  for  a  nasal  polypus,  resulted  in  meningitis 
and  death. 

Echinococci. — FraenkeP  refers  to  the  presence  of  these  tumors,  which  he 
regards  as  of  rare  occurrence. 

Cysts—TYUQ  cystic  tumors  occasionally  occur  in  the  nasal  cavities  proper, 
and  originate  in  the  lining  mucous  membrane.  I  have  seen  and  treated  one 
such  case,  in  which  the  tumor,  closely  resembling  an  ordinary  mucous 
polypus,  both  in  color  and^  configuration,  was  seen  by  posterior  rhinoscopic 
examination  to  be  situated  in  the  left  posterior  naris ;  seized  by  the  polypus- 
forceps,  it  burst,  discharged  its  contents,  and  all  vestiges  quickly  disappeared  ; 
there  was  no  recurrence.^  A  similar  case,  the  cyst  being  located  in  the  right 
posterior  naris,  is  reported  by  Johnson,^  and  others  by  Seller^  and  Ingals.^ 

J^EUROSES  OF  THE  ^ASAL  PASSAGES. 

The  olfactory  nerve  is  the  only  one  upon  whose  integrity  depends  the  sense 
of  smell.  After  passing  the  lamina  cribrosa  of  the  ethmoid  bone,  its  branches, 
as  is  well  known,  are  distributed  in  the  mucous  membrane  covering  the  upper 
part  of  the  septum,  to  a  limited  extent,  and  more  richly  to  that  covering  spe- 
cially the  upper  turbinated  bone  and  perhaps  the  upper  part  of  the  middle  one. 
The  epithelium  of  these  parts  has  a  special  arrangement,  also,  which  differs  from 
that  of  the  lower  portion  of  the  nasal  passage,  and  which  may  have  some 
special  relation  to  the  function  of  olfaction.  The  terminal  branches  of  the 
nerve  are  probably  in  immediate  connection  with  certain  peculiar  terminal 
organs,  which  receive  olfactory  impressions  and  conduct  them  to  the  nerve- 
fibres,  ^^"othing  certain,  however,  is  known  in  regard  to  the  central  course  of 
the  olfactory  nerves ;  the  so-called  external  root  contains  the  greater  number 
of  fibres,  and  may  be  traced  centrally  into  the  neighborhood  of  the  island  of 
Eeil.  (Erb.)  The  first  and  second  divisions  of  the  fifth  pair  constitute  the 
true  sensory  nerves  of  the  mucous  membrane  of  the  nose ;  they  conduct 
tactile  and  common  sensations,  but  are  uninfluenced  by  odorous  substaiices.^ 
These  anatomical  and  physiological  facts  have  a  direct  bearing,  as  will  be 
seen,  upon  the  various  neuroses  to  be  considered.  It  may  be  appropriate  to 
here  likewise  recall  to  recollection  the  necessity  for  carefully  distinguishing 
between  the  sense  of  taste  and  that  of  smell,  in  investigating  a  supposed  case 

'  Des  Polypes,  p.  130.  2  Ziemssen's  Cyclopaedia,  vol.  iv.  p.  171. 

3  Phila.  Medical  Times,  Dec,  15,  1883.  i  British  Medical  Journal,  May,  1874. 

5  Phila.  Med.  Times,  vol.  xiv.  No.  423,  Feb.  9,  1884. 
5  Chicago  Med.  Review,  vol.  ix.  No.  5,  Feb.  2,  1884. 

7  See  also  Althaus,  The  Physiology  and  Pathology  of  the  Olfactory  Nerve.  Lancet,  May  14, 
1881,  et  seq. 


NEUROSES  OF  THE  NASAL  PASSAGES. 


827 


of  loss  of  the  latter,  and  to  the  rules  for  deteriuiniiig  whether  such  loss  is 
limited  to  one  nasal  passage,  or  affects  both.  It  is  no  unusual  matter  for 
individuals  affected  with  anosmia  to  declare  that  the  sense  of  taste  is  also 
lost,  and  this  because  they  are  unable  to  perceive  differences  of  flavor,  a 
matter  of  olfaction  alone.  Careful  examination  and  test  of  the  gustatory 
sense  will  show,  however,  that  the  taste  of  acid,  sweet,  bitter,  and  saline  sub- 
stances can  be  perceived— perception  of  flavor  alone  is  in  abeyance.  In  other 
words,  if  smell  be  lost  and  taste  preserved,  flavors  can  no  longer  be  distin- 
o-uished,  though  simple  perceptions  of  taste  remain.  This  is  true,  as  a  rule ; 
but  even  though  there  be  complete  inability  to  appreciate  odorous  substances 
inhaled  through  the  nose,  perception  of  flavors  may  still  exist  in  certain  cases. 
This  can  only  happen,  however,  when  the  posterior  nares  and  passage  between 
the  velum  and  posterior  pharyngeal  wall  are  free ;  in  cases  wliere  the  anterior 
nasal  openings  and  passages  arc" occluded,  the  odorous  particles  of  food  and 
fluids  reach  the  olfactory  region  through  the  posterior  nares  alone.  Ogle^ 
reports  two  interesting  cases  in  which  tlie  posterior  nares  were  obstructed  in 
consequence  of  the  adhesion  of  the  soft  palate  to  the  posterior  wall  of  the 
pharynx  ;  in  both,  the  sense  of  smell  and  power  of  perceiving  flavors  were  com- 
pletely lost.  In  one,  an  artificial  opening  was  made  through  the  soft  palate, 
and  both  olfaction  and  perception  of  flavors  were  again  restored  as  soon  as 
the  communication  was  established. 

Loss  of  smell  may  affect  one  side  of  the  nose  alone ;  in  such  instances  the 
patient  mav  not  be  aware  of  his  defect,  and  the  surgeon  can  only  prove  it  by 
carefully  testing  each  olfactory  region  separately,  the  nostrils  being  alternately 
held  closed.  For  this  test,  articles  must  be  chosen  that  are  truly  odoriferous, 
and  not  irritant  to  the  sensory  fibres  of  the  fifth  nerve.  Ammonia,  snuff, 
and  the  like,  are  thus  to  be  avoided,  and  the  test  made  with  cologne-water, 
musk,  camphor,  or  any  of  the  volatile  essential  oils.  That  the  test  may  be 
complete,  and  the  fact  proven  that  complete  anosmia  exists,  it  is  well  to  ex- 
periment likewise  with  the  perception  of  flavor  in  the  given  case.  Coffee, 
wine,  liqueurs,  and  many  other  articles,  depend  for  their  agreeable  flavor 
upon  the  participation  of  tlie  sense  of  smell  with  that  of  taste.  If  com- 
plete anosmia  exists,  flavor  is  lost,  as  has  been  shown,  even  though  the 
posterior  nares  be  patent. 

The  neuroses  referable  to  the  nasal  organ  are  those  of  olfaction,  sensation, 
and  motion. 

Anosmia  may  be  caused,  in  the  first  instanca,  by  any  condition  of  the  nasal 
passages  that  gives  rise  to  obstruction,  or  reriders  the  action  of  odorous  sub- 
stances upon  the  olfactory  apparatus  impossible ;  and  secondly,  by  impaired 
function  or  destruction  of  the  nerve-nlaments  distributed  in^  this  olfac- 
tory region,  or  by  impaired  function  or  destruction  of  the  olfactory  bulbs 
themselves.  It  is  understood  that  the  term  anosmia  is  applied  only  to  such 
cases  as  those  in  which  the  intensity  of  the  perception  of  smell  is  progres- 
sively diminished  until  extinguished,  without  the  sensibility  of  the^  mucous 
membrane  to  irritant  substances  being  affected ;  thus,  tobacco,  for  instance, 
will  cause  sneezing,  though  its  peculiar  smell  be  not  perceived. 

Any  obstruction  to  the  entrance  and  free  passage  of  air  to  the  upper  por- 
tions of  the  nasal  passage,  may  constitute  an  efiicient  cause  of  anosmia.  The 
commoner  causes  are  probably  chronic  hypertrophy  of  the  tissues,  as  seen  in 
old  standing  eases  of  catarrh ;  the  presence  of  thick,  dry  crusts  and  secre- 
tions, nasal  polypi,  and  finally,  as  a  common  temporary  cause,  acute  inflamma- 
tion— coryza  or  influenza.    Among  the  rarer  causes  may  be  mentioned  anses- 


I  Med.-Chir.  Trans.,  vol.  liii.  p.  273.  1870. 


828      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


thesia  of  the  trigerainns,  with  diminished  or  suppressed  nasal  and  lachrymal 
secretion,  and  hence  an  abnormally  dry  nasal  mucous  membrane,  incompatible 
with  the  exercise  of  the  full  function  of  smell ;  occlusion  of  the  nostrils 
from  congenital  or  accidental  causes;  paralysis  of  the  dilator  muscles  of  the 
nostrils  (paralysis  of  the  portio  dura  of  the  seventh  pair) ;  and  occlusion  of 
the  pharyngeal  or  post-nasal  cavities  as  the  result  of  syphilitic  cicatricial 
contraction,  or  other  mechanically  occluding  causes  elsewhere  mentioned. 

Ogle  dwells  upon  the  importance  of  the  pigment  of  the  olfactory  region 
for  the  integrity  of  the  sense  of  smell,  and  quotes  an  interesting  case  in  sup- 
port of  his  views.i 

Various  pathological  lesions,  which  involve — perhaps  destroy — the  terminal 
distributions  of  the  olfactory  nerve,  secondarily  give  rise  to  anosmia.  Such 
lesions  are  not  infrequently  seen  in  the  various  idiopathic,  traumatic,  and  con^ 
stitutional  affections  of  the  nose  already  alluded  to.  Watson  believes  that  cer- 
tain cases  of  anosmia,  after  severe  catarrhal  attacks  with  violent  sneezing,, 
may  be  due  to  local  mischief  implicating  the  fibres  of  the  nerve  in  the  olfac- 
tory region,^  or  to  hemorrhage  which  has  taken  place  into  the  olfactory  bulbs. 
In  Yirchow's  Archives,^  a  case  is  recorded  in  which  the  continued,  accidental 
inspiration  of  the  fumes  of  ether  caused  a  gradual  failure  of  the  sense  of 
smell,  and  at  last  its  total  abolition,  the  effect  'being  attributed  to  the  con- 
tinuous contact  of  the  drug  with  the  minute  branches  of  the  olfactory  nerve. 

Finally,  cerebral  disease,  either  directly  or  indirectly  involving  the  olfac- 
tory bulbs,  and  impairing  their  nutrition  and  functional  activity,  gives  rise 
to  loss  of  smell.  These  cases,  too,  are  not  infrequently  associated  with  subjec- 
tive derangements  of  olfaction,  the  subjective  odor  being  usually  complained 
of  as  offensive. 

Hughlings  Jackson  calls  attention  to  effusion  into  the  lateral  ventricles  as. 
a  possible  cause,^  through  pressure  on  the  olfactory  bulbs.  Blows  upon  the 
head,  whether  on  the  forehead,  parietal  region,  vertex,  or  occiput,  have  long 
been  recognized  as  causes  of  anosmia.  Hilton  attributes  this  result  to  rup- 
ture of  the  olfactory  bulbs,  or  their  separation  from  their  beds,  owing  to  the 
fact  that  they  lie  directly  on  the  fioor  of  the  cranium,  unprotected  by  a  cushion 
of  cerebro-spinal  fluid,  as  are  the  parts  of  the  base  of  the  brain  behind  the 
bulbs.  Ogle  believes  that  it  is  due  to  rupture  of  the  olfactory  nerves  as  they 
pass  from  the  bulb  through  the  perforations  in  the  ethmoid  bone.  The  fur- 
ther deductions  and  conclusions  reached  by  him,  in  his  admirable  article,  may 
be  thus  summarized :  Anosmia  of  the  affected  side  is  present  in  every  well- 
marked  case  of  facial  palsy.  He  believes  that  the  external  root  of  the  olfac- 
tory nerve  is  the  only  one  directly  concerned  in  olfaction,  and  that  it  depends 
upon  the  degree  in  which  this  root  or  its  central  termination  has  been  disor- 
ganized, whether  the  loss  of  smell  is  complete  or  partial;  In  support  of  this 
view,  he  cites  an  observation  of  M.  Serres^ — founded  on  the  results  of  nine- 
teen post-mortem  examinations  of  the  bodies  of  paralytic  patients — that 
lesion  of  the  external  is  much  more  efficacious  in  determining  anosmia 
than  is  lesion  of  the  internal  root.  Wickham  Legg^  and  Hybord^  have 
shown  that  anosmia  may  not  develop  Until  several  months  after  an  injury  to 
the  skull,  and  then  as  the  result  of  an  extension  of  inflammatory  or  other  pro- 
cesses. Prevost  has  demonstrated  degeneration  and  atrophy  of  the  olfactory 
nerve  as  the  cause  of  senile  anosmia.  E^otta^  has  reported  instances  of  con- 
genital loss  of  smell,  in  which  the  absence  of  an  olfactory  tract  was  shown 

1  Am.  .Jour.  Med.  Sci.,  1852.  a  Op.  cit.,  p.  337. 

»  Archiv  fiir  path.  Anat.,  Bd.  iv.  S.  41.    1867.  *  Med.  Times  and  Gaz.,  Oct.  17,  1874. 

*  Aiiatomie  Comp.  du  Cerveau,  t.  i.  p.  295.  ^  Lancet,  Nov.  8,  1873. 

'  Arch.  G6n.  de  Med.,  Mars,  1874. 

8  Recherches  sur  la  Perte  de  I'Odorat.    Arch.  Gen.  de  Med.,  Avril,  1870. 


NEUROSES  OF  THE  NASAL  PASSAGES. 


829 


to  be  the  cause  by  Rosenniuller  and  Pressat.  Cases  of  anosmia  which  accom- 
pany aphasia  and  dextral  hemiplegia,  and  are  always  limited  to  the  left  nasal 
cavity,  are  to  be  credited  to  elackson,  Fletcher,  Ransome,  Ogle,  and  Erb. 
The  latter  holds  that  the  loss  of  smell  occurring  so  frequently  with  hysteria 
is  of  central  origin,  and  associated,  as  a  rule,  with  loss  of  taste  and  with  cuta- 
neous and  muscular  aujiesthesia.  The  anosmia  of  the  insane  may  likewise  be 
attrihuted  to  central  lesion. 

Treatment,  as  a  rule,  is  not  encouraging  in  its  results.  If  the  cause  of  the 
anosmia  be  central,  its  cure  is  probably  hopeless;  while  if  it  be  de[)endent 
upon  mere  mecbanical  obstruction  to  the  entrance  of  the  odoriferous  particles 
to  the  olfactory  region,  it  can  be  relieved,  in  the  majority  of  instances,  by 
removal  of  the  impediment,  by  the  means  alluded  to  when  treating  of  the 
various  conditions  of  the  nasal  passages  which  give  rise  to  occlusion^  or 
obstruction.  Treatment  must,  then,  in  many  instances  at  least,  be  limited 
to  that  of  the  primary  disease,  and  to  the  removal  of  ascertained  and  present* 
causes.  Direct  treatment  of  the  affected  parts,  viz.,  the  upper  portions  of 
the  Schueiderian  membrane,  should  always,  however,  be  undertaken  in  the 
hope  of  success,  a-nd  electric  excitation  by  means  of  the  interrupted  gal- 
vanic current  is  indicated  if  treatment  of  the  i>rimary  cause  is  not  followed 
by  restoration  of  the  sense.  Cohen^  has  found  that,  under  certain  circum- 
stances, the  only  way  in  which  he  could  arouse  the  sensation  of  smell  was  by 
using  the  covered  negative  electrode  in  the  nasal  passage,  and  the  positive 
electrode  over  the  course  of  the  sympathetic  nerve  behind  the  angle  of  the 
jaw.  Mollei^  applies  strychnia  with  a  brush  to  the  nasal  mucous  membrane 
with  good  results.  JTotta  gained  only  negative  results  wath  irritating  snuffs, 
but  calls  attention  to  an  important  fact  that  should  be  remembered,  viz., 
that  many  chronic  cases  recover  even  without  any  treatment. 

Hyperesthesia. — Abnormal  acuteness  of  smell  may  exist  to  such  a  degree 
as  to  cause  intense  annoyance  and  even  distress  to  its  unfortunate  possessor. 
iJsTumerous  well-authenticated  and  curious  examples  are  upon  record,  as,  for 
instance,  that  of  Anne  of  Austria,  who  fainted  upon  inhaling  the  odor  of 
roses.  But,  on  the  other  hand,  many  absurd  claims  are  based  upon  the 
alleged  acuteness  of  the  sense :  thus,  it  has  been  claimed  that  smell  alone  is 
adequate  to  the  recognition  of  syphilis ;  that  the  difference  between  pneu- 
monia and  bronchitis  may  be  detected  by  the  nose  alone;  and  even  that  recent 
participants  in  coitus  may  be  distinguished  by  their  peculiar  odor.^ 

Other  facts  in  relation  to  increased  development  of  this  special  sense  are  of 
more  diagnostic  and  practical  value.  Hysterical  patients  not  infrequently 
can  distinguish  the  most  minute  traces  of  odorous  substances;  subjective 
sensations  of  smell  occur  both  in  epileptics,-*  when  they  usher  in  the  seizure, 
and  in  insane  patients  \^  nervous  disorders  of  various  kinds,  as  well  as  the 
most  various  forms  of  cerebral  disease,^  are  occasionally  complicated  by  de- 
rangements of  olfaction ;  and  tumors,  softening,  and  degeneration  of  the 
olfactory  nerve,  are  associated  with  like  phenomena,  which  disappear  with 
the  complete  destruction  of  the  nerve  and  the  establishment  of  anosmia. 

Sterxutatio,  or  excessive  sneezing,  may  be  the  direct  result  of  simple 
irritation  of  the  Schueiderian  membrane,  especially  if  this  be  hyper^esthetic, 

1  Op.  cit.,  p.  403.  ^  Rev.  des  Sci.  Med.,  Oct.  1876. 

3  See  also  Ishara,  On  Smell  in  the  Diagnosis  of  Disease  (Cincinnati  Lancet  and  Clinic,  Oct. 
-9,  1875)  ;  and  Clinton  Wagner,  On  Smell,  liygienically  and  medico-legally  considered  (The  iEs- 
culapian,  Feb.  1884). 

4  Hughlings  Jackson,  Med.  Times  and  Gaz.,  Aug.  13,  1864. 
6  Forbes  Winslow,  On  Obscure  Diseases  of  the  Brain,  etc. 

6  Manigault,  Dubois,  Westphal,  Sander,  Schlager. 


830      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

tlie  stimulus  being  transmitted  through  the  fifth  nerve  to  the  medulla,  and 
thence  reflected,  mainly  to  the  muscles  of  respiration ;  or  the  cause  may  be 
central,  as  in  the  curious  cases  where  it  is  excited  by  the  emotions :  thus, 
Stalphat  van  der  WeiP  reports  instances  in  vi^hich  coitus  was  always  preceded 
by  violent  paroxysms  of  sneezing  ;2  Schubart,  one  of  a  young  girl,  who  for 
several  nights  suffered  from  fits  of  sneezing,  repeated  three  hundred  times 
and  more  on  each  occasion ;  Albrecht,  again,  relates  one  of  an  infant 
in  whom  sneezing  occurred  one  hundred  times  an  hour,  and  caused  death 
(Watson);  and  Hosier,  the  case  of  a  girl  with  an  ear  affection,  a  sequel  of 
tj^phoid  fever,  where  the  paroxysms  lasted  twenty-four  hours.  More  modern 
instances  also  are  not  wanting  in  profusion.^ 

As  a  rule,  the  affection,  if  it  may  be  so  termed,  is  an  unimportant  one, 
especially  in  the  first  class  of  cases  alluded  to ;  but  that  serious  results  may 
follow  prolonged  and  violent  attacks  of  sneezing  can  be  readily  appreciated. 
Epistaxis,  haemoptysis,  monorrhagia,  and  even  cerebral  hemorrhage,  have 
been  known  to  ensue,  as  well  as,  in  rarer  instances,  amaurosis  from  retinal 
hemorrhage,  epilepsy,  abortion,  and  sudden  death  from  rupture  of  an  aneu- 
rism.   (Watson,  Cohen.) 

Treatment. — In  many  cases  of  hypersesthesia  dependent  upon  the  central 
causes  outlined  above,  the  treatment  of  the  symptom  is  useless,  being  unat- 
tended by  anj^  good  result.  If  sneezing  be  dependent  only  upon  hyperses- 
thesia  of  the  mucous  membrane,  the  local  use  of  sedative  ointments,  such  as 
stramonium,  aconite,  and  camphor,  will  play  a  useful  part.  If  due  to  hysteria, 
preparations  of  assafoetida  and  valerian  (Cohen),  valerianate  of  iron,  and 
the  use  of  a  weak  solution  of  aq.  laurocerasi,  snuffed  up  the  nostrils 
(Mayer),  and  the  inhalation  of  tobacco  snuff  (Gray),  may  be  employed  ;  while 
if  it  occur  in  the  course  of  a  neuralgia  of  the  facial  nerve,  sedatives  are  indi- 
cated, with  tonics. 

Spasmodic  twitching  of  the  nose,  if  not  the  result  of  mere  habit,  probably 
depends  upon  chorea,  and  is  associated  with  similar  convulsive  muscular 
contractions  of  the  face,  or  even  of  the  body.  The  indications  for  treatment 
suggest  themselves. 

Paralysis  of  the  nostrils  is  probably  a  partial  manifestation  of  paralysis 
of  the  facial  nerve,  though  it  may  exist,  it  is  true,  but  rarely,  as  a  purely 
local  affection.  It  amounts  to  a  serious  inconvenience  only  when  both 
nostrils  are  affected,  and  oral  respiration  becomes  a  necessity.  The  nature 
of  the  treatment  must  depend  upon  the  cause  of  the  paralysis ;  locally,  the 
use  of  the  electric  current  is  indicated. 

Nasal  Cough,  and  the  Existence  of  a  Sensitive  Refiex  Area  in  the  Nose. — 
Attention  has  been  called,  in  a  previous  section  of  this  essay,  to  the  fact  that 
violent  or  paroxysmal  cough  is  not  infrequentl}^  a  symptom  of  nasal  disease, 
and  is  specially  attendant  upon  those  pathological  conditions  which  affect 
the  inferior  turbinated  bones.  J.  I^.  Mackenzie^  has  investigated  the  question 
both  experimentally  and  clinically,  and  in  an  interesting  paper  has  given  his 
results  or  conclusions  as  follows : — 

'  Obs.  Rares  de  M^decine.  ^tc. 

2  See,  also,  J.  N.  Mackenzie,  Irritation  of  the  Sexual  Apparatus  as  an  Etiological  Factor  in  the 
production  of  Nasal  Disease  (A'-n,  Jour.  Med.  Sci.,  April,  1884). 

^  Russell,  case  due  to  cerumen  (Brit.  Med.  Jour.,  vol.  ii.  p.  937.  1879)  ;  Woakes  (Lancet, 
March,  1880,  p.  253);  also  Lancet,  Nov.  1873,  p.  864;  Brit.  Med.  Jour.,  Jan.  1889,  p.  90  ;  Ibid., 
Dec.  1879,  p.  1021. 

*  Am.  Jour.  Med.  Sciences,  -luly,  1883. 


INJURIES  TO  THE  NOSE. 


831 


1.  In  the  nose  there  exists  a  well-defined  sensitive  area,  the  stimulation  of  which, 
either  through  a  local  })atlioloo:ical  process,  or  through  the  action  of  an  irritant  intro- 
duced Irom  without,  is  capahle  of  producing  an  excitation  which  finds  its  expression  in 
a  reflex  action  or  in  a  series  of  reflected  phenomena.  2.  This  sensitive  area  corres- 
ponds, in  all  [)robability,  with  that  portion  of  the  nasal  mucous  membrane  wiiich  covers 
the  turbinated  corpora  cavernosa.  3.  Reflex  cough  is  produced  only  by  stimulation  ot 
this  area,  and  is  only  exceptionally  evoked  when  the  irritant  is  applied  to  other  por- 
tions of  the  nasal  mucous  membrane.  4.  All  parts  of  this  area  are  not  equally  capjible 
of  generating  the  reflex  act,  the  most  sensitive  spot  being  probably  represented  by  that 
portion  of  the  membrane  which  clothes  the  posterior  extremity  of  the  turbinated  body, 
and  that  of  the  septum  immediately  opposite,  o.  The  tendency  to  reflex  action  varies 
in  difterent  individuals,  and  is  probably  dependent  upon  the  varying  degree  of  excita- 
bility of  the  erectile  tissue.  In  some,  the  slightest  touch  is  sufficient ;  in  others,  chronic 
hypersemia  or  hypertrophy  of  the  cavernous  bodies  seems  to  evoke  it  by  constant  irrita- 
tion of  the  reflex  centres,  as  occurs  in  similar  conditions  of  other  erectile  organs. 
6.  This  exaggerated  or  disordered  functional  activity  of  the  area  may  i)Ossibly  throw 
some  light  on  the  physiological  destiny  of  the  erectile  bodies.  Among  other  properties  , 
which  they  possess,  they  act  as  sentinels  to  guard  the  lower  air-passages  and  pharynx 
against  the  entrance  of  foreign  bodies,  noxious  exhalations,  and  other  injurious  agents 
to  which  they  might  otherwise  be  exposed. 

Injuries  to  the  ^^'ose. 

Fractures  of  the  nasal  bones  are  caused  by  severe  blows  or  falls  upon 
the  or2:an.  If  the  force  comes  from  before  and  from  above,  a  transverse 
fracture  is  usaally  the  result,  within  from  three  to  six  lines  of  the  lower 
and  free  margins  of  the  nasal  bones,  and  the  fragments  are  simply  displaced 
backwards ;  or  if  the  blow  is  received  partially  upon  one  side,  they  are  dis- 
placed more  or  less  laterally.  Greater  force  will  generally  break  the  ossa 
nasi  transversely,  and  a  little  above  their  middle,  while  at  the  same  time  the 
nasal  processes  of  the  superior  maxillary  bones  may  be  slightly  involved  ;  and 
finally,  the  amount  of  force  requisite  to  break  in  the  nasal  bones  at  their  upper 
third  is  very  great.  Hamilton*  asserts  that  if  they  do  yield  at  this  point,  there 
is  no  doubt  but  that  the  base  of  the  skull  must  yield  also,  and  that  patients 
can  hardly  be  expected  to  recover  from  so  severe  an  accident.  In  children 
the  nasal  bones  may  be  spread  and  flattened,  the  lateral  margins  not  being 
depressed  or  displaced,  but  only  the  mesial  line  or  arch  forced  back  so  as  to 
press  aside  the  processes  of  the  superior  maxillae.  This  deformity  may 
become  permanent.  (Hamilton.) 

The  attendant  injury  to  the  soft  parts,  and  the  rapidity  with  which  swell- 
ing ensues  after  these  accidents,  render  the  diagnosis  at  times  diflicult. 
Careful  inspection  and  palpation,  if  at  once  instituted,  rarely  tail,  howes'er,  to 
establish  the  fact,  and  crepitation,  which  can  usually  be  felt,  especially  if  the 
fracture  be  multiple,  confirms  it.  Bleeding,  which  may  be  so  profuse  as  to 
endanger  life,  commonly  attends  the  accident,  and  if  the  lachrymal  bone  be 
involved,  emphysema  of  the  eyelids  and  of  the  cellular  tissue  of  the  orbit,  due 
to  an  escape  of  air  from  the  nose,  will  exist. 

Gross^  calls  attention  to  the  fact  that  sometimes  violent  cephalic  symptoms 
attend  these  fractures,  depending  upon  the  intimate  connection  between  the 
nasal  and  frontal  bones,  which  permits  the  jarring  effects  of  the  blow  or  fall 
to  be  communicated  to  the  brain  and  its  envelopes.  Danger  to  life  is  to  be 
apprehended,  however,  only  when  there  is  serious  cerebral  involvement,  as 
when  the  lesion  is  associated  with  fracture  of  the  cribriform  plate  of  the 


1  Fractures  and  Dislocations,  p.  90. 


2  System  of  Surgery,  vol.  i.  p.  946. 


832      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


ethmoid  bone,  separation  of  the  dura  mater  at  the  anterior  part  of  the  base 
of  the  skull,  copious  effusion  of  blood,  or  severe  concussion  of  the  brain. 
Under  such  circumstances  the  patient  may  die  from  shock,  from  compression, 
or  from  inflammation. 

Reduction  of  the  fractured  bones  if  undertaken  early,  before  swelling  has 
masked  the  field  of  operation,  is  usually  readily  accomplished.  External 
manipulation  alone  may  succeed  in  replacing  the  fragments,  but  usually  the 
combined  method — the  finger  externally,  and  some  small  instrument,  a 
straight  steel  director  or  a  sound  passed  up  into  the  nasal  cavity — will  be 
necessary.  By  these  means  the  loose  fragments  are  gently  pressed  back  into 
position  ;  to  hold  them  there,  however,  is  no  easy  matter ;  the  swelling  of  the 
soft  parts  has  a  constant  tendency  to  depress  them,  unsupported,  as  they  are, 
by  any  counter-force.  The  use  of  pledgets  of  lint  or  compresses  within  the 
nose,  is  deprecated  by  all  modern  writers,  as  practically  useless  and  painful  to 
the  patient.  Hamilton  only  advises  them  in  cases  where  the  amount  of 
♦  €omminution  of  the  bones  is  great.  The  same  is  true  of  canulas,  hollow  bou- 
gies, and  the  like.  When  the  fragments  exhibit  a  tendency  to  become  depressed 
or  to  fall  asunder,  after  they  have  been  replaced.  Gross  recommends  that  they 
be  held  in  position  by  a  stout  adhesive  strip  carried  across  the  bridge  of  the 
nose  from  one  cheek  to  the  other,  and  Hamilton  uses  nicely  adjusted  com- 
presses made  of  soft  cotton  or  lint,  and  secured  upon  the  outside  of  the  nose 
with  delicate  strips  of  adhesive  plaster,  or  rollers,  to  accomplish  the  same  result. 
Mason,^  in  fractures  of  the  nasal  bones  with  depression  of  the  bridge,  and  also 
of  the  nasal  processes  of  the  superior  maxillae,  recognizing  the  difficulty  of 
holding  the  fragments  in  place  after  reposition,  suggests  the  following  method  : 
pass  an  ordinary  surgical  needle,  nickel-plated  or  gilded,  and  by  means  of  a 
strong  needle-holder,  through  the  line  of  fracture  of  the  nasal  processes  on 
either  side.  After  the  parts  have  been  replaced  in  position,  this  aftbrds 
not  only  a  posterior  support  to  the  nasal  bones,  but  acts  as  a  tie-rod  holding 
together  the  sides  of  the  nasal  arch.  To  complete  the  dressing,  a  small  strip 
or  ribbon  of  pure  rubber-bandage  is  placed  over  the  bridge  of  the  nose,  by 
puncturing  either  end  on  the  head  and  point  of  the  needle,  giving  the  rubber 
sufiicient  tension  to  exert  a  gentle  downward  and  lateral  compression,  but  not 
enough  to  interfere  with  the  circulation  of  the  part,  or  to  exert  injurious 
pressure  on  the  fragments.  At  the  end  of  about  the  sixth  day  the  needle  may 
be  withdrawn,  for  the  less  serious  forms  of  these  fractures  are  repaired  with 
great  rapidity  and  without  the  interposition  of  provisional  callus,  and  therefore 
the  need  of  constant  supervision  and  readjustment  of  the  apparatus,  which  is 
required  in  whatever  method  be  employed,  will  not  long  tax  the  surgeon. 
The  amount  of  deformity  sometimes  resulting  from  apparently  an  insignifi- 
cant amount  of  injury,  warrants,  how^ever,  careful  attention  to  both.  To  re- 
lieve the  deformity  resulting  in  old  cases  where  fractures  of  the  nasal  bones 
have  either  been  left  unreduced,  or  where  the  result  of  treatment  has  been  bad — 
no  unusual  occurrence — ^various  methods  have  been  suggested.  That  recom- 
mended by  Adams  in  cases  where  the  septum  is  also  displaced,  has  been 
alluded  to  elsewhere.  Weir,^  not  satisfied  with  the  results  gained  by  Adams's 
method  of  refracturing  and  readjusting  these  old  fractures  of  the  nasal  bones 
with  lateral  displacement,  and  believing,  as  the  result  of  several  trials,  that 
the  Adams  forceps  is  too  Jarge  at  its  end  to  be  satisfactorily  carried  up 
under  the  nasal  bones,  and  that  the  fracturing  force  is  not  ample  enough, 
has  devised  a  new  procedure.  This  is  nothing  less  than  to  perform  an  osteo- 
clastic operation,  or,  in  more  ordinary  words,  to  make  an  incision — not  directly 

I  Annals  of  the  Anat.  and  Surg.  Society.    Brooklyn,  March,  1880. 
«  Med.  Record,  March  13,  1880. 


INJURIES  TO  THE  NOSE. 


838 


to  the  bone,  but  bevelled,  as  Packard,  of  l*hiladelphia,  has  suggested,  as 
creating  the  least  cicatrix — not  more  than  one-eighth  or  a  quarter  of  an  inch 
long,  over  the  greatest  convexity  of  the  bony  deformity  and  })arallcl  to  the 
free  border  of  the  nose,  so  as  to,  as  nearly  as  may  be,  strike  the  naso-maxillary 
junction,  and  then,  by  the  introduction  through  this  small  cut  of  a  very 
narrow  chisel,  to  cut  through  the  bone  with  a  few  strokes  of  the  mallet ;  if 
the  tilting  action  of  tJie  imbedded  chisel  prove  insufficient  to  loosen  the 
other  side  of  the  nose,  it  is  oidy  necessary  to  chisel  that  side  also  through 
the  same  incision,  which  is  the  only  one  required.  Replacement  can  now  be 
effected  with  eiise  and  rapidity,  and  the  retention  of  the  nose  in  its  corrected 
position  is  readily  accomplished.  If  depression  also  exist,  the  elevation  of 
the  refractured  bone  is  brought  about  by  pushing  it  upwards  by  an  instru- 
ment from  within  the  nose.  A  piece  of  sticking  plaster  rolled  up  with  the 
sticky  side  out  is  now  laid  along  the  nose  on  its  formerly  prominent  side,  to 
form  a  compress,  and  another  strip  drawn  across  this  and  the  face,  to  hold 
everything  snugly  in  its  place.  A  nose  truss,  a  modification  of  that  of 
Adams,  may  be  worn  for  a  few  days. 

Dislocation  of  the  nasal  bones  is  a  very  infrequent  accident,  and  cannot 
occur  except  as  the  result  of  direct  violence,  nor  unless  associated  with  dis- 
location of  the  septum.  Fracture  of  the  cribriform  plate  of  the  ethmoid 
bone  may  likewise  coexist,  and  may  very  seriously  complicate  the  condition, 
through  the  injury  which  the  displacement  of  its  fragments  may  inflict  upon 
the  brain  or  its  membranes.^  Considerable  force  is  necessary  to  replace  the 
nasal  bones  when  dislocated  backwards,  mainly  because  they  are  jamn>ed  be- 
tween the  nasal  processes  of  the  superior  maxillary  bones,  which  hold  them 
tightly.  Once  replaced,  however,  by  the  same  means  that  are  used  in  fracture 
of  the  nasal  bones,  no  retentive  apparatus  is  required. 

Wounds  of  the  nose,  whether  they  be  contused,  incised,  or  lacerated, 
demand  careful  treatment,  in  view  of  the  possible  future  deformity.  In  the 
case  of  incised  or  lacerated  wounds,  accurate  coaptation  of  the  edges  of  the 
wound  by  means  of  numerous  fine  sutures,  the  readjustment  of  the  parts  in 
their  normal  position,  and  their  retention  by  means  of  delicate  adhesive  strips, 
demand  careful  attention  and  good  surgical  skill.  Primary  union  is  the  rule, 
unless  there  be  much  contusion  of  the  parts.  The  question  Avhether  an  incised 
wound,  resulting  in  partial  or  total  separation  of  a  portion  of  the  nose,  can 
be  followed  by  complete  union  of  the  severed  part  even  after  it  has  been  sepa- 
rated from  the  main  portion  of  the  organ  for  a  considerable  time,  is  answered 
in  the  affirmative  by  Watson,^  and  a  number  of  curious  and  interesting  illus- 
trative cases  are  given  by  him  in  support  of  this  position.  In  any  doubtful 
case,  it  will  be  wise,  he  holds,  to  give  the  patient  the  benefit  of  the  doubt.  The 
detached  portion  should  be  carefully  cleansed,  the  raw  surface  of  the  stump 
revivified  by  scarification,  and  the  parts  adapted  to  each  other,  and  then  retained 
in  position  by  strapping — if  possible  without  sutures.  Cotton-wool  steeped  in 
collodion,  used  as  a  dressing  to  the  edges  of  the  wound,  has  the  advantage  of 
rendering  a  support  to  the  parts  which  other  dressings  do  not. 

Injuries  to  the  nose  with  the  lodgment  of  foreign  bodies,  are  almost  ex- 
clusively met  with  as  the  result  of  gunshot-wounds  with  penetration  and 
lodgment  of  the  ball.    The  history  of  the  case,  the  presence  of  scars  or  fis- 

•  LoTiguet  (On  the  Luxation  of  the  Nasal  Bones),  Rec.  de  Mem.  de  Med.,  etc.,  tome  xxxvii. 
p.  280.   Paris,  1881. 
2  Op.  cit.,  p.  295. 

VOL.  IV. — 53 


.834      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


tulse,  and  the  result  of  a  careful  exploration  of  the  parts  as  detailed  when 
speaking  of  the  treatment  of  foreign  bodies  in  the  nose,  usually  leave  no 
room  for  doubt  as  to  the  nature  of  the  injury,  even  though  a  considerable 
time  has  elapsed  since  its  reception.  Interesting  cases  are  given  of  this  form 
of  accident  by  Williamson^  and  Lawson  f  in  the  case  recorded  by  the  latter, 
the  right  cavity  of  the  nares  was  necessarily  laid  open  by  incision,  to  afford 
space  for  the  extraction  of  the  foreign  body,  a  portion  of  the  breech  of  a 
fowling-piece  that  had  exploded  in  the  patient's  hands.  A  somewhat  similar 
case,  reported  by  Noyes,  is  alluded  to  elsewhere  in  this  essay. 

Burns  and  scalds  of  the  nose  are  of  special  importance,  in  view  of  the 
possible  distortion  of  the  organ,  of  the  partial  closure  of  one  or  both  nasal 
orifices  by  cicatricial  tissue,  or  of  the  results  of  cicatricial  contraction  if  the 
lesion  be  at  all  extensive.  Their  ultimate  effects  exceed  therefore  in  gravity 
those  which  are  immediate,  and  are  to  be  guarded  against  during  the  healing 
process  by  promptly  meeting  the  indications  that  suggest  themselves.  The 
operation  necessary  for  the  restoration  of  the  calibre  of  the  nostril  has  already 
been  considered. 


Deficiencies  and  Deformities  of  the  ^^ose. 

Congenital  absence  of  the  nasal  organ  is  a  rare  condition.  A  case  is 
reported  by  Maisonneuve,^  in  which  the  nose  of  a  female  infant  of  7  months 
was  replaced  by  a  plane  surface,  merely  pierced  by  two  small  holes.  Other 
cases  are  said  to  be  upon  record,  but  I  am  unable  to  find  them.  Holmes 
regards  the  malformation  as  incurable. 

Congenital  clefts  and  fissures  of  the  nostrils  are  simply  prolongations 
of  the  natural  opening,  outwards  into  the  cheek,  or  upwards  towards  the 
angle  of  the  eye.  They  are  very  unusual,  and  as  a  rule  can  be  closed  by 
plastic  operations. 

Double  I^ose. — Dr.  S.  W.  Gross  has  related  to  me  the  particulars  of  an 
interesting  case  of  this  unusual  condition.  The  auxiliary  organ,  apparently 
an  outgrowth  of  the  first,  was  of  about  one-half  its  size,  and  into  it  the  tear- 
duct  opened.  Borellus^  mentions  a  similar  case,  and  Bartholinus^  one  in 
which  a  little  tumor,  like  a  second  nose,  grew  on  the  root  of  the  principal  or 
normal  one.  (Watson.)  There  would  probably  be  no  great  difficulty,  in 
such  instances,  in  remedying  the  deformity  by  a  simple  operation. 

Congenital  occlusion  of  the  nostrils  and  of  the  posterior  nares  has  been 
elsewhere  considered  (see  page  796). 

Slight  deformities  in  the  size  and  position  of  the  nose  are  commonly 
seen.  The  central  portions  of  the  face  and  skull  are  but  slowly  developed,  when 
compared  with  the  rate  of  growth  of  other  parts,  and  this  is  particularly 
true  of  the  frontal  eminences  and  the  sinuses  communicating  with  the  nose. 
Thus,  the  latter  organ  in  the  infant  always  presents  a  flattened  appearance, 
which  may  persist^in  later  years.  The  same  reason  sufiSces  to  account  for 
other  well-known  .deviations  from  the  normal  contour.    Harrison  Allen^ 


1  Quoted  by  Watson,  op,  cit. 

8  BiilL  de  Therap.,  tome  xlix.  p.  559.  1855. 

4  Hist,  et  Obs.  Medico-i)hysic.  Cent.  III.,  Obs.  43. 

6  Phila.  Med.  Times,  Dec.  (i,  1879. 


2  Diseases  and  Injuries  of  tlie  Eye,  2d  ed. 
5  Hist.  Anat.  Rar.  Ceni.  I.  Hist.  25. 


DEFICIENCIES  AND  DEFORMITIES  OF  THE  NOSE. 


835 


has  ealled^  attention  to  an  asymmetrical  rate  of  growth  of  the  viytcral 
arches,  which  prevents  the  perfect  shaping  of  the  oral  and  nasal  cavities : 
one  arch  being  more  actively  (levcl()[)e(l  than  its  fellow,  one  nasal  cavity  will 
be  found  narrowed  and  obstructed,  the  other  abnormally  large,  and  the 
septum  deflected  from  the  median  line.  In  such  cases  of  congenital  deformity, 
the  teeth  also  are  irregular,  especially  the  permanent  incisors  ;  the  two  halves 
of  the  upper  dental  arch  are  Y-shaped,  and  the  vault  of  the  mouth  is  high  and 
narrow.  The  nose  will  thus  be  rendered  miss]iai)en,  prominent,  and  jtroject- 
ing,  not  only  on  account  of  the  high-pitched  hard  palate  which  pushes  its 
parts  forward,  but  likewise  on  account  of  the  retarded  growth  of  the  i»er[)en- 
dicular  plate  of  the  ethmoid,  which  prevents  its  normal  development  [)Oste- 
riorly.  The  marked  influence  which  the  cartilaginous  septum  plays  when 
congenitally  misshapen  or  distorted,  in  producing  a  lateral  distortion  of  the 
nose  in  its  external  contour,  has  been  already  alluded  to  (see  page  799),  and 
the  operative  measures  necessary  for  the  relief  of  that  condition  have  been 
described.  When  nasal  bones  and  al?e  as  well  as  septum  are  laterally  distorted, 
surgical  attempts  at  remedying  the  condition  are  not  attended  with  much  suc- 
cess ;  and,  unless  the  deformity  be  excessive,  which  is  rarely  the  case,  had  better 
not  be  undertaken.  Various  "  nose-machines"  have  been  devised  to  effect  a 
cure  by  straightening  the  organ  mechanically ;  one  consists  of  two  parallel  plates 
of  iron,  well  padded  inside,  and  properly  curved  so  as  to  adjust  themselves 
to  the  shape  of  the  nose  to  be  operated  upon.  The  upper  and  lower  portions 
of  these  plates  are  furnished  with  screws,  passing  horizontally  from  one 
plate  to  the  other,  so  that  they  may  be  properly  adjusted  as  regards  the 
degree  of  compression.  Another  apparatus  consists  of  a  metallic  arm,  fast- 
ened to  a  head-band,  and  furnished  at  its  end  with  a  small  pad,  which,  wdien 
the  instrument  is  in  position,  is  so  arranged  as  to  press  directly  upon  the  point 
of  greatest  convexity  of  the  distorted  nose ;  the  degree  of  compression  is 
regulated  by  means  of  a  cog-w^heel  joint.  It  is  possible  that,  could  the 
patient  be  induced  to  wear  either  of  these  forms  of  apparatus  for  a  sufli- 
ciently  long  time,  some  change  in  the  position  of  the  nasal  parts  would 
follow. 

The  SEVERE  deformity  which  FOLLOWS  INJURIES  AND  CERTAIN  DESTRUCTIVE 

DISEASES,  such  as  lupus,  erosive  syphilitic  ulcer,  and  the  like,  and  which  involves 
not  unfrequently  parts  of  the  cheeks  and  lips,  as  w^ell  as  the  whole  of  both  in- 
ternal and  external  parts  of  the  nose,  is  commonly  such  as  to  tax  both  tlie  skill 
and  the  ingenuity  of  the  surgeon  who  is  required  to  repair  the  damage  sustained 
by  the  loss  of  the  parts,  to  remove  the  disflgurement  produced  by  the  destruc- 
tive disease,  or  by  violence,  or,  it  may  be  added,  to  remedy  the  deformities  of 
congenital  malformation.  Fortunately,  how^ever,  the  results  obtained  by 
operation  within  the  last  half  century  in  such  cases,  are  among  the  most 
satisfactory  achievements  of  surgery.  In  extreme  cases,  where  the  exter- 
nal nose  has  been  entirely  destroyed,  the  hideous  and  disfiguring  chasm 
left  in^  the  face  m.'iy  be  to  some  extent,  in  probably  all  cases,  covered  in  by 
operation ;  it  can  at  least  be  hidden  by  an  artificial  organ,  even  where  the 
natural  and  necessary  framework  of  cartilage  and  bone  is  altogether  lost. 
The  modern  surgeon  does  not  despair  of  success  in  forming  at  least  a  sightly 
if  not  beautiful  nose.  Where  some  portion  only  of  the  organ,  usually  its 
extreme  point,  is  wanting  as  the  result  of  accident  or  dis'ease,  or  where 
depressions  with  loss  of  substance  exist  as  the  result  of  svphilis,  a  rhinoplastic 
operation  of  some  nature  is  indicated,  and  is  often,  by  the  ingenious  methods 
of  modern  surgery,  rendered  a  brilliant  success.  The  details  of  the  various 
methods  w^hich  are  employed  in  cases  of  this  kind,  are  fully  considered  in 


836      DISEASES  AND  INJUKIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

various  surgical  works,  notably  that  of  Buck,^  and  hardly  come  within  the 
scope  of  this  article.  [See  Appendix,  page  844,  infra.'] 

Injuries  and  Diseases  of  the  Frontal  Sinus. 

Direct  violence  expended  upon  the  forehead  between  the  eyes,  or  upon  the 
superciliary  projections,  may  cause  either  a  simple,  a  compound,  or  a  commi- 
nuted fracture  of  the  walls  of  the  frontal  sinus. 

Simple  Fracture. — A  simple  fracture  at  this  point  offers  a  more  favor- 
able prospect  than  fractures  of  the  skull  in  general,  on  account  of  the 
space  which  exists  between  the  skull  walls  ;  but  such  a  case  should  be  carefully 
watched,  and  a  guarded  prognosis  given,  until  the  exact  extent  of  the  lesion  is 
known.  In  the  absence  of  all  cerebral  symptoms  it  is  not  an  important  one, 
and  its  only  unfavorable  result  may  be  an  emphysematous  condition  of  the 
scalp,  face,  and  eyelids,  which  occurs  from  the  escape  of  air  from  the  nose 
into  the  surrounding  connective  tissue.  When  the  outer  table  is  depressed, 
it  should  be  elevated  to  prevent  subsequent  disfigurement. 

Compound  and  comminuted  fractures  are  usually  the  result  of  gunshot 
wounds,  blows,  stabs,  or  explosions,  and  may  be  complicated  by  the  lodg- 
ment of  a  foreign  body.^  The  results  are  more  serious,  but  not  necessarily 
fatal,  even  when  the  posterior  wall  of  the  sinus  is  fractured,  and  the  dura 
mater  exposed.  The  indication  of  course  is  at  once  to  remove  the  foreign 
body  and  all  loose  fragments  of  bone,  to  do  which  it  may  be  necessary  to 
trephine  or  cut  away  with  bone-forceps  a  part  of  the  overhanging  edges  of 
the  cavity,  and  thus  afford  space  for  extraction.  Simple  antiseptic  dressings 
are  then  applied,  and  the  wound  kept  well  drained,  until  cicatrization  is  com- 
plete. As  a  result  of  such  injuries,  fistulous  openings  may  remain  through 
which  air  passes,  and  these  may  require  plastic  operations  for  their  closure  ;  or 
if  cicatrization  has  been  complete,  but  bony  defect  remain  below  it,  the  skin 
will  be  swollen  out  into  an  elastic,  crepitating  tumor,  whenever  the  patient 
blows  his  nose.  (Dupuytren.)  The  use  of  a  pad  and  compress  will  usually, 
however,  effect  a  cure  in  these  cases,  w^hich  are  rare. 

Acute  inflammation,  with  or  without  resulting  abscess,^  is  usually  due  to 
tertiary  syphilis,  or  to  the  extension  of  catarrhal  inflammation  from  the  nose, 
through  direct  continuity  of  structure  ;  it  may  also  follow  the  use  of  forcible 
injections  high  up  into  the  nasal  passage,  or  the  use  of  the  nasal  douche. 
In  these  latter  cases,  a  continuance  of  the  exciting  cause  may  lead  to  a  chronic 
inflammation  of  the  sinus  (chronic  abscess  or  mucocele)  accompanied  by  a 
purulent  or  muco-purulent  discharge  from  the  nose,  extremely  difficult  to 
relieve  and  often  offensive  in  its  character,  and  may  result  in  permanent  dis- 
tension of  the  cavity,  displacement  of  the  eyeball,  if  the  outlet  of  the  sinus 
become  closed  by  sw^elling  or  by  plugging  with  inspissated  mucus  or  crusts, 
and  deformity  of  the  face.  In  acute  inflammation  also,  especially  if  pus  be 
formed,  all  of  the  symptoms  to  which  it  gives  rise  are  much  aggravated  if 
communication  between  the  anterior  ethmoidal  cells  and  the  nasal  passage  is 
cut  oft*  by  acute  swelling  of  the  mucous  membrane,  so  that  the  secretions, 
instead  of  finding  a  ready  exit  through  the  nose,  are  pent  up,  causing  marked 

1  Reparative  Surgery.    New  York,  1876. 

2  For  a  number  of  interesting  examples,  see  Watson,  Diseases  of  the  Nose,  p.  129,  and  appendix. 

3  See  Hartman  on  Empyema  of  the  Frontal  Sinus.  Deutsch.  Archiv  fiir  klin.  Med.,  1877,  S. 
531 


INJURIES  AND  DISEASES  OF  THE  FRONTAL  SINUS. 


837 


distension  of  the  parts,  deformity  of  the  eyeball,  and  swelling  of  the  npper 
eyelid.  In  such  a  case,  if  it  be  not  evacuated  by  artificial  means,  pus  will 
usually  pass  into  the  other  sinus  by  breaking  down  the  septum,  or  may  pos- 
sibly perforate  through  the  anterior  wall,  if  it  cannot  find  its  way  out  by  the 
nose,  which  is  the  most  favorable  direction.  The  possibility  also  must  always 
be  borne  in  mind,  that  an  acute  abscess  may  make  its  way  into  the  cranial 
cavity  through  the  posterior  wall  of  the  sinus,  or,  if  the  orbit  be  involved, 
through  the  optic  foramen,  and  that  the  brain  may  thus  become  implicated, 
especially  in  tertiary  syphilis.^  jBizet^  reports  such  a  case  of  perforation 
from  syphilitic  abscess,  in  which  there  was  a  hernia  of  the  Schneiderian 
membrane,  through  the  aperture. 

The  symptoms  of  acute  inflammation  and  of  abscess  are  usually  marked : 
pain,  weight  and  fulness  over  the  forehead,  headache,  and  all  the  local 
symptoms  of  an  acute  coryza,  are  early  complained  of.  The  formation  of  an 
abscess  is  indicated  by  an  accession  of  the  local  swelling  and  an  increase  in 
the  local  suffering,  high  febrile  disturbance,  excessive  headache,  rigors,  and 
delirium  ;  even  se"mi-coma  may  result,  and  perhaps  paralysis  of  the  limbs  of 
the  opposite  side,  showing  the  course  taken  by  the  pus.  (Watson.)  An 
erysipelatous  blush  appearing  upon  the  surface  is  regarded  by  many  authors 
as  an  almost  unerring  sign  of  the  nature  of  the  disease. 

Treatment  by  leeching  over  the  affected  sinus  early  in  the  acute  form  of 
the  disease,  may  abort  it ;  if  it  fail,  pus  form,  and  the  case  become  urgent,  as 
shown  by  the  cerebral  disturbance  and  excessive  local  inflammation, an  attempt 
may  be  flrst  made  to  establish  a  communication  with  the  cavity  of  the  sinus 
through  the  nose,  and  thus  draw  oft* the  accumulated  matter,  by  passing  a  stout 
probe  up  though  the  natural  channel  with  some  force  ;  if  this  fail,  an  incision 
:s  made,  directly  through  the  swollen  tissues  down  to  the  bone,  and  a  smdl 
'.rephine  is  then  used,  to'make  an  opening  into  the  most  dependent  part  of  the 
sinus.  If  there  be  no  evidence  of  swelling  or  pointing  at  any  one  place,  the 
rnstrument  should  be  applied  at  the  upper  and  inner  angle  of  the  orbit.  The 
opening  made,  the  cavity  may  be  washed  out  with  warm,  disinfectant,  astrin- 
gent, anodyne,  or  detergent  solutions,  and  a  drainage  tube  inserted.  If  necrosed 
bone  be  present,  as  in  syphilis,  it  must  be  carefully  removed  ;  much  relief  may 
be  given,  also,  by  the  use  of  various  sedative  ointments  applied  to  the  nasal 
mucous  membrane,  by  means  of  a  probe  wrapped  with  cotton.  Cohen  recom- 
mends one  of  stramonium,  or  simple  cerate  in  which  a  few  grains  of  morphine 
to  the  ounce  have  been  w^ell  incorporated.  Chronic  abscess,  or  mucocele, 
in  its  early  stage,  resembles  very  closely  a  bony  tumor ;  if  it  has  lasted  any 
length  of  time,"it  usually  causes  either  an  absorption  of  the  expanded  portion 
of  bone  over  it,  or  renders  this  so  thin  that  it  is  readily  compressible ;  an 
exploratory  puncture  is  thus  easily  made  into  the  tumor,  and  its  true  nature 
established ;  a  direct  incision  will  now  serve  to  free  it  of  its  contents,  and 
attempts  must  then  be  made  to  establish,  either  by  the  natural  way  or  by 
an  artificial  puncture,  communication  with  the  nasal  passage ;  and  this  must 
be  kept  open  by  means  of  a  drainage  tube,  until  its  permanency  has  been 
established. 

Dropsy  of  the  frontal  sinus,  cases  of  which  have  been  reported,  is  proba- 
bly of  the  same  nature  as  mucocele,  and  requires  the  same  treatment. 

Tumors  of  the  Frontal  Sinus. — Cystic  growths^  which  are  more  frequently 
found  than  tumors  of  any  other  variety,  may  be  serous,  hydatid,  or  steato- 
matous  in  their  nature ;  they  may  occur  at  any  age,  or  even  be  congenital ; 


'  Richter,  Observai.  cliir.  Fasc.  ii. 


2  Gaz.  Med.  de  Paris,  p.  663.  1863. 


838      DISEASES  A^^D  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


of  the  hydatid  and  steatomatous  varieties,  cases  are  reported  by  Lans^enbeck^ 
and  Brunn,  in  addition  to  several  instances  collected  by  Demarquay.^  The 
diagnosis  is  necessarily  obscure,  until  the  growth  of  the  cyst,  which  resembles 
a  chronic  abscess  in  its  development,  has  so  thinned  the  anterior  wall  of  the 
frontal  sinus  that  fluctuation  can  be  detected,  and  an  exploratory  puncture 
made.  The  contents  of  the  cyst  may  then  be  evacuated,  and  its  sac  either 
excised  or  stimulated  to  contraction  by  the  use  of  an  injection  of  iodine  or 
some  astringent  wash,  or  it  may  be  pierced  through  into  the  nasal  passages, 
for  the  establishment  of  thorough  drainage,  as  in  chronic  abscess, 

3Iijxomatbus  or  gelatinous  joolypi  may  either  be  developed  within  the  frontal 
sinus,  or  extend  into  it  from  the  nose,  causing  by  their  growth,  in  either  case, 
deformity,  attenuation  of  the  bony  walls,  and  pain.  They  are  commonly 
single,  but  may  be  multiple.  Seven  examples  of  polypi  of  all  descriptions — 
including  the  fibrous  variety,  which  is  very  rare,  but  which  may  by  its  rapid 
growth  extend  into  all  the  neighboring  cavities,  even  that  of  the  cranium — 
are  reported  by  Demarquay ;  and  additional  cases  of  interest  may  be  found 
detailed  by  Watson^  and  Leveret.^  Viallet  and  Rouger  report  a  case  in 
which  a  polypus  was  associated  with  an  exostosis  of  the  cavity.  The  diag- 
nosis having  been  established,  the  removal  of  the  growth  is  effected  by 
either  the  knife  or  the  gouge,  after  the  trephine  and  a  crucial  incision  through 
the  skin  have  given  direct  access  to  it. 

Osteomata^^  curiously  enough,  have  a  peculiar  preference  for  this  region  of 
the  body,  but  constitute  a  very  rare  variety  of  tumor.  Composed  either  of 
cancellated  tissue,  or  of  a  compact  tissue  which  renders  the  growth  hard, 
ivory-like,  or  eburnated,  and  developed  in  the  diploe  of  the  frontal  bone, 
they  may  attain  a  considerable  size  and  occasion  much  distortion  of  the  parts. 
Diagnosis  as  to  their  nature  is  not  always  easy.  Attention  has  already 
been  called  to  the  fact  that  the  tendency  of  all  affections  of  the  frontal  sinus 
is,  in  the  first  instance,  to  cause  distension  of  its  bony  walls,  and  thus  to  simu- 
late very  closely  a  bony  tumor.  The  slow  progress,  unyielding  hardness, 
and  absence  of  inflammatory  symptoms  in  true  bony  grow^ths,  will  serve,  in 
a  short  time,  however,  to  render  their  true  character  plain.  Occasionally, 
when  small,  they  may  readily  be  extirpated  through  an  external  incision 
made  into  the  anterior  wall  of  the  orbit,  or  into  the  sinus ;  but  the  fact  that 
they  often  extend  backwards  as  well  as  forwards,  even  into  the  cranial  fossae, 
involving  both  bones  and  membranes,  w^ill  render  the  surgeon  cautious  in 
undertaking  operative  interference  which  may  be  both  difficult  and  danger- 
ous. In  many,  perhaps  a  majority,  of  cases,  if  we  may  judge  from  those 
recorded,  an  operation  is  out  of  the  question. 

Malignant  disease  of  a  sarcomatous  character,  is,  according  to  Gross,  more 
common  than  is  generally  imagined.  jEpithelioina,  when  found  in  the  frontal 
sinus,  will  usnally  have  extended  from  some  of  the  adjacent  structures.  Of 
scirrhous,  colloid  and  melanotic  cancer  of  the  sinus,  we  possess  no  examples 
recorded  in  literature. 

The  development  of  any  of  the  varieties  of  tumor  here  enumerated  is 
attended  by  certain  characteristic  appearances ;  the  external  distortion  in  the 
configuration  of  the  frontal  sinus  and  its  adjacent  parts,  often  to  such  an  ex- 
tent as  to  produce  the  most  hideous  deformity,  has  already  been  alluded  to, 
while  absorption  of  the  bony  walls  b}^  the  continued  pressure,  displacement 
of  the  eyeball  outwards  or  downwards,  distortion  of  the  nose  and  of  various 

'  Mackenzie,  Diseases  of  the  Eye,  p.  16.  2  Tumeurs  de  I'Orbite,  p.  95. 

3  Op.  cit.,  p.  139. 

*  Observations  sur  la  Cure  de  plusieurs  Polypes,  p.  235.    Paris,  1749. 

5  See  Boenhaupt  (Case  of  osteoma  of  the  left  frontal  sinus,  with  remarks  on  osteotomata  de- 
veloping in  the  accessory  cavities  of  the  nose),  Arch,  fiir  klin.  Chir.,  Bd.  xxvi.  S.  589.  1881. 


0 


DISEASES  OF  THE   ETHMOIDAL  CELLS. 


889 


other  parts  of  the  face,  oedema  and  tumefaction  of  all  the  tissues,  impaired 
vision,  epistaxis,  profuse  discharge  from  the  nasal  passagc^s,  and  intense  head- 
ache— readily  mistaken  in  the  earlier  stages  for  the  manifestations  of  a  cachec- 
tic or  syphilitic  cephalalgia — with  compression  and  ultimate  perforation  of  the 
bony  structures  at  the  base  of  the  skull,  and  involvement  of  the  anterior 
lobe  of  the  cerebrum,  with  serious  cerebral  disturbance,  are,  unfortunately, 
but  common  results. 

Foreign  Bodies  in  the  Frontal  Sinuses. — The  entrance  and  lodgment  of 
foreign  bodies  in  these  cavities,  as  the  result  of  gunshot  womids  or  other 
injuries,  have  been  referred  to.  Reference  must  now  be  made  to  the  presence 
of  living  insects,  flies  and  worms,  which  either  crawl  up  from  the  nasal  fos- 
sae, or  are  developed  from  ova,  deposited  directly  within  the  sinuses  or  intro- 
duced in  the  act  of  smelling  certain  flowers  or  fruits  upon  which  they  have 
been  placed  by  the  insect.  (Saltzman.)  Fatal  disease  from  such  causes  is 
said  to  be  not  rare  in  some  countries,  notably  in  India,  where  it  is  called 
Peenash.^  The  symptoms  of  their  presence  are  well  marked,  and  consist  in 
continuous  or  intermittent  headache,  located  over  the  frontal  sinus,  cerebral 
excitement  and  maniacal  delirium,  fainting,  sudden  vertigo  and  even  sudden 
and  temporary  blindness,  a  profuse  muco-purulent  or  fetid  discharge,  and  epis- 
taxis. (Pozzi,  Schneider.)  In  the  further  course  of  the  afl'ection  the  bones  be- 
come necrosed,  the  eyeball  is  invaded,  the  soft  parts  become  gangrenous,  and 
the  mouth,  gums,  and  superior  maxilla  are  attacked,  and  perhaps  denuded — 
the  latter  conditions,  however,  only  occurring  in  extreme  cases.  The  diag- 
nosis is  confessedly  difiicult,  unless  there  be  a  clear  history  of  the  entrance  of 
the  insect,  or  some  evidence  of  its  life,  in  the  discharges  from  the  nose.  To 
dislodge  these  insects,  various  expedients  are  recommended.  Vapors  of  car- 
bolic acid,  sulphur,  or  iodine,  forced  into  the  cavities  by  means  of  compressed 
air,  one  nasal  passage  being  held  closed,  and  injections  of  saline  solutions,  or 
of  those  containing  permanganate  of  potassium  or  carbolic  acid,  have  all 
answered  a  good  purpose.  The  inhalation  of  chloroform  may  be  tried,  or 
the  insufflation  of  irritant  snuffs  may,  by  exciting  the  act  of  sneezing,  be 
sufficient  to  cause  their  dislodgment.  In  extreme  cases,  the  sinus  must  be 
trephined,  to  afford  direct  access  to  its  interior.  (Kohts.) 

Foreign  bodies  may  be  formed  within  the  frontal  sinus:  thus  Bartholinus 
details  instances  in  which  he  has  seen,  in  the  sinuses,  earthy  concretions 
similar  to  those  which  are  sometimes  found  in  the  nose.  Their  treatment,  if 
they  give  rise  to  any  irritation,  would  be  that  of  any  other  foreign  body  in 
this  locality. 

Diseases  of  the  Ethmoidal  Cells. 

Owing  to  the  direct  continuity  of  the  mucous  membrane  of  the  nose  with 
that  lining  the  cells  of  the  sphenoid  bone,  all  those  processes  which  aflect  the 
former  may  likewise  exert  their  influence  upon  the  latter.  Catarrhal  inflam- 
mations, inflammatory  thickenings,  pol^^poid  excrescences,  and  even,  according 
to  Virchow,  osteitis  and  caries,  with  perforation  of  the  base  of  the  skull, 
may  thus  find  their  seat  within  the  walls  of  this  cavity.  Diphtheritic  ulce- 
ration of  its  mucous  membrane  has  been  reported.  Chronic  inflammation  of 
the  cells  is,  if  we  may  credit  Michel,  the  most  frequent  cause  of  so-called 
ozsena. 

1  See  Med.  Times  and  Gazette,  January  30  and  February  6,  1875,  and  Indian  Med.  Graz., 
August  18,  1874. 


840      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


Diseases  of  the  Antrum  of  Highmore. 

The  mucous  membrane  which  lines  the  interior  of  the  cavity  of  the  antrum, 
being  but  a  direct  continuation  of  the  nasal  or  Schneiderian  membrane,  is 
liable,  though  not  to  the  same  degree  as  the  latter,  to  develop  inflammatory 
conditions,  which  are  the  result  of  a  direct  extension  of  the  process  by  con- 
tinuity of  tissue  from  the  nasal  passage,  and  the  converse  is  likewise  true.^ 
In  many  cases,  the  primary  evidences  of  the  antral  afiection  may  be  detected 
in  the  nasal  passage,  by  means  of  an  anterior  or  posterior  rhinoscopic  exami- 
nation ;  and  as  the  resulting  inflammation,  swelling,  and  displacement  of  the 
nasal  parts  may  be  great  in  either  case,  and  well  calculated  to  deceive,  a  brief 
consideration  of  the  commoner  diseases  of  the  antrum  which  occur  in  con- 
nection with  those  of  the  nose,  is  desirable  at  this  point. 

Inflammation  and  abscess  are  the  atfections  most  frequently  met  with.  Any 
extension  of  a  severe  catarrhal,  syphilitic,  or,  more  rarely,  herpetic  or  variolous 
inflammation  of  the  nasal  mucous  membrane,  is  an  efiicient  factor  in  producing 
a  like  condition  of  that  of  the  antrum — one  which  varies  both  in  its  degree, 
extension,  and  rapidity  of  development,  as  w^ell  as  in  the  amount  and  charac- 
ter of  the  attendant  secretion,  which  may  be  either  mucous  or  muco-purulent. 
Salter  has  called  attention  to  the  peculiar  circumstance  which  here  gives 
importance  to  this  altered  and  more  abundant  secretion,  and  to  the  disease  ; 
viz.,  that  it  may  be  confined  within  the  sinus  by  means  of  the  swelling  and 
turgescence  of  the  mucous  membrane  around  its  orifice,  and  that  thus,  from 
a  mere  anatomical  arrangement,  a  catarrhal  inflammation,  spending  itself 
by  superficial  suppuration,  may  lead  to  the  formation  of  a  shut,  expanding 
sac,  in  many  respects  equivalent  to  a  deep-seated  abscess,  though  by  no  means 
identical  with  that  condition  either  in  pathological  history  or  absolute  ana- 
tomy. Aside  from  the  above  causes,  afi'ections  of  the  teeth — dental  caries,  or 
alveolar  abscess,  in  some  stage,  associated  with  disease  of  the  teeth — are  by  far 
the  commonest  factors  in  the  production  of  the  disease.  The  peculiar  ana- 
tomical relation  which  the  antrum  bears  to  the  teeth  is  well  known  ;  it  varies 
greatly,  as  regards  both  the  extension  of  the  antrum  over  the  fangs  of  many 
or  few  teeth,  and  the  degree  in  which  these  fangs  approach  or  pierce  the  floor 
of  the  sinus.  (Salter.)  Other  causes  only  occasionally  exist ;  thus  a  blow  upon 
the  cheek  has  been  known  to  excite  acute  inflammation  within  the  antrum, 
and  it  has  developed  in  the  infant  from  injuries  received  during  labor.^  A  case 
of  abscess  depending  upon  the  presence  of  polypi  within  the  antrum,  is  reported 
by  Watson.  Another,  in  which  the  cause  was  a  bony  tumor  lying  loose  within 
the  cavity,  w^ill  be  found  in  the  Edinburgh  Medical  Review,  October,  1867  ; 
and,  finally,  necrosis  of  the  alveolar  ridge,  the  presence  of  a  tooth  thrust  into 
the  cavity  in  endeavoring  to  extract  it,  and  that  of  various  other  foreign 
bodies,  introduced  by  violence,  may  all  act  as  exciting  causes  of  inflammation 
and  suppuration.^  The  tendency  of  the  inflammatory  process  arising  from  any 
of  these  causes,  to  extend  to  or  involve  the  nasal  passage,  has  been  alluded 
to.  The  physical  signs  of  inflammation  and  pus-formation  in  the  cavity  of 
the  antrum,  vary  necessarily  in  degree,  and  diflfer  according  to  the  exciting 
cause.  Much  depends,  in  regard  to  their  severity,  upon  whether  there  be  an 
outlet  for  the  discharge  of  the  pus,  either  through  the  natural  opening  of  the 

1  Wolfram  (On  the  treatment  of  catarrli  of  the  antrum),  Berlin  klin.  Wochenschr.,  No.  6. 
1879. 

2  Druitt,  Surgeon's  Vade  Mecum,  p.  431. 

3  See,  also,  Weichselbaum  (On  phlegmonous  inflammation  of  the  accessory  cavities  of  the  nose), 
Med.  Jahrbuch,  Heft.  ii.  1881. 


DISEASES  OF  THE  ANTRUM  OF  HIGHMORE. 


841 


cavity  into  the  nasal  passage,  or,  in  rarer  instances,  through  the  socket  of  some 
tooth  that  has  been  removed,  or  fistulous  passage  that  has  been  made ;  or 
whether,  no  ready  outlet  presenting  itself,  and  the  natural  one  being  closed 
by  the  swelling  of  the  tissues  about  it,  the  pus  is  pent  up,  a  confined  abscess 
resulting.  In  the  first  class  of  cases,  the  only  indication  that  the  process  of 
suppuration  is  proceeding  within  the  antrum,  aside  from  the  probably  inflamed 
and  swollen  appearance  of  the  nasal  passage,  may  be  the  occasional  discharge 
of  quantities  of  offensive  pus  into  the  nose — especially  when  the  head  is  held 
in  certain  positions — and  the  ozsenic  smell ;  and  the  cause  will  be  found,  in 
many  cases,  as  has  been  stated,  to  be  a  decayed  tooth,  one  fang  of  which, 
perhaps,  protrudes  through  the  floor  of  the  cavity.  An  examination  with 
the  nasal  speculum  may  disclose  the  fact  that  pus  trickles  into  the  middle 
meatus  of  the  nose,  and  the  diagnosis  is  thus  confirmed.  If  a  decayed  and 
tender  tooth  be  determined  upon  as  the  cause,  it  may  be  extracted ;  and 
through  the  passage  thus  made,  and  enlarged,  if  necessary,  by  means  of  a  drill, 
the  cavity  of  the  antrum  may  be  thoroughly  washed  out  with  disinfectant 
solutions.  This  will,  in  all  probability,  be  all  that  is  necessary  to  effect  a 
cure.  Should,  however,  discharge  persist,  a  thorough  exploration  of  the 
whole  antrum,  with  scoop  and  probe,  must  be  made  through  the  perfora- 
tion, in  order  to  detect  the  foreign  body,  necrosed  bone,  fragment  of  tooth,  or 
the  like,  which  lies  at  the  root  of  the  matter  and  keeps  up  the  discharge. 

If,  on  the  other  hand,  the  matter  is  confined  within  the  antrum— if  abscess, 
in  other  words,  result — the  symptoms  are  marked  and  painful.  As  a  class, 
these  do  not  vary  from  the  symptoms  attendant  upon  like  collections  of  matter 
within  resistant  walls  in  other  parts  of  the  body,  though  certain  signs 
are,  in  this  instance,  incident  to  its  particular  locality.  Thus,  the  expansion 
of  the  whole  jaw ;  the  elevation  of  the  malar  bone,  with  its  fossa  full  and 
prominent ;  the  apparent  elongation  of  the  molar  teeth  upon  the  afi'ected 
side ;  the  convexity  of  the  normally  concave  hard  palate  ;  and  the  swelling 
of  all  the  soft  parts  of  the  nasal  passage,  as  shown  in  both  anterior  and  pos- 
terior rhinoscopic  examination,  bespeak  beyond  doubt  the  true  nature  and 
exact  situation  of  the  disease.  If  relief  be  delayed,  the  eyeball  may  be  dis- 
placed, and  amaurosis — consequent  upon  periosteal  inflammation  extending 
into  the  orbit  and  involving  the  sheath  of  the  optic  nerve — may  occur.  The 
ultimate  result,  if  nature  be  unaided  by  the  surgeon,  will  vary  much.  Occa- 
sionally the  abscess  bursts  into  the  nose,  or  the  pus  flnds  its  way  out,  by  bur- 
rowing alongside  the  fang  of  some  tooth,  into  the  mouth.  More  rarely  it 
perforates  the  cheek  or  tlie  floor  of  the  orbit,  and  passes  into  the  lower  eyelid. 
Before,  however,  these  latter  accidents  happen,  fluctuation  will  usually  be  dis- 
tinctly perceptible  at  some  point  upon  the  anterior  surface,  or  in  the  hard 
palate,  and  the  appropriate  means  of  relief  will  be  thereby  suggested.  If  doubt 
still  exist — if  some  portion  of  the  bony  walls  be  not  so  thin  but  that  it  yields 
on  pressure,  and  gives  to  the  finger  the  sensation  of  dry,  tightly-stretched 
parchment — the  use  of  a  small  trocar  will  serve  to  draw  oft"  enough  fluid, 
usually  no  thicker  than  ordinary  pus,  and  sometimes  serous,  to  ascertain  the 
nature  of  the  swelling;  and  can  do  no  injury  to  a  solid  growth  if  such  be  the 
true  character  of  the  expansion.  Diagnosis  is  only  diftlcult  where  the  dis- 
tension of  the  sinus  goes  on  for  years,  as  it  sometimes  does,  slowly  and  pain- 
lessly, and  with  so  little  local  disturbance  that  the  idea  of  an  abscess  is  not 
suggested  ;  and  in  those  rare  instances  in  which  abscess  is  complicated  by  the 
presence  of  a  tumor  within  the  antrum.  Both  classes  of  cases,  and  the  errors 
in  treatment  to  which  a  faulty  diagnosis  may  lead,  are  illustrated  by  instances 
in  Watson's  work,^  and  are  alluded  to  by  other  authors. 


1  Op.  cit.,  p.  162. 


842      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

Treatment. — Before  the  abscess  has  formed,  when  it  is  as  yet  only  immi- 
nent, the  inflammatory  process  may  probably  be  arrested  by  removing  some 
carious  or  tender  tooth,  which  a  skilful  dental  examination  has  shown  to  be 
its  probable  exciting  cause.  The  first  permanent  molar,  as  a  rule,  is  the  one 
indicated,  though  the  removal  of  several  teeth  may  be  necessary.  When  pus 
has  already  accumulated  and  no  outlet  exists,  a  free  opening  for  its  evacuation 
becomes  necessary,  and  the  method  consists  in  the  removal  of  a  tooth  and 
the  perforation  of  the  antrum  at  its  base.  Hunter^  long  since  clearly  sketched 
out  this  and  the  other  surgical  steps  required The  first  part  of  the 
cure,  as  well  as  .that  of  all  other  abscesses,  is  to  make  an  opening,  but  not  in 
the  part  where  it  threatens  to  point,  for  that  would  generally  be  through  the 
skin  of  the  cheek.  If  the  disease  is  known  early,  before  it  has  caused  the 
destruction  of  the  fore  part  of  the  bone,  there  are  two  ways  of  opening  the 
abscess :  one  by  perforating  the  partition  between  the  antrum  and  the  nose, 
which  may  be  done ;  and  the  other  by  drawing  the  first  or  second  grinder  of 
that  side,  and  perforating  the  partition  between  the  roots  of  the  alveolar  pro- 
cess and  the  antrum,  so  that  the  matter  may  be  discharged  for  the  future  that 
way.  But  if  the  fore  part  of  the  bone  has  been  destroyed,  an  opening  may 
be  made  on  the  inside  of  the  lip,  where  the  abscess  most  probably  will  be  felt ; 
but  this  w^ill  be  more  apt  than  the  other  perforation  to  heal,  and  thereby  may 
occasion  a  new  accumulation,  which  is  to  be  avoided  if  possible  by  putting 
in  practice  all  the  common  methods  of  preventing  openings  from  healing  or 
closing  up ;  but  this  practice  will  rather  prove  troublesome,  therefore  the 
drawing  of  the  tooth  is  to  be  preferred  because  it  is  not  so  liable  to  this 
objection." 

The  opening  having  been  made  as  thus  described,  it  will  usually  need  to  be 
enlarged  by  the  careful  use  of  a  large  trocar,  and  the  floor  of  the  antrum  may 
then  be  broken  up  sufiiciently  to  aftbrd  a  free  opening  for  the  discharge  of  the 
pus.  A  careful  examination  with  the  probe  will  now  have  to  be  made  to 
detect  the  possible  presence  of  any  foreign  substance,  or  of  necrosed  bone,  and, 
if  such  be  discovered,  it  must  be  removed,  even,  if  necessary,  by  still 
further  enlarging  the  opening.  In  conducting  this  examination,  the  thorough- 
ness of  which  is  important,  the  fact  that  the  cavity  of  the  antrum  is  occa- 
sionally divided  by  partial  septa  of  bone  projecting  from  its  walls,  as  shown 
by  Giraldes,2  must  not  be  forgotten,  for  in  such  an  instance  a  foreign  body 
might  lie  concealed  in  some  circumscribed  region  of  the  sinus,  and  could  only 
be  removed  by  a  curved  scoop  and  by  breaking  down  the  partitions.  The 
subsequent  treatment  will  consist  in  securing  "thorough  cleanliness  by  the 
daily  free  use  of  disinfectant  and  stimulating  solutions — carbolic  acid,  per- 
manganate of  potassium,  sulphate  of  zinc,  alum,  nitrate  of  silver  (gr.  ij-oj) 
and  the  like— until  the  discharge  becomes  healthy  in  its  character,  and  loses 
its  fetid  smell.  The  opening  made  may  be  kept  patent  by  the  use  of  a 
silver  or^  leaden  style,  secured  in  position  by  fastening  it  with  wire  to  the 
neighboring  teeth ;  or  a  small  silver  drainage  tube  may  be  used,  secured  in 
the  same  way.  Salter  has  contrived  an  ingenious  apparatus  to  effect  the 
same  purpose.^ 

A  few  points  remain  to  be  considered.  Should  it  for  any  reason  be  desir- 
able or  necessary  to  open  into  the  antrum  at  some  point  other  than  through 
the  alveolar  ridge,  experience  has  shown  that  it  is  preferable  to  do  so  at  the 
lower  part  of  the  canine  fossa,  the  trocar  being  directed  backwards  and  a 
little  outwards.    In  cases  where,  on  account  of  the  swelling  of  the  parts,  the 

*  Practical  Treatise  on  Diseases  of  the  Teeth.    London,  1771. 
2  Des  Maladies  du  Sinus  maxillaire.    Paris,  1851. 
Holmes's  System  of  Surgery,  3d  ed.,  vol.  ii.  p.  468. 


DISEASES  OF  THE  SKIN  AND  SUBCUTANEOUS  TISSUES  OF  THE  NOSE.  843 


patient's  mouth  cannot  be  opened  sufficiently  to  allow  of  the  extraction  of 
a  tooth  and  perforation  of  the  alveolar  ridge,  the  opening  may  best  be  made 
through  the  canine  fossa,  as  in  the  former  instance,  for  the  sake  of  tempo- 
rary relief,  and  when  the  acute  symptoms  have  passed  off,  the  operation  may 
be  completed  by  perforating  in  the  usual  way  through  a  tooth  cavity  into 
the  antrum.  The  latter  operation  again  is  indicated  in  those  instances,  rare 
thouo'h  they  be,  where  a  troublesome,  fistulous  opening  remains  as  the  result 
of  the  perforation  of  an  abscess  through  the  cheek  or  lower  eyelid.  Enlarge- 
ment of  the  sinus,  for  the  purposes  of  drainage,  cannot  be  undertaken  for  fear 
of  increasing  rather  than  diminishing  the  deformity,  and  its  locality  prevents 
its  serving  the  same  purpose  as  a  more  depeiulent  opening,  which  should  in 
all  instances  be  made  to  secure  thorough  drainage. 

Effusions  OF  blood  may  occasionally  occur  in  the  antrum,  either  as  the  result 
of  direct  violence,  or  in  consequence  of  nasal  hemorrhage,  the  blood  passing 
into  the  antrum  through  the  nasal  opening.  Suppuration  may  thus  be  caused. 
The  treatment  would  be  that  of  ordinary  abscess  of  the  antrum. 

Tumors.— Morbid  growths  of  varied  nature  are  extremely  liable  to  originate 
within  the  antrum,  or  less  frequently  from  the  alveolar  border  of  the  superior 
maxilla,  and  involve,  in  their  too  often  rapid  and  destructive  course,  not  only 
the  whole  cavity  of  the  antrum,  but,  by  gradual  extension  and  breaking  down 
of  the  thin  bony  partitions,  the  cavities  of  both  nose  and  orbit ;  the  re- 
sultant displacement  and  deformity  are  excessive.  Weber,  in  a  careful  and 
instructive  study  of  307  cases  of  tumor  of  the  antrum,  has  shown  their  rela- 
tive frequency  to  be  as  follows:  carcinoma,  133  ;  sarcoma,  84  ;  osteoma,  32  ; 
cystoma,  20 ;  fibroma,  17  ;  enchondroma,  8  ;  gelatinoid  polypus,  7  ;  melanotic 
sarcoma  and  carcinoma,  5  ;  and,  finally,  angeioma,  1 ;  but  he  remarks  that 
carcinoma  occurs  too  frequently  in  the  list,  doubtless  from  its  having  been 
frequently  confounded  with  medullary  sarcoma.  He  believes  that  the  latter 
embraces  rather  more  than  one-third,  and  carcinoma  less  than  one-third,  of 
all  morbid  growths  of  the  superior  maxillary  bone. 

These  tumors,  their  differential  diagnosis,  and  the  operations  necessary  for 
their  removal,  are  fully  considered  in  other  articles. 

Diseases  of  the  Skin  and  Subcutaneous  Tissues  of  the  I^ose. 

A  number  and  variety  of  affections  may  develop  primarily  in  the  integu- 
ment covering  the  nasal  organ,  or  may  involve  it  by  a  process  of  extension 
from  neighboring  parts ;  of  these  the  commonest  are  herpes,  acne,  eczema, 
nsevus,  syphilis,  lupus,  and  epithelioma  ;  more  rarely,  rhino-scleroma  and 
malignant  pustule.  Gangrene  and  frost-bite  also  may  claim  the  attention 
of  the  surgeon.    These  affections  are  elsewhere  considered.^ 

1  See  Vol.  I.,  pages  228,  745,  787,  and  Vol.  III.  pages  54  et  seq. 

Note  to  page  767. — Several  very  valuable  contributions  to  our  knowledge  of  the  pathology  ol 
hay  fever,  which  the  reader  should  by  all  means  consult,  are  the  following  :  J.  0.  Roe,  The  Patlio- 
logy  and  Radical  Cure  of  Hay  Fever  or  Hay  Asthma  (New  York  Med.  Journal,  May  3,  1884)  ; 
Ibid.,  May  12  and  19,  1883  :^  Harrison  Allen,  Amer.  Journ.  Med.  Sciences,  Jan.  1884;  C.  E. 
Sajous,  Hay  Fever  and  Hs  Successful  Treatment  (Trans.  Amer.  Laryngological  Association,  1884. 
Abstract,  with  discussion  and  remarks  by  Drs.  Shurly,  Bosworth,  Mackenzie,  Robinson,  and 
Johnson,  Medical  News,  May  24,  1884).  The  reader  should  consult  also  Hack,  Ueber  eine  opera- 
live  Radical-behandlung  bestirnmter  Formen  von  Migrane,  Asthma,  Heufieber,  sowie  zahlreicher 
verwandter  Erscheinungen.  Wiesbaden,  1884.  These  contributions  to  the  subject  of  hay  fever 
have  appeared  since  the  above  article  was  written.  They  throw  much  new  light  upon  the 
obscure  and  disputed  question  of  causation,  and  should  certainly  be  read  in  connection  with, 
what  is  said  in  the  text. 


844     DISEASES  AKD  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSOKY  SINUSES. 


[APPEi^DIX. 

Ehino'plastic  Operations. 

{By  the  Editor.) 

Rhinoplastic  operations,  or  operations  designed  to  accomplisli  the  partial 
or  complete  restoration  of  a  nose,  may  be  required  to  correct  a  congenital 
deformity,  to  remedy  the  effects  of  injury,  or  to  repair  the  ravages  occasioned 
b}^  ulceration,  with  or  without  necrosis  or  caries,  by  lupus,  by  constitutional 
syphilis,  etc.  It  is  an  invariable  rule  in  nasal  surgery  that  no  operation  of 
this  kind  shall  be  undertaken  until  the  process  of  destruction  by  which  it  is 
rendered  necessary  has  been  entirely  and  detinitively  checked. 

Rhinoplastic  operations  may  be  divided  into  those  designed  to  repair  a 
nose  which  has  been  only  partially  lost,  and  those  intended  to  remedy  com- 
plete destruction  of  the  organ. 


I.    Operations  for  Partial  Restoration  of  the  IN'ose. 

Repair  of  Columna  and  Septum. — Should  the  loss  of  tissue  be  limited  to 
the  colmmia  nasi  and  septum^  a  new  columna  may  be  conveniently  formed 
from  the  uj^per  lip,  by  making  an  incision  on  either  side  of  the  median  line, 
and  through  the  whole  thickness  of  the  part,  thus  separating  a  portion  about 
one-third  of  an  inch  in  width,  and  of  a  length  equal  to  the  depth  of  the  lip ; 
this  strip  is  then  turned  upwards,  and  its  end,  having  been  suitably  trimmed, 
is  adapted  to  the  tip  of  the  nose,  which  must  be  freshened  for  the  purpose, 
and  is  secured  in  its  new  position  by  the  twisted  or  shotted  suture.  The  labial 
mucous  membrane  which  is  thus  turned  outwards,  gradually  loses  its  normal 
character  and  becomes  assimilated  to  skin.  The  sides  of  the  lip  are  approxi- 
mated with  harelip  pins  and  interrupted  sutures,  and  a  few  narrow  strips  of 
plaster  are  so  adjusted  as  to  support  the  transplanted  portion  until  it  becomes 
firmly  adherent  in  its  new  position.  The  dimensions  of  the  newlj^-made 
nostrils  must  be  maintained  by  occasionally  introducing  into  each  a  silver 
or  gutta-percha  tube. 

Deficiency  of  one  of  the  al^  may  be  repaired,  if  the  loss  of  tissue  be  but 
slight,  by  taking  a  flap  from  the  upper  part  of  the  nose  itself,  and  attaching 
it  with  numerous  points  of  the  interrupted  suture  to  the  previously  freshened 
edges  of  the  gap.  If  the  deficiency  be  greater,  it  will  be  necessary  to  take 
a  flap  from  the  cheek  or  forehead,  the  former  plan  being,  I  think,  the  better. 
The  cheek-tissues  are  very  vascular,  and  a  flap  large  enough  to  replace  almost 
half  the  nose  can  be  readily  obtained,  and  by  curving  the  ends  of  the  inci- 
sions can  be  slid  into  place,  without  any  necessity  of  twisting  the  pedicle 
upon  itself,  as  must  be  done  when  the  flap  is  taken  from  the  forehead.  If 
the  latter  plan  be  adopted,  to  prevent  sloughing  of  the  pedicle,  a  groove 
should  be  cut  on  the  dorsum  of  the  nose  for  its  recei>tion.  When  union  is 
coTrijilctod,  the  pedicle  may  be  raised  and  cut  away,  and  the  groove  then 
(closed  airain  with  sutures. 


RHINOPLASTIC  OPERATIONS. 


845 


Undue  shortness  of  the  nose  is  sometimes  the  source  of  much  annoyance, 
and  may  be  remedied  by  the  plan  adopted  by  Prof.  Weir,  of  New  York, 
which  consists  in  cutting  across  the  nose  in  a  transverse  direction,  drawing 
down  the  tip  to  the  desired  position,  and  tilling  the  wedge-shaped  gap  which 
results  by  transplanting  flaps  from  the  cheeks. 

Should  the  patient  seek  relief  on  account  of  the  opposite  condition — too 
great  length  of  nose — it  would  probably  be  sufficient  to  remove  a  transverse 
wedge  from  the  elongated  tip  of  the  organ,  and  close  the  wound  with  sutures. 

Operation  for  Depressed  !N"ose. — Disease  of  the  nasal  bones  and  cartilages 
may  cause  the  organ  to  have  a  flat  and  sunken  appearance,  without  there 
being  any  external  ulceration.  The  late  Sir  William  Fergusson,  in  a  case  of 
this  kind,  succeeded  in  remedying  the  deformity  b}^  a  modification  of  the 
procedure  originally  suggested  by  Diefl:enbach.  Introducing  a  narrow 
knife  within  the  nostrils,  he  separated  the  soft  tissues  from  the  underlying 
bones,  and  then  brought  the  whole  nose  forward  by  passing  long,  steel-pointed, 
silver  needles  through  its  base  from  cheek  to  cheek,  and  then  twisting  them 
over  strips  of  perforated  leather.  A  new  columna  was  afterwards  formed 
in  the  ordinary  manner. 

Fistulous  openings  through  the  bones  of  the  nose  are  occasionally  met 
with,  as  the  result  of  necrosis  following  scarlet  fever,  etc.  The  treatment 
consists  in  freshening  the  edges  of  the  orifice,  and  adapting  a  flap  taken  from 
either  cheek  or  forehead  as  may  be  found  most  convenient. 

II.    Operations  for  Restoration  of  the  Whole  ^Tose. 

Several  methods  are  employed  for  restoring  the  entire  nose,  wlien  this  is 
necessary,  those  which  are  best  known  being  respectively  called  the  Talia- 
cotian  and  the  Indian  operation. 

The  Taliacotian  method  has  received  its  name  from  Tagliacozzi,  or  Talia- 
cotius,  an  eminent  Italian  surgeon  of  the  sixteenth  century,  who  published 
an  account  of  his  operation,  with  numerous  illustrations,  in  1597.^  It  is 
])erhaps  hardly  necessary  to  say  that  the  Iludibrastic  notion  that  Taliacotius 
fashioned  noses  for  his  patients  from  the  nates  of  persons  hired  for  the 
purpose,  is  unfounded,  having,  according  to  Dr.  Ferriar,  originated  in  a 
malicious  jest  of  Van  Helmont.  The  part  from  which  the  Taliacotian 
nose  was  really  derived,  was  the  upper,  and  usually  the  left,  arm  of  tlie 
patient  himself.  A  flap  of  skin  and  connective  tissue  of  sufficient  size  is, 
in  this  operation,  first  marked  out  on  the  upper  arm  and  partially  de- 
tached, and  is  left  in  this  condition  for  about  two  weeks,  in  order  that  it 
may  become  vascular  and  thickened  by  the  process  of  granulation.  At  the 
end  of  this  time  the  stump  of  the  original  nose  is  pared,  and  the  flap  then 
reduced  to  proper  shape,  and  attached  by  numerous  stitches  in  its  intended 
position,  the  arm  being  brought  up  to  the  head  and  fixed  by  a  complicated 
arrangement  of  slings  and  bandages.  After  about  ten  days  more,  when  the 
new  nose  is  supposed  to  be  firmly  adherent,  its  connections  with  the  arm  are 
severed,  and  any  needful  trimming  of  the  new  organ  is  eft'ected.  Finally  a 
columna  is  made  from  the  upper  lip. 

This  operation  has  been  varied  by  Warren  and  others,  by  taking  the  flap 


'  De  Curtorum  Chirurgia  per  Insitionem  Libri  Duo.    Venetiis,  1597. 


846      DISEASES  AND  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 


from  the  forearm,  and  by  diminishing  the  time  during  which  the  head  and 
arm  are  kept  in  contact ;  but  even  with  these  modifications,  it  is  so  tedious 
and  irksome  that  it  is  seldom  employed  at  the  present  day,  though  it  has 
been  occasionally  adopted,  and  with  success,  as  by  Sir  William  MacCormac, 
and  by  Dr.  Stokes,  of  Dublin.  In  order  to  provide  a  bony  support  for  the 
new  nose.  Dr.  Hardie,  of  Manchester,  in  the  case  of  a  young  girl,  transplanted 
the  ungual  phalanx  of  one  of  her  fingers,  keeping  his  patient's  arm  fastened 
up  to  her  face  for  no  less  than  three  months. 

The  Indian  method,  which  is  that  now  commonly  adopted,  was  introduced 
into  England  by  Mr.  Carpue,  in  1816.1  By  this  method  the  nose  is  made 
from  a  flap  taken  from  the  forehead,  supplemented  if  necessary  by  a  columna 
derived  from  the  upper  lip.  As  ordinarily  performed,  the  operation  may  be 
divided  into  three  stages. 

In  ihe  first  stage,  a  ilap  of  proper  size  and  shape  is  cut  from  the  skin  of  the 
forehead,  and  attached  in  the  position  which  it  is  meant  to  occupy.  A  piece 
of  thin  gutta-percha  or  card-board  is  first  modelled  to  the  form  and  dimen- 
sions of  the  wished-for  organ,  and  is  then  flattened  out  and  laid  upon  the 
forehead  as  a  guide  for  the  future  incisions.  The  flap  may  be  taken  from 
the  centre  of  the  forehead,  or  from  either  side,  as  may  be  thought  most  con- 
venient. As  the  flap  is  sure  to  shrink  after  it  is  detached,  it  is  a  good  rule 
to  allow  a  margin  of  one-fourth  of  an  inch  on  all  sides  of  the  pattern,  and  the 
lines  of  incision  should  be  carefully  marked  with  a  dark  crayon,  or  with 
tincture  of  iodine. 

The  error  is  sometimes  committed  of  making  the  flap  needlessly  large,  and 
I  have  known  of  cases  in  which  the  new  nose  has  by  its  prodigious  bulk 
been  a  source  of  quite  as  much  mortification  to  the  patient  as  his  previous 
lack.  Hence  the  importance  of  carefully  outlining  the  form  of  the  needed 
part,  and  of  not  allowing  more  than  the  quarter-in cli  margin  which  has  been 
directed.  Should  the  patient  have  an  unusually  high  forehead,  the  central 
portion  of  the  flap  may  be  prolonged  in  order  to  furnish  a  columna,  but 
under  other  circumstances  this  part  of  the  operation  is  better  left  for  a  sub- 
sequent occasion.  I  may  add  that  Prof.  Bennett,  of  Dublin,  advises  against 
the  formation  of  a  columna  altogether,  finding  that  the  contraction  of  the 
deep  surface  of  the  flap  leaves  an  orifice  none  too  large  for  the  admission  of 
air,  and  that  the  overhanging  of  the  middle  lobe  of  the  flap  prevents  any 
deformity. 

In  raising  the  frontal  flap  the  incision  is  begun  at  the  root,  which  is  made 
long,  so  that  its  circulation  may  not  be  interfered  with  when  it  is  twisted  ; 
the  incision  is  usually  prolonged  further  on  one  side  than  on  the  other,  so 
that  the  root  may  be  twisted  more  readily.  All  the  soft  tissues  of  the  fore- 
head should  be  embraced  in  the  flap,  and  it  has  even  been  recommended  that 
the  periosteum  should  be  likewise  included,  in  hope  that  by  its  osteo2:enetic 
power  bone  might  be  developed  in  the  transplanted  tissue.  Such  a'result, 
however,  would  not  be  very  likely  to  ensue,  nor,  if  it  did  occur,  would  it  be 
of  much  benefit  to  the  patient,  while  by  depriving  the  frontal  bone  of  its 
periosteum,  some  risk  is  entailed  of  necrosis.  When  the  flap  has  been 
formed,  it  is  temporarily  replaced  over  a  piece  of  wet  lint,  while  the  stump 
of  the  old  nose  is  prepared  for  its  reception.  This  is  done  by  freshening  its 
edges,  dissecting  up  the  skin  in  such  a  way  as  to  make  a  groove  to  receive 
the  flap,  w^hich  should  itself  have  its  edges  bevelled  so  as  to  provide  two  raw 
surfaces.    All  bleeding  having  been  arrested — if  possible  without  using  any 

'  Account  of  Operations  for  restoring  a  Lost  Nose  from  the  Integuments  of  the  Forehead,  etc. 
London,  1816. 


RHINOPLASTIC  OPERATIONS. 


847 


ligatures— the  flap  is  lightly  twisted  upon  its  root  and  adjusted  in  its  new 
position,  being  secured  with  numerous  points  of  the  interrupted  or  shotted 
suture,  or  with  the  ino;enious  tongue-and-groove  suture"  reconiniended  for 
the  purpose  by  the  late  Prof.  Joseph  Pancoast,  of  Philadelphia,  who  had 
o-reat  success  in  rhinoplastic  operations.  The  flap  should  be  supported  by 
Sently  introducing  below  it  a  plug  of  oiled  lint,  or  two  small  plugs,  one  on 
either  side  of  the  columna,  if  there  be  one,  and  a  fold  of  oiled  lint  may  be 
lio-htlv  laid  over  the  part,  to  assist  in  preserving  its  temperature.  The 
wound  on  the  forehead  may  be  partly  closed  with  harelip  pins  and  adhesive 
strips,  but  must  be  mostly  left  to  heal  by  granulation.  The  patient,  after  tlie 
operation,  should  be  put  to  bed  in  a  warm  room;  the  dressings  sliould  not  be 
disturbed  for  several  days,  when  it  will  probably  be  necessary  to  remove  the 
plug  and  introduce  a  new  one;  the  sutures  should  remain  until  Arm  union 
has  taken  place. 

The  second  stage  of  the  Indian  method  consists  in  forming  a  columna  from 
the  upper  lip,  if  one  has  not  already  been  made  from  the  forehead.  This 
may  be  done,  in  the  way  heretofore  described,  either  at  the  time  of,  or  two 
or  three  weeks  after,  the  former  operation.  As  has  been  mentioned,  Prof. 
Bennett  thinks  it  better  to  dispense  with  the  columna  altogether. 

The  third  and  final  stage  consists  in  separating  the  root  of  the  frontal  flap, 
which  should  not  be  done  until  at  least  a  month  after  the  first  operation.  A 
narrow  bistoury  is  thrust  beneath  the  pedicle,  and  made  to  cut  its  way  up- 
wards, removing  a  wedge-shaped  portion  so  as  to  give  a  smooth  bridge  to  the 
nose;  or  Fergusson's  plan  may  be  adopted,  the  root  of  the  new  nose  itself 
being  cut  into  a  wedge,  and  laid  into  a  groove  made  for  it  in  the  forehead. 

The  size  of  the  opening  or  openings  left  for  the  admission  of  air,  must  be 
maintained  by  the  patient's  wearing,  for  several  months,  a  tube  or  tubes  of 
silver  or  gutta-percha.  The  results  of  the  Indian  operation  are  commonly 
quite  satisfactory,  though  failure  may  ensue  from  the  flap  sloughing,  or  from 
a  recurrence  of  the  disease  which  rendered  the  operation  necessary.  In  one 
of  Liston's  cases,  secondary  hemorrhage  followed  on  the  ninth  day,  and  death 
even  has  resulted,  in  the  practice  of  a  no  less  distinguished  operator  than 
Dietlenbach. 

Syme's  Method. — This  mode  of  operating,  which  w^as  introduced  by  the 
late  Prof.  Syme,  of  Edinburgh,  aims  to  utilize  the  tissues  of  the  cheeks,  from 
which  flaps  are  taken,  and  united  in  the  median  line  by  sutures,  while  their 
outer  edges  are  attached  to  raw  surfaces  which  have  been  previously  prepared 
at  a  suitable  distance  from  the  nostrils.  The  nose  made  by  this  method  is 
apt  to  be  rather  flat,  to  prevent  which  it  might  be  well  to  keep  it  pressed 
forward,  until  the  occurrence  of  union,  by  fastening  the  sides  together  with 
steel-pointed  silver  needles,  in  the  way  already  described  in  speaking  of  the 
treatment  of  depressed  nose. 

Wood's  Method.— Prof.  John  Wood,  of  King's  College,  London,  following 
in  the  same  lines  as  in  his  ingenious  operation  for  extroverted  bladder,  em- 
ploys an  inverted  flap,  taken  from  the  upper  lip  and  elongated  by  separating 
its  mucous  from  its  cutaneous  surface,  from  the  ro(^t  of  the  flap  to,  but  not 
through,  its  free  border,  and  then  covers  this  with  lateral  flaps  derived  from 
the  cheeks. 

Ollier's  Method. — Prof.  Oilier,  of  Lyons,  likewise  employs  an  inverted 
flap,  but  taken  from  the  forehead  and  made  to  include  the  periosteum,  and 
covers  it  with  side  flaps  taken  by  preference  from  the  stump  of  the  nose. 


I 


848      DISEASES  A^D  INJURIES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 

Finally,  I  feel  bound  to  say  that,  in  some  cases,  it  may  be  better  not  to 
attempt  any  rhinoplastic  operation,  bat  to  be  satisfied  with  the  adaptation 
of  an  artificial  nose,  which  may  be  supported  by  a  spectacle-frame,  and  kept 
in  place  hy  the  pressure  of  a  light  spring  within  the  nostrils.  The  best 
material  for  the  manufacture  of  artificial  noses,  is  said  by  Prof.  N.  W.  Kings- 
ley,  of  I^ew  York,  who  has  been  quite  successful  in  this  branch  of  prothetic 
surgery,  to  be  the  substance  which  is  known  to  dentists  as  "  rose  pearL"  and 
which  is,  I  believe,  a  preparation  of  collodion.] 


INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS, 

AND  LIPS. 


BY 

ALFRED  C.  POST,  M.D.,  LL.D., 

EMERITUS  PROFESSOR  OF  CLINICAL  SURGERY  IN  THE  UNIVERSITY  OF  THE  CITY  OF  NEW  YORK,  CONSULTING 
SURGEON  TO  THE  NEW  YORK  HOSPITAL,  ST.  LUKE's  HOSPITAL,  THE  PRESBYTERIAN  HOSPITAL, 
AND  THE  woman's  STATE  HOSPITAL. 


Wounds  of  the  Cheeks. 

These  are  often  attended  with  considerable  hemorrhage,  from  division  of 
branches  of  the  facial  and  transverse  facial  arteries.  There  is,  for  the  most 
part,  no  difficulty  in  securing  these  vessels  by  torsion  or  b}^  ligature.  When 
the  wounds  are  deep  and  extensive,  they  should  be  accurately  closed  by  fine 
sutures,  as  in  this  situation  agglutinative  plasters  are  entirely  unreliable. 
When  the  wound  involves  the  duct  of  Steno,  there  is  danger  that  it  will  be 
followed  by  salivary  fistula.  This  is  to  be  guarded  against  by  extending  the 
wound  freely  into  the  buccal  cavity,  and  by  special  cai-e  in  the  accurate  adjust- 
ment of  the  edges  of  the  divided  skin.  When  the  tacial  nerve  or  its  branches 
are  divided,  the  muscles  to  which  they  are  distributed  will  be  paralyzed.  It  is 
important,  in  such  cases,  that  the  divided  ends  of  the  nerve  should  be  brought  in 
contact,  and  secured  by  fine  sutures.  If  a  twig  of  the  trifacial  nerve  should  be 
included  between  the  edges  of  the  wound,  it  may  become  the  seat  of  neuralgic 
pains,  and  in  such  cases  the  affected  portion  of  the  cicatrix  should  be  excised. 

Badly  lacerated  or  contused  wounds,  and  gunshot  wounds,  of  the  face, 
may  lead  to  sloughing  with  considerable  loss  of  substance,  followed  by  cica- 
tricial contractions  which  distort  the  features  and  cause  morbid  adhesions  of 
the  lips  and  cheeks  to  the  jaw-bones.  Great  care  should  be  taken,  during  the 
treatment  of  such  wounds,  to  guard  against  these  distortions  and  adhesions. 
In  many  cases,  these  unpleasant  effects  cannot  be  altogether  prevented,  but 
in  most  instances  they  may  be  subsequently  remedied,  in  part  at  least, 
by  plastic  operations.  The  face  is  often  much  disfigured  by  a  deeply  de- 
pressed cicatrix,  occasioned  by  adhesion  of  the  skin  to  the  periosteum  or  bone. 
I  have  succeeded  in  relieving  this  disfigurement  by  the  very  ingenious  opera- 
tion introduced  by  Mr.  Wm.  Adams,  of  London. ^  This  operation  consists  in 
the  free  subcutaneous  division  of  the  constricting  band,  followed  by  the 
elevation  of  the  cicatrix  above  the  level  of  the  surrounding  inte2:ument, 
this  position  being  maintained  for  three  days  by  means  of  two  harelip  pins 
crossing  each  other  at  right  angles. 

Poisoned  wounds  of  the  face  are  not  uncommon,  such  as  are  inflicted  by 
the  stings  of  bees,  wasps,  and  hornets,  and  by  the  bites  of  spiders.  The 


'  British  Med.  Journal,  April  29,  1876. 

VOL.  IV.— 54 


(849) 


850 


INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


burning  heat  and  pain,  and  the  other  inflammatory  symptoms,  are  promptl\) 
reheved  by  the  application  of  a  strong  solution  of  bicarbonate  of  sodium 

Severe  inflammatory  swellings  of  the  face  are  also  occasioned  by  contact 
with  poison-ivy.  Among  the  remedies  which  have  been  highly  recommended 
for  the  relief  of  these  symptoms  are  saturated  solutions  of  sulphite  and  hypo- 
sulphite of  sodium ;  liquor  sodse  chlorinatse  of  full  strength,  or  diluted  with 
from  three  to  six  parts  of  water ;  and  bromine  dissolved  in  olive  oil  g-tt 
XX  to  f^j.i  '  ^ 


Facial  Paralysis. 

The  facial  nerve  may  be  paralyzed  in  consequence  of  a  wound  dividing  its 
trunk,  or  from  pressure  in  any  part  of  its  course,  within  or  without  the 
cranium.  Paralysis  may  result  from  exposure  to  a  draft  of  cold  air,  and  from 
other  causes,  some  of  which  are  quite  obscure.  The  face  is  drawn  towards 
the  opposite  side,  the  mouth  cannot  be  perfectly  closed,  the  eyelids  of  the 
aflfected  side  remain  widely  open,  and  the  eyeball  is  exposed  to  injury 
When  the  paralysis  is  the  result  of  division  of  the  nerve,  the  divided  ends 
may  be  united  by  suture.  When  it  occurs  from  other  causes,  benefit  may 
sometimes  be  derived  from  the  use  of  electricity,  and  from  the  administration 
of  strychnia,  either  by  the  mouth  or  hypodermically. 


Salivary  Fistula. 

This  may  be  the  result  of  wounds,  burns,  or  sloughing  or  phao-edenic 
ulceration,  involving  the  duct  of  Steno.  The  outflow  of  saliva  is  an  occasion 
of  much  annoyance  to  the  patient,  and  it  sometimes  taxes  the  ingenuity  of 
the  surgeon  to  efi:ect  a  cure.  The  main  indication  for  treatment  is  to  establish 
a  free  communication  between  the  duct  and  the  interior  of  the  buccal  cavity 
and  to  close  the  external  orifice  of  the  fistula.  This  object  may  sometimes 
be  accomplished  by  introducing  a  seton  or  tent  through  the  fistula  hito  the 
cavity  of  the  mouth,  and  wearing  it  until  a  sufiSciently  large  internal  orifice 
has  become  established,  and  then  closing  the  external  orifice,  either  by  the 
application  of  the  actual  cautery  or  by  paring  its  edges  and  drawing;  them 
together  with  sutures.  In  obstinate  cases,  after  establishing  the  internal 
opening,  the  external  orifice  may  be  closed  by  a  plastic  operation. 

Desault  gives  minute  directions  for  the  cure  of  salivary  fistula  by  seton  ^ 

In  cases  of  unusual  difficulty,  the  fistulous  orifice,  with  the  portion  of  the 
duct  communicating  with  it,  may  be  dissected  from  the  surrounding;  parts 
and  introverted  into  the  cavity  of  the  mouth,  where  it  may  be  fixed  with 
silver  wire  sutures.  Operations  of  this  kind  have  been  performed  by 
Langenbeck,  Van  Buren,  J.  R.  Wood,  and  Erskine  Mason.^  Dr.  H.  H. 
Smith,  in  his  work  on  Operative  Surgery,  describes  an  operation  devised  by 
the  late  Dr.  Horner,  who  punched  a  hole  through  the  cheek,  makino-  a 
free  opening  into  the  buccal  cavity,  and  then  closed  the  external  wound.  * 

Rodolfi  succeeded  in  closing  a  salivary  fistula  by  painting  the  surface  with 
collodion.'* 

'  See  Med.  Record,  July  12,  1879,  p.  46  ;  Aug.  2,  p.  117;  Sept.  20,  p.  284 :  Avr.  20  1878  r> 
320 ;  and  July  1,  1873,  p.  313.  ^       '         '  ^' 

^  ffiuvres  Chirurgicales  de  Desault,  par  Bichat,  tome  ii.  p.  221. 
3  See  Med.  Record,  Aug.  7,  1880,  p.  163. 
*  Gazz.  Med.  Ital.  Lombard.,  t.  iii.  1854. 


4 


FACIAL  NEURALGIA  OR  TIC  DOULOUREUX. 


851 


Facial  Neuralgia  or  Tic  Douloureux. 

This  is  an  exceedingly  painful  aflection  of  the  nerves  of  the  face,  chiefly 
affecting  the  branches  of  the  fifth  pair.  It  may  be  the  result  of  traumatic 
lesions,  or  it  may  occur  from  malarial  exposure,  or  from  a  variety  of  consti- 
tutional or  local  causes.  Its  most  common  cause  is  direct  irritation  of  the  dental 
nerves,  but  it  may  be  the  result  of  reflex  irritation  originating  in  parts  more  or 
less  remote.  The  pain  often  occurs  in  paroxysms  of  frightful  severity,  aggra- 
vated even  by  the  slightest  touch  or  motion  of  the  atfected  parts.^  During 
the  intervals  between  the  paroxysms,  the  remissions  are  often  quite  incom- 
plete, and  the  sufferings  of  the  patient  are  so  severe  and  persistent,  as  to 
render  life  an  almost  intolerable  burden. 

Treatmeyit. — Special  attention  should  be  paid  to  the  causal  ^  indication. 
When  the  neuralgic  pains  are  the  result  of  reflex  irritation,  the  primary  cause 
should  be  carefully  investigated,  and  appropriate  remedies  should  be  employed 
to  remove  it,  or  to  counteract  its  agency. 

When  the  neuralgia  is  the  result  of  direct  irritation  of  the  branches  of  the 
fifth  pair  of  nerves,  relief  may  sometimes  be  afforded  by  powerful  revulsion, 
as  by  the  application  of  the  moxa  or  the  actual  cautery.  Bartholow  cured 
several  cases  by  injecting  chloroform  deeply  into  the  tissues  in  the  vicinity 
of  the  nerve  involved  in  the  disease.  He  injected  half  a  drachm,  passing 
the  needle  from  the  border  of  the  upper  lip  to  the  vicinity  of  the  infraorbital 
foramen.^  Dr.  J.  B.  Mattison,  of  Chester,  J.,  adopted  the  same  treatment, 
injecting  20  minims  of  chloroform.  There  was  severe  pain  at  first,  followed 
by  complete  relief.^ 

Dr.  Henry  Hunt  published  a  treatise  on  tic  douloureux,  in  London,  in 
1844.  He  entered  largely  into  the  etiology  and  the  medical  treatment  of  the 
disease.  He  regarded" it  as  often  due  to  functional  disorder  or  organic  disease 
of  the  digestive  organs,  atonic  dyspepsia  being  one  of  its  common  causes. 
When  the  tongue  was  heavily  furred,  and  the  urine  turbid,  he  recommended  an 
emetic  at  the^beginning  of  the  treatment,  followed  by  a  mercurial  cathartic. 
After  this  preparatory  treatment,  he  often  gave  wath  advantage  Fowler's 
solution,  beginning  with  four  minims,  and  gradually  increasing  the  dose  to 
ten  or  twelve  minims  three  times  a  day.  When  this  disagreed  with  the 
patient,  he  gave  two  or  three  minims  of  Scheele's  prussic  acid,  and  small 
doses  of  nitrate  of  potassium,  with  three  or  four  grains  of  James's  powder 
at  bedtime.  He  attached  much  importance  to  the  use  of  warm  clothing, 
and  to  moderate  exercise  in  the  open  air,  avoiding  fatigue,  especially  just 
before  or  after  eating.  For  the  relief  of  the  severe  paroxysms  of  pain  which 
continued  after  the  removal  of  visceral  congestion,  he  prescribed  opium,  bel- 
ladonna, camphor,  and  other  narcotics.  Among  these  he  found  belladonna 
the  most  efiicient.  In  severe  cases  he  gave  one  grain  of  the  extract  hourly, 
until  three  grains  had  been  given.  He  then  suspended  the  remedy  and 
watched  the  "case.  After  the  first  strong  impression,  he  usually  found  that 
smaller  doses  suflaced.  He  always  avoided  the  use  of  anodynes  while  there 
were  symptoms  of  visceral  congestion.  As  a  local  application  affording  tem- 
porary relief.  Hunt  recommended  an  ointment  composed  of  one  grain  of  aco- 
nitine  and  one  ounce  of  cerate,  rubbed  upon  the  part  for  two  or  three  minutes 
at  a  time,  and  repeated  twice  a  day.  Dr.  Hunt  had  seen  excellent  results 
from  the  removal  of  neuralgic  patients  from  low  and  damp  places  to  a  high 
and  dry  locality. 

When  neuralgia  is  evidently  the  result  of  exposure  to  malaria,  and  when 


1  Med.  and  Surg.  Reporter,  No.  871. 


8  Med.  Record,  May  1,  1874,  p.  227. 


852 


INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


the  paroxysms  recur  at  regular  intervals,  it  may  sometimes  be  cured  by  large 
doses  of  quinine.  The  internal  use  of  aconitine  has  been  highly  recommended 
in  the  treatment  of  neuralgia.  It  was  brought  to  the  attention  of  the  pro- 
fession by  Dr.  Gubler,  who  published  an  article  on  the  subject  in  1877.i 
Prof.  Grubler  used  Hottot's  preparation  of  nitrate  of  aconitine,  commencing 
with  doses  of  -j-io  gi'^in  and  increasing  them  when  necessary  to  2:rain. 
He  regarded  heart-disease  as  contraindicating  the  drug.  Dr.  E.  C.  Seguin^  has 
published  a  report  made  to  the  ^ew  York  Therapeutical  Society,  giving  hm 
experience  in  the  use  of  aconitine  in  facial  neuralgia.  He  has  obtauied  good 
results  from  the  use  of  this  remedy.  The  internal  use  of  salicylate  of  sodium 
in  doses  of  from  1  to  5  grammes  daily  has  been  recommended  by  Dr.  Descroi- 
zelles.3  Dr.  Howard  Pinkney  reports  a  case  of  facial  neuralgia  of  two  years^ 
standing,  cured  by  the  use  of  sulphite  of  sodium,  in  scruple  doses  four  time& 
a  day  Relief  has  been  afforded  by  the  use  of  tonga.^  Drs.  Rockwell,  Beard, 
and  i^eftel  report  successful  results  from  the  employment  of  electricity.^ 
Cases  are  said  to  have  been  cured  by  hypodermic  injections  of  a  two-per-cent. 
solution  of  carbolic  acid.' 

Lennox  Brown  highly  recommends  the  external  application  of  a  mixture 
of  equal  parts  of  chloral  hydrate  and  camphor.^  Dr.  J.  Mason  Warren,  in 
his  Surgical  Observations,  relates  cases  in  which  great  relief  was  afforded  by 
the  persistent  use  of  hypodermic  injections  of  morphia.  In  some  of  these 
cases,  a  permanent  cure  seems  to  have  been  effected.  An  ointment  of  vera- 
trine,  10  grs.  to  §j,  has  been  used  as  an  external  application  with  marked 
advantage,  being  rubbed  over  the  painful  parts  at  intervals  of  two  or  three 
hours. 

The  division  of  the  affected  branches  of  the  fifth  pair  of  nerves  has  been 
resorted  to  in  a  large  number  of  cases.  In  some  of  these,  complete  relief  has 
followed  the  operation,  but  in  most  instances  the  pain  has  returned  after  a 
longer  or  shorter  interval.  The  mere  division  of  the  nerve  generally  fails 
to  afford  a  permanent  cure.  Excision  of  a  considerable  portion  of  the  nerve 
yields  better  results,  but  in  many  cases  the  cure  is  not  permanent.  The 
operation  of  neurectomy  is  often  unsuccessful,  because  the  nerve  is  not  excised 
sufficiently  near  to  its  origin.  Dr.  Carnochan,  of  ^^'ew  York,  is  entitled  to 
the  credit  of  having  first  d^irected  the  attention  of  surgeons  to  this  important 
fact  in  the  case  of  the  superior  maxillary  nerve,  and  of  having  devised  an  ope- 
ration for  the  excision  of  the  nerve  in  the  immediate  vicinity  of  the  foramen 
rotundum.  He  performed  this  operation  for  the  first  time  on  the  16th  of 
October,  1856.^  He  raised  a  triangular  flap,  bounded  by  two  incisions  extend- 
ing downward^  and  outward  from  the  inner  canthus,  and  downward  and 
inward  from  the  outer  canthus,  meeting  at  a  point  half  an  inch  in  a  vertical 
line  below  the  infra-orbital  foramen.  From  the  apex  of  this  triangular  flap,, 
a  sharp-pointed  straight  bistoury  was  next  thrust  through  the  cheek  into  the 
cavity  of  the  mouth,  and  an  incision  was  carried  downward  and  inward 
through  the  upper  lip,  dividing  it  completely  to  a  point  midway  between 
the  median  line  and  the  labial  commissure.    The  upper  triangular  flap 

1  Gaz.  Hebdom.,  9  Fev.  1877;  Am.  Journ.  Med.  Sci.,  April,  1877  ;  Practitioner,  Aug.  1877. 

2  New  York  Med.  Journal,  Dec.  1878.  He  has  published  another  paper  on  the  subject  in  the- 
Archives  of  Medicine,  Aug.  1881,  p.  89.  See  also  Med.-chir.  Rundschau,  Aug.  1878  ;  Med. 
Record,  Dec.  28,  1878,  p.  512. 

3  Progres  Medical,  21  Jnillet,  1877;  Med.  Record,  Sept.  1,  1877,  p.  558. 

4  Med.  Record,  Dec.  1,  1868,  p.  433. 

6  Lancet,  March  6,  1880;  Med.  Record,  May  8,  1880,  p.  513. 

6  Med.  Record,  March  15,  1869,  p.  28  ;  June  15,  1869,  p.  169  ;  Feb.  1870,  p.  97. 

'  Allg.  med.  Cent.-Zeitung,  6  Sept.  1876  ;  Med.  Record,  Nov.  18,  1876,  p.  750. 

8  Brit.  Med.  Journal;  Med.  Record,  Aug.  1,  1874,  p.  404. 

•  American  Journal  of  the  Medical  Sciences,  January,  1858. 


BUKNS  OF  THE  LIPS  AND  CHEEKS  FROSTBITE. 


853 


way  dissected  upward,  and  the  two  lower  flaps  were  turned,  one  inward 
toward  the  nose,  and  the  other  outward  over  the  malar  bone.  The  ante- 
rior surface  of  the  superior  maxillary  bone,  and  the  lower  margin  of  the 
orbit,  were  thus  exposed  to  view.  The  crown  of  a  tix^phine,  three-quarters 
of  an  inch  in  diameter,  was  then  applied  to  the  anterior  wall  of  the  antrum, 
just  below  the  infra-orbital  foramen,  and  a  disk  of  bone  was  removed,  exposing 
the  cavity.  The  anterior  portion  of  the  trunk  of  the  nerve  was  now  ex[)Osed. 
The  infra-orbital  canal  was  next  laid  open  with  a  delicate  chisel  and  a 
hammer,  and  the  posterior  wall  of  the  antrum  dealt  with  in  like  manner, 
exposing  the  nerve  in  the  spheno-maxillary  fossa.  The  posterior  dental 
nerves  were  divided,  as  also  the  branches  going  to  Meckel's  ganglion,  and 
the  branch  running  up  to  the  orbit.  Lastly,  the  trunk  of  the  nerve  was 
divided  with  blunt-pointed  scissors,  curved  on  the  flat,  close  to  the  foramen 
rotunduni.  The  hemorrhage  was  not  profuse,  and  the  edges  of  the  wound 
were  brought  together  with  thirteen  points  of  twisted  suture.  Fourteen 
months  after  the  operation  the  patient  was  in  good  health,  and  was  entirely 
free  from  neuralgic  pain.  Dr.  Carnochan  reported  two  other  cases  in  which  he 
had  performed  the  same  operation  with  results  which  were  good,  although 
a  sufficiently  long  time  had  not  elapsed  to  test  the  permanence  of  the  cure. 

Dr.  Carnochan's  operation  has  been  repeated  by  a  number  of  surgeons,  with 
variable  success.  The  operations  of  neurotoni}"  and  neurectomy  have  also 
been  performed  with  more  or  less  success  on  the  ophthalmic  and  infci*ior 
dental  branches  of  the  fifth  pair  of  nerves.\ 

As  a  substitute  for  neurectomy,  the  operation  of  nerve-stretching  has  been 
resorted  to  with  some  measure  of  success  in  the  treatment  of  facial  neuralgia, 
as  well  as  in  that  of  other  nervous  disorders.^ 


Burns  of  the  Lips  and  Cheeks. 

These  injuries  are  of  frequent  occurrence.  They  are  very  painful,  and 
greatly  interfere  with  the  prehension  ot  food.  When  they  are  deep,  they  are 
very  apt  to  be  followed  by  cicatricial  contractions,  w^hich  distort  the  features 
and  greatly  disfigure  the  patient.  Special  care  is  required  to  guard  against 
such  distortions.  When  the  face  is  burned  by  the  explosion  of  gunpowder, 
the  grains  of  powder  are  often  deeply  imbedded  in  the  skin  ;  they  should 
be  carefully  removed,  one  by  one,  while  the  patient  is  under  the  influence  of 
an  anaesthetic. 

Frostbite. 

The  lips  and  cheeks  may  he  injured  by  exposure  to  severe  cold,  and  ulcera- 
tion, or  sloughing,  may  be  the  result.    The  sores  may  be  treated  by  the 

>  See  Annals  of  Anatomy  and  Surgery  of  Brooklyn,  April  and  May,  1880  ;  Med.  Record,  Nov.  1, 
1871,  p.  392  ;  Jan.  2,  1872,  p.  485  ;  Aug.  18,  1877,  p.  520  ;  June  5,  1880,  p.  620  ;  Aug.  13,  1881, 
p.  187;  Nov.  15,  1879,  p.  468;  La  France  Medicale,  16  Juin,  1877;  New  York  Med.  Journal, 
June,  1879;  Ernst  Burow,  Mittheilungen  aus  der  chirurgischen  Privat^Klinik,  1875-1877; 
Transactions  of  Am.  Med.  Association,  1880;  J.  M.  Warren,  Surgical  Observations;  Med.  and 
Surg.  Reporter,  1869  ;  Med.  Record,  Aug.  16,  1869,  p.  271 ;  Oct.  1,  1869,  pp.  345  and  346  ;  Apr.  1, 
1868,  p.  60;  Jan.  2,  1872,  p.  485  ;  Dec.  15,  1877,  p.  792;  June  19,  1880,  p.  701  ;  Oct.  23,  1880, 
p.  449;  Am.  Jour.  Med.  Sciences,  1868  and  1869;  Cincin.  Lancet  and  Observer,  1869;  Detroit 
Med.  Journal,  Nov.  1877  ;  New  England  Journal  of  Medicine  and  Surgery,  vol.  xii.  p.  216  ;  New 
York  Journal  of  Medicine,  Nov.  1856  ;  Transactions  of  King's  County  Med.  Soc,  1877. 

2  See  Brit.  Med.  Jour.,  Oct.  18,  1879;  Med.  News  and  Abstract,  .Tan.  1880,  p.  49  ;  Quarterly 
Epitome  of  Pract.  Medicine  and  Surgery,  March,  1880,  p.  86;  London  Med.  Record:  Hosp. 
Gazette;  Med.  Record,  March  27,  1880,  p.  346  ;  July  24,  1880,  p.  Ill  ;  Aws.  14.  1880.  pp.  172, 
183 ;  Jan.  15,  1881,  p.  71  ;  Jan.  22,  1881,  p.  107  ;  Aug.  13,  1881,  p.  180  ;  Aug.  27,  1881,  p.  245! 


854  INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS 


application  of  a  stimulating  ointment  made  by  the  mixture  of  5j  or  5ij  of  oil 
of  turpentine,  or  of  Peruvian  balsam,  with  of  vaseline.  The  healing  pro- 
cess may  be  attended  by  cicatricial  contraction,  requiring  the  same  treatment 
as  that  which  is  demanded  when  contraction  attends  the  healing  of  a  burn 
or  other  severe  injury. 


Facial  Erysipelas. 

The  integument  of  the  face  is  peculiarly  liable  to  erysipelatous  inflamma- 
tion. This  may  occur  as  a  consequence  of  local  injury,  or  it  may  be  the  result 
of  constitutional  causes.  It  ma^'  occur  sporadically,  or  it  may  be  endemic^ 
as  in  the  wards  of  a  hospital.  It  is  especially  apt  to  occur  where  cleanliness 
and  ventilation  are  neglected.  It  is  apt  to  be  communicated  by  foul  sponges 
and  other  similar  appliances.  It  may  be  simple  or  phlegmonous  in  its 
character.  Its  general  course  is  the  same  as  that  of  erysipelas  in  other  parts 
of  the  body,  but  the  prognosis  is  more  unfavorable,  as  the  inflammation  is 
very  apt  to  involve  the  brain  and  its  membranes.  The  treatment  should  be 
prompt  and  active,  to  arrest  the  disease  as  early  as  possible.  Laxatives  and 
diaphoretics  may  be  administered  at  the  very  beginning  of  the  disease,  fol- 
lowed by  tonics,  such  as  the  sulphate  of  quinia,  or  the  tincture  of  the  sesqui- 
chloride  of  iron.  As  local  applications,  blisters  may  be  applied  to  the  sur- 
face, or  the  inflamed  parts  may  be*painted  with  tincture  of  iodine,  or  covered 
w^ith  cloths  moistened  with  a  solution  of  sulphate  of  iron,  5ij  to  Oj  ;  or  hypo- 
dermic injections  may  be  made  of  a  2J  per-cent.  solution  of  carbolic  acid. 

Malformations  and  Deformities  of  the  Cheeks  and  Lips. 

Macrostoma. — This  term  is  used  to  indicate  a  condition  in  which  the 
opening  between  the  lips  is  abnormally  large,  so  as  to  constitute  a  marked 
deformity.  The  commissures  of  the  lips  may  be  extended  outward  and 
backward  into  the  cheeks,  on  one  or  both  sides,  in  a  horizontal  line,  or 
obliquely  upward  or  downward.  The  deformity  may  be  congenital,  or  it 
may  be  the  result  of  a  wound  imperfectly  healed.  It  may  be  successfully 
treated  by  paring  the  edges  of  the  fissure,  and  uniting  them  by  sutures.  In 
this  w^ay,  the  mouth  may  usually  be  restored  to  its  normal  size  and  shape. 

Microstoma. — This  name  indicates  a  deformed  condition  in  w4iich  the  labial 
orifice  is  abnormally  small.  It  may  be  congenital,  or  it  may  be  the  result  of 
cicatricial  contraction,  following  a  burn,  sloughing,  or  phagedenic  ulceration. 
In  some  cases,  the  opening  of  the  lips  is  so  much  contracted  as  to  interfere 
with  the  introduction  of  food  into  the  mouth.  The  opening  maybe  enlarged 
by  making  a  horizontal  incision  on  each  side  into  the  cheek,  and  by  attach- 
ing the  mucous  membrane  to  the  skin  by  a  number  of  fine  sutures.  When  the 
tissues  are  very  much  consolidated  by  cicatricial  contraction,  there  will  be 
diflftculty  in  maitjtaining  the  opening,  and  it  will  be  necessary  to  stretch  the 
parts  mechanically,  and  to  maintain  the  dilatation  for  a  long  period.  Tljis 
dilatation  may  be  eflected  by  metallic  arcs  introduced  into  the  angles  of  the 
mouth,  after  free  incisions  have  been  made,  and  drawn  asunder  by  elastic 
bands  passing  around  the  back  of  the  neck. 

Atresia  Oris. — This  is  described  by  authors  as  a  congenital  defect,  in 
which  the  anterior  buccal  orifice  is  entirely  wanting.  If  such  a  malforma- 
tion should  be  met  with,  it  would  be  necessary  to  make  a  horizontal  incision 


MALFORMATIOXS  AND  DEFORMITIES  OF  THE  ri[EEKS  AND  LIl'S, 


855 


into  the  cavity  of  the  mouth,  and  to  form  a  vermilion  border  for  each  of  the 
newly  constructed  lips  by  uniting  the  mucous  membrane  with  the  skin. 

Distortions  of  the  mouth  in  various  direc^tions  may  be  the  result  of  cica- 
tricial contraction  from  burns,  or  from  other  causes.  The  angles  of  the 
mouth  may  be  drawn  upward,  or  downward,  or  outward  and  backward  ;  or 
the  lips  may  be  widely  separated  from  each  other,  so  that  the  mouth  cannot 
be  closed,  and  the  saliva  cannot  be  retained.  Something  may  be  done,  dur- 
ing the  process  of  cicatrization,  to  prevent  these  distortions,  or  to  diminish 
their  extent.  The  principal  means  to  be  employed  for  this  purpose  are  the 
free  application  of  caustic,  methodical  pressure  by  adhesive  phisters  and 
baudasces — to  repress  the  growth  of  exuberant  granulations — and  the  stretch- 
'm%  of  the  affected  parts  in  the  opposite  direction  to  the  threatened  distortion. 
When  a  large  granulating  surface  is  exposed,  benefit  may  often  be  derived 
from  skiu-grafliug,  inserting  small  pieces  of  very  thin  integument  in  the 
midst  of  the  granulations,  covering  them  with  goldbeaters'  skin,  and  main- 
taiuing  close  contact  for  several  days  by  strips  of  adhesive  plaster  and 
bandages.  When  cicatrization  has  already  taken  place,  and  dense  bands  of 
iuodular  tissue  have  greatly  distorted  the  buccal  orifice,  these  bands  should 
be  freely  divided  through  their  whole  breadth  and  depth  by  a  number  of 
parallel  incisions,  and  the  healing  process  should  be  retarded  by  keeping  the 
affected  parts  upon  the  stretch,  and  by  frequently  repeated  passive  movements. 
Or,  in  appropriate  cases,  a  single  free  and  deep  incision  may  be  made  through 
the  cicatricial  band,  the  margin  of  the  lip  may  be  at  once  brought  into  its 
proper  position,  and  a  flap  of  integument  from  the  vicinity  may  be  inserted, 
so  as  to  till  up  the  chasm  produced  by  the  incision  and  by  the  reposition  of 
the  labial  margin. 


Hypertrophy  of  the  Lips. — This  occurs  sometimes  as  a  congenital  affec- 
tion, or  it  may  commence  at  a  period  subsequent  to  birth.  It  may  in- 
volve either  lip  or  both.  When 

it  exists  to  any  considerable  Fig-  996. 

extent,  it  constitutes  a  very 
conspicuous  deformity,  and 
seriously  interferes  with  the 
functions  of  the  lips.  It  pre- 
sents itself  in  two  forms,  partial 
and  general.  Partial  hyper- 
trophy, which  affects  chiefly 
the  upper  lip,  involves  the 
mucous  membrane  and  the 
submucous  cellular  tissue,  and 
is  usually  more  prominent  on 
either  side  than  in  the  median 
line.  It  has  been  described  by 
writers  as  Doable  Lip.  It  is 
cured  by  excising  the  hyper- 
trophied  parts  and  bringing 
together  the  edges  of  the  wound 
with  sutures.  Dr.  Agnew,  in 
his  work  on  Surgery,^  gives  a 
wood-cut  of  Double  Lip.  (Fig. 
996.)    General  hypertrophy  of  the  lip  involves  the  skin  and  mucous  membrane 


Double  lip.    (After  Agnew.) 


J  Principles  and  Practice  of  Surgery,  vol.  ii.  p.  891. 


856  INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


with  all  the  intervening  tissues.  It  is  treated  by  excision  of  a  wedge- 
shaped  segment  of  the  lip,  the  base  of  the  wedge  corresponding  with  the 
vermilion  border.  An  interesting  case  of  this  deformity,  illustrated  by 
wood-cuts,  is  described  by  Dr.  BuclE.^ 


Harelip. 

Harelip  is  a  congenital  malformation  of  the  upper  lip,  resulting  from  arrest 
of  development,  and  presenting,  in  the  more  mature  state,  a  continuance 
of  that  which  is  the  normal  condition  in  the  earlier  stages  of  embryonic 
development.  It  derives  its  name  from  its  resemblance  to  the  cleft  which 
exists  in  the  upper  lip  of  the  hare,  the  rabbit,  and  other  allied  animals.  It 
consists  of  a  fissure,  usually  extending  through  the  whole  thickness  of  the 
lip,  from  the  nose  to  the  vermilion  border"  There  are  several  varieties, 
indicated  by  the  names  single  and  double,  simple  and  complicated.  The 
term  single  implies  that  there  is  but  one  fissure.  The  term  double  denotes 
that  there  are  two.  A  simple  harelip  is  one  in  which  there  is  no  concomi- 
tant malformation  of  the  upper  jaw  or  palate.  A  complicated  harelip  is 
one  in  which  there  is  a  deviation  from  the  normal  development  of  the  jaw 
or  palate,  or  in  which  the  malformation  involves  both  of  these  parts. 

In  a  single  harelip^  the  fissure  is  rarely  situated  exactly  in  the  median 
line.  In  the  large  majority  of  cases  it  is  on  the  left  side,  so  that  the  right 
portion  of  the  lip  is  broader  than  the  left.  In  some  cases  the  fissure  in- 
volves only  the  lower  portion  of  the  lip,  not  extending  up  to  the  nose.  In 
some  cases  the  margins  of  the  fissure  are  nearly  parallel,  and  are  almost  in 
contact,  while  in  other  cases  they  are  widely  divergent  towards  the  free 
border  of  the  lip. 

In  double  harelip,  the  two  fissures  are  usually  on  the  two  sides  of  the 
median  line,  and  the  intermediate  portion  may  be  quite  narrow,  or  may  be 
of  considerable  breadth.  It  is  usually  broader  towards  the  nose  than  towards 
the  free  margin  of  the  lip.  In  many  cases  it  does  not  extend  as  low  as  the 
free  border  of  the  lateral  portions  of  the  lip. 

In  complicated  harelip,  the  malformation  of  the  upper  jaw  may  be  twofold. 
There  may  be  an  advance  of  the  median  portions  of  the  superior  maxillary 
bones  far  beyond  their  ordinary  position,  these  projecting  portions  being 
detached  from  the  main  body  of  the  jaw,  and  constituting  intermaxillary 
bones  such  as  exist  normally  in  some  of  the  inferior  animals.  The  middle 
incisor  teeth  are  usually  developed  in  these  intermaxillary  bones.  Or,  instead 
of  a  projection  of  the  maxillary  bones,  there  may  be  a  fissure,  single  or  double, 
extending  through  the  alveolar  portion  of  the  jaw.  The  fissure  may  also 
involve  the  bony  and  soft  palate.  In  many  cases  of  complicated  harelip,  the 
abnormal  prominence  of  the  jaws  and  fissures  of  the  bony  and  soft  palate  are 
found  to  coexist.  In  such  cases,  when  the  harelip  is  double  as  well  as  com- 
plicated, the  columna  nasi  is  generally  deficient,  and  the  portion  of  the  lip 
intermediate  between  the  two  fissures  is  attached  above  to  the  tip  of  the  nose 
and  behind  to  the  projecting  intermaxillary  bone,  and  seems  to  be  an  appurte- 
nance of  the  nose  rather  than  of  the  lip. 

In  the  majority  of  cases,  harelip  occurs  sporadically,  not  showing  any  re- 
markable tendency  to  afiect  difi'erent  members  of  the  same  family.  But  I 
have  become  acquainted  with  two  families  in  which  nearly  all  of  the  children 
presented  some  variety  of  this  malformation.  In  one  of  these  families,  the 
mother  also  had  harelip. 

'  Contributions  to  Reparative  Surg'erj,  pp.  159-164. 


HARELIP. 


857 


Demarquay  reports  the  case  of  a  family  in  which,  in  three  generations, 
eleven  persons  had  either  harelip  or  malformation  of  the  lower  lip.^ 

The  treatment  of  harelip  consists  in  paring  the  margins  of  the  fissure, 
brint'-ino-  the  two  raw  surfaces  into  close  contact  with  each  other,  and  holding 
them  too;ether  by  sutures  until  the  two  sides  of  the  lip  have  become  firndy 
united.  ^This  is  a  comparatively  easy  matter  when  the  fissure  is  both  single 
and  simple,  when  the  two  sides  of  the  lip  are  nearly  symmetrical,  when  they 
are  nearly  parallel,  and  when  they  are  not  widely  separated  from  each  other. 
But  under  less  favorable  conditions,  it  is  often  a  matter  of  great  difiiculty  to 
secure  union  of  the  two  sides  of  the  lip  without  some  remaining  deformity. 
Without  great  care  on  the  part  of  the  surgeon,  there  is  apt  to  be  a  want  of 
conformity  in  the  line  of  the  vermilion  border  on  the  two  sides  of  the  lip, 
and  there  is  often  a  more  or  less  conspicuous  notch  in  its  free  border. 

It  is  very  important,  in  order  to  insure  the  complete  success  of  the  ope- 
ration, that  the  two  sides  of  the  lip  should  be  brought  together  without 
tension,  and  that  they  should  be  maintained  in  close  contact  while,  at  the 
same  time,  the  sutures  are  so  applied  as  not  to  make  injurious  pressure. 

In  the  simplest  and  most  favorable  cases,  the  following  are  the  steps  of  the 
operation.  A  broad  bandage  is  applied  around  the  child's  trunk  and  upper 
extremities,  so  as  to  prevent  him  from  moving  his  hands  during  the  ope- 
ration. He  is  then  placed  upon  a  table  or  on  the  lap  of  an  assistant, 
brought  under  the  full  influence  of  an  anaesthetic,  and  kept  in  a  supine  i>osi- 
tion.°  A  needle  armed  with  a  strong  thread  is  next  passed  through  the  lip 
near  the  junction  of  one  side  of  the  fissure  with  the  vermilion  border,  and  the 
two  ends  of  the  thread  are  tied  so  as  to  form  a  loop  about  six  inches  in  length. 
Another  thread  in  like  manner  is  passed  on  the  other  side  of  the  fissure,  and 
its  ends  secured  in  the  same  way.  These  loops  facilitate  the  subsequent 
steps  of  the  operation,  by  enabling  the  surgeon  or  his  assistant  to  make 
traction  in  any  required  direction.  The  two  sides  of  the  lip  are  then  drawn 
together,  and  if  any  resistance  is  ofi:ered  to  their  close  approximation,  a  free 
division  of  the  mucous  membrane  and  of  the  submucous  cellular  tissue  is 
made  on  either  side  with  scissors  curved  on  the  flat,  until  the  resistance  is 
completely  overcome.  The  sides  of  the  fissure  are  now  to  be  pared  so  as  to 
present  broad  surfaces  denuded  of  integument.  This  is  best  accomplished  by 
making  downward  traction  by  means  of  the  loop  of  thread  on  one  side  of  the 
fissure,''aad  then  inserting  a  Beer's  cataract  knife  through  the  lip  just  above 
the  loop,  with  its  cutting  edge  looking^  upward,  and  cutting  up  towards  the 
nose.  The  knife  is  then  inserted  on  the  other  side  of  the  fissure,  aiid  the 
incision  completed  in  the  same  manner.  It  is  not  usually  necessary  to  tie  any 
vessels,  as  the  lip  can  be  compressed  between  the  thumb  and  finger  of  an 
assistant  until  the  surgeon  is  ready  to  apply  the  sutures.  The  edges  of  the 
wound  are  to  be  brought  together  by  a  pin  passed  through  the  two  divisions 
of  the  lip,  midway  between  its  free  border  and  the  nose.  The  pin  should  enter 
on  one  side  and  emerge  on  the  other  about  seven  or  eight  mm.  from  the  margin 
of  the  fissure,  and  should  penetrate  the  whole  thickness  of  the  lip,  except  the 
mucous  membrane.  A  number  of  turns  of  darning  cotton  should  then  be  passed 
around  the  endsof  the  pin  in  the  form  of  the  figure's.  The  sides  of  thelip  should 
be  brought  together  so  that  the  two  lateral  portions  of  the  vermilion  border 
should  exactly  correspond.  A  second  pin  should  be  applied  in  the  sanie  man- 
ner at  the  junction  of  the  skin  with  the  vermilion  border  on  each  side.  _  A 
third  suture,  of  fine  silk,  should  be  applied  near  the  junction  of  the  lip  with 
the  nose.  A  fourth  suture,  also  of  fine  silk,  may  be  applied  through  the  ver- 
milion border,  and  a  fifth  through  the  mucous  membrane.    The  two  last 


See  Med.  Record,  Oct.l,  1868,  p.  348. 


INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


named  sutures  are  often  omitted,  but  I  think  that  they  secure  a  more  perfect 
coaptation  of  the  two  divisions  of  the  lip.  I  think  it  best  to  trust  entirely 
to  the  sutures  to  hold  the  sides  of  the  lip  together,  and  to  dispense  with 
adhesive  plasters,  which  are  entirely  unnecessary,  and  which  are  a  source  of 
discomfort  and  irritation.  The  sutures  may  be  removed  on  the  fourth  or 
fifth  day,  and  then  the  lip  should  be  supported  by  a  strip  of  adhesive  plaster 
having  a  narrow  isthmus  across  the  lip,  and  a  broad  circular  expansion  over 
each  cheek.  If  the  support  of  the  adhesive  plaster  be  omitted  after  the 
removal  of  the  sutures,  there  is  reason  to  fear  that  the  unitins:  medium  may 
become  attenuated,  and  that  the  middle  portion  of  the  lip  may  present  an 
abnormal,  sunken  appearance.  The  adhesive  plaster  should  be  renew^ed  from 
time  to  time,  and  its  use  should  be  continued  for  two  or  three  weeks. 

In  cases  in  which  the  fissure  is  broad,  and  its  margins  widely  divero-ent 
towards  the  free  border  of  the  lip,  the  edges  may  be  pared  by  a  semi-ellipti- 
cal  incision  on  either  side,  the  concavities  looking  towards  each  other,  and 
in  this  way  the  formation  of  a  notch  at  the  vermilion  border  may  be  avoided 
(Figs.  997  and  998.) 

Fig-  997.  Fig.  998. 


Operation  for  harelip  with  divergent  margins. 

Or  in  cases  in  w^hich  the  divergence  is  still  greater,  the  method  of  Mal- 
gaigne,  called  by  Agnew  the  method  of  Collis,  may  be  adopted.  This  consists 
in  leaving  the  flaps  pared  from  the  margins  of  the  fissure,  attached  to  the 
vermilion  border  of  the  lip,  reflecting  them  downwards  so  that  their  raw 
surfaces  are  brought  into  contact.  These  flaps  are  trimmed  to  a  proper 
length,  and  are  then  secured  by  sutures,  so  as  to  form  a  prominence  beneath 
the  inferior  edge  of  the  lip.  (Figs.  999  and  1000.)  I  have  found  this  a  most 
eftectual  mode  of  guarding  against  the  occurrence  of  a  notch.  After  the 
wound  has  healed,  and  when  the  subsequent  contraction  has  reached  its  full 
limit,  if  the  prominence  should  continue,  it  may  readily  be  reduced  to  its 
proper  level. 

In  cases  in  which  there  is  a  marked  inequality  in  the  breadth  of  the  two 
sides  of  the  lip,  the  margin  of  the  fissure  on  the  narrower  side  may  be  pared 
three-fourths  of  the  distance  from  the  nose  to  the  vermilion  border,  the  inci- 
sion being  then  sloped  outwards  to  the  free  margin  of  the  lip,  while  on  the 
broader  side  the  incision  does  not  extend  quite  to  the  vermilion  border,  and 


Fig.  999. 


llAliELIP. 


Fig.  1000. 


Malgaigne's  operation  for  harelip. 


the  small  flap  dissected  from  the  margin  is  made  to  overlap  the  lower 
margin  of  the  narrower  side.  (Figs.  1001  and  1002.) 

Fig.  1001.  Fig-  1002. 


Operation  for  harelip  with  marked  inequality  ot  sides. 

When  the  fissure  is  very  wide,  and  when  the  lateral  portions  of  the  lip 
cannot  otherwise  be  approximated  without  undue  tension,  incisions  may  be 
made  outwards  into  the  cheeks  from  the  junction  of  the  lip  with  the  nose, 
and,  if  necessary,  from  the  angles  of  the  mouth.  .  i     .       •  p 

In  cases  of  double  harelip,  not  complicated  with  deformity  of  the  jaw,  if 
the  portion  of  the  lip  intermediate  between  the  two  fissures  is  of  considerable 
breadth,  and  extends  nearly  or  quite  down  to  the  level  of  the  free  b(^rders  of 
the  lateral  portions,  the  operation  may  first  be  performed  on  one  side,  and  after 
the  wound  has  healed,  and  when  the  union  has  become  firmly  consolidated, 
may  be  repeated  on  the  other.  But  when  the  intermediate  portion  is  of 
smaller  dimensions,  the  operation  on  both  sides  may  be  completed  at  the 
same  time. 


860  INJURIES   AND  DISEASES  OF  THE  FACE,   CHEEKS,  AND  LIPS. 

In  cases  of  harelip  complicated  with  intermaxillary  projection,  the  promi- 
nent portion  of  the  jaw  may,  in  very  early  infancy,  be  pressed 'back  to  its 
proper  level.  This  may  be  accomplished  with  the  thumb  and  fingers,  or 
with  strong  forceps  guarded  with  buckskin.  But  when  the  bone  has  become 
too  firm  to  be  reduced  in  this  way,  it  may  be  partly  divided  with  Butcher's 
forceps,  and  then  pressed  back  into  its  position.  In  children  of  larger 
growth,  or  in  persons  of  mature  age,  the  projecting  portion  of  the  jaw  must 
be  removed,  with  the  aid  of  a  saw,  chisel,  or  cutting-forceps. 

In  cases  of  double,  complicated  harelip,  where  the  columna  nasi  is  deficient 
and  where  the  intermediate  portion  of  the  lip  appears  to  be  an  appurtenance 
of  the  nose,  this  portion  of  the  lip  should  be  used  in  the  reconstruction  of  the 
columna  nasi.  For  this  purpose  it  should  be  dissected  oft"  from  the  project- 
ing portion  of  the  bone,  and  should  be  reflected  backward  so  that  its  posterior 
surface  may  be  applied  to  the  inferior  part  of  the  septum  nasi,  the  two  corres- 
ponding surfaces  being  freshened  for  the  purpose,  and  being  held  in  contact 
by  one  or  more  sutures.  It  is  best,  in  such  cases,  to  leave  the  new  columna 
of  its  full  breadth,  until  it  has  firmly  united  with  the  adjacent  parts,  and 
then  to  trim  it  to  its  proper  size  and  shape. 

There  is  a  difterence  of  opinion  among  surgeons  as  to  the  best  time  of 
operating  for  harelip,  when  the  surgeon  is  consulted  at  the  time  of  birth. 
There  is  a  general  agreement  that  the  operation  should  be  performed  before 
the  commencement  of  dentition.  In  cases  of  simple  harelip,  whether  the 
fissure  be  single  or  double,  I  would  recommend  the  performance  of  the  opera- 
tion about  three  or  four  months  after  the  birth  of  the  child,  as  at  that  time 
the  parts  have  acquired  a  good  degree  of  development,  and  the  irritation  of 
dentition  has  not  yet  commenced.  But  in  cases  of  complicated  harelip, 
whether  there  be  maxillary  projection,  or  fissure  of  the  alveolar  portion  of 
the  jaw  and  of  the  bony  palate,  it  is  better  to  operate  at  a  much  earlier  period, 
as  the  pressure  of  the  reconstructed  lip  exerts  an  important  influence  in  dim- 
inishing the  deformity  of  the  bones  while  they  are  in  a  soft  and  yielding 
condition.  Some  surgeons  recommend  the  performance  of  the  operation  on 
the  day  of  the  child's  birth.  This  practice  seems  to  me  objectionable,  as  the 
child  has  not  yet  recovered  from  the  shock  attending  the  transition  from 
intra-uterine  to  extra-uterine  life,  i^ew-born  infants  generally  lose  weight 
during  the  first  week  of  extra-uterine  life,  and  do  not  regain  what  they  have 
lost  until  after  the  lapse  of  another  week.  I  think  that  the  most  favorable 
time  for  the  performance  of  the  operation,  in  these  complicated  cases,  is  when 
the  child  is  three  or  four  weeks  old,  as  at  that  time  the  functions  of  extra- 
uterine life,  circulation,  respiration,  and  digestion,  have  become  fully  estab- 
lished, and  the  bones  of  the  face  have  not  yet  undergone  any  remarkable 
increase  of  solidification. 

If  the  surgeon  is  not  consulted  until  the  child  is  five  or  six  months  old,  it 
is  generally  best  to  defer  the  operation  until  the  first  dentition  is  completed, 
as  during  the  progress  of  dentition  children  are  more  subject  than  at  other 
periods  to  convulsions  and  other  serious  derangements  of  the  nervous  system. 

A  congenital  fissure  in  the  median  line  of  the  lower  lip  has  been  observed  in  a 
very  small  number  of  cases.    The  treatment  is  like  that  of  simple  harelip. 


Wounds  of  the  Lips. 

These  wounds  bleed  very  freely,  but  the  hemorrhage  may  be  readily 
arrested  by  torsion  or  by  ligature ;  or  the  sutures,  by  which  the  wound  is 
closed,  may  be  so  adjusted  as  to  compress  the  bleeding  vessels.    When  the 


i 


PLATE  XXXI. 


ULCERS  OF  THE  CHEEKS  AND  LIPS. 


861 


wound  involves  the  vermilion  border,  the  edges  should  be  very  carefully 
adjusted  by  sutures,  so  as  to  guard  against  the  occurrence,  of  permanent 
fissure,  and  secure  perfect  symmetry  in  the  line  of  union. 

Furuncle  and  Carbuncle  of  the  Lips. 

These  forms  of  gangrenous  inflammation  are  often  observed  in  the  lips.  » 
They  are  very  painful,  and  are  often  attended  with  marked  symptoms  of 
cerebral  disturbance,  sometimes  leading  to  fatal  results.  The  special  danger 
of  the  disease  in  this  situation  has  been  ascribed  to  absorption  of  septic  poison 
by  the  facial  vein.  The  most  reliable  treatment  consists  in  free  incision 
through  the  whole  thickness  of  the  inflamed  and  indurated  parts,  followed 
by  stimulating  dressings,  such  as  lint  moistened  with  oil  of  turpentine,  or 
balsam  of  Peru.  The  best  results  are  obtained  when  the  incision  is  made  at 
a  very  early  period  of  the  disease.  The  incision  should  be  made  through  the 
free  border  of  the  lip. 

At  a  very  early  stage  of  the  disease,  the  morbid  action  may  be  promptly 
arrested  by  the  application  of  a  cauterizing  needle  to  the  depth  of  three  or 
four  millimetres,  at  several  points  along  the  labial  margin.  If  this  is  done 
under  the  influence  of  an  anaesthetic,  it  is  not  a  severe  remedy,  and  it  does 
not  disfigure  the  patient. 

Fissures  of  the  Labial  Margin,  or  Cracked  Lips. 

These  are  usually  the  result  of  exposure  to  cold,  and  they  are  most  apt  to 
occur  when  there  is  some  derangement  of  the  general  health.  When  the  lip 
is  stretched,  they  are  very  painful,  and  they  are  disposed  to  bleed.  They 
will  generally  heal  when  they  are  protected  from  cold  and  are  occasionally 
touched  with  sulphate  of  zinc,  sulphate  of  copper,  or  nitrate  of  silver.  When 
they  are  neglected,  they  may  lead  to  deep  ulceration  of  an  intractable  character, 
sometimes  requiring  excision.  Obstinate  fissures  at  the  angles  of  the  mouth 
should  lead  to  careful  investigation  as  to  a  possible  syphilitic  origin. 

Ulcers  of  the  Cheeks  and  Lips. 

Aphthous  ulcers  of  the  mucous  membrane  of  the  lips  are  apt  to  be  very 
painful.  Great  relief  is  often  aftbrded  by  touching  them  with  sulphate  of 
zinc,  sulphate  of  copper,  or  nitrate  of  silver,  but  the  application  for  the  mo- 
ment gives  severe  pain.  Attention  should  always  be  paid  to  the  general 
health,  and  especially  to  the  digestive  organs.  A  charcoal  mixture,  or  a 
mixture  of  rhubarb  and  soda,  will  often  be  of  great  service. 

Lupus. — This  disease  may  aftect  the  lips  and  cheeks,  assuming  the  form  of 
either  lupus  exedens  or  lupus  non-exedens.  It  often  greatly  disfigures  the 
patient.  The  afiected  parts  may  be  excised,  or  they  may  be  destroyed  by  the 
actual  or  potential  cautery.  If  the  extent  of  the  disease  be  limited  within 
narrcv/  bounds,  the  edges  of  the  wound,  after  incision,  may  be  brought  into 
contact,  and  secured  by  sutures.  But  when  there  has  been  great  loss  of  sub- 
stance, a  plastic  operation  will  be  required  to  fill  up  the  chasm. 

Rodent  ulcer  and  epithelioma  (Plate  XXXI.)  may  both  occur  in  the  same 
situations  as  lupus,  and  may  require  substantially  the  same  treatment. 


862  INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 

Syphilitic  and  chancroidal  ulcers  may  occur  upon  the  lips,  the  virus  of 
the  former  being  usually  applied  in  the  act  of  kissing.    These  sores  present 
in  their  main  features  the  same  characters,  and  require  the  same  treatment,  , 
as  when  they  are  found  on  the  genitals. 

Cancer  of  the  Lip. 

This  is  a  very  common  disease  in  the  male  subject  after  the  age  of  forty- 
five  years.  It  affects  almost  exclusively  the  lower  lip,  although,  in  some 
rare  instances,  it  has  been  observed  in  the  upper  lip.  It  is  comparatively 
rare  in  females.  In  the  great  majority  of  cases  it  presents  the  characters  of 
epithelioma.  There  seems  to  be  good  reason  to  believe  that  tobacco  smoking 
plays  an  important  part  in  the  production  of  the  disease,  and  that  it  occurs 
more  frequently  in  those  who  smoke  clay  pipes,  than  in  those  who  use  other 
kinds  of  pipes,  or  who  smoke  cigars.  Dr.  J.  Mason  Warren,  in  his  Surgical 
Observations,  gives  the  statistics  of  all  the  cases  of  cancer  of  the  lip  which 
had  occurred  at  the  Massachusetts  General  Hospital  for  forty  years : — 


Whole  number  of  cases    .       .       .       .       .       .       .       .       .       .  77 

Males                                                                                            .  73 

Females         ............  4 

No.  of  those  that  smoked  pipes        ........  44 

No.  that  did  not  smoke  pipes  .        .        .        .        .        .        .        .        .  7 

Not  ascertained      .       .       .       .       .       .       .       .       .       .       .  26 


Of  the  four  women,  three  were  known  to  have  smoked  pipes.  Epithe- 
lioma of  the  lip,  in  its  earliest  stage,  may  present  itself  as  a  simple  des- 
quamation of  the  cuticle  at  the  margin  of  the  lip,  with  a  slight  induration  of 
the  subjacent  tissue,  or  there  may  be  a  crack  or  fissure,  or  a  wart-like  growth 
from  the  surface,  or  a  small,  hard  tubercle  like  a  shot  imbedded  in  the  part. 
In  either  case,  there  is  apt  to  be  some  induration,  but  it  is  often  ver^^  slight. 
The  disease,  in  its  early  stage,  is  often  quite  indolent,  scarcely  giving  rise  to 
any  symptoms,  and  frequently  remaining  many  months  without  making  any 
considerable  progress.  After  a  time,  varying  greatly  in  difi'erent  cases,  it 
assumes  a  more  active  character,  extending  along  the  vermilion  border  and 
through  the  substance  of  the  lip,  and  giving  rise  to  lancinating  pains.  At  a 
later  period,  ulceration  takes  place,  with  an  offensive  sanious  discharge,  and 
the  disease  extends  along  the  lymphatics  to  the  glands  beneath  the  base  of 
the  jaw,  and  involves  all  the  adjacent  tissues,  including  the  periosteum  and 
the  bone.  The  general  health  becomes  seriously  disturbed,  and  the  continued 
irritation  and  exhaustion,  occasioned  by  the  disease,  ultimately  destroy  the 
patient's  life. 

Treatment. — The  only  safety  of  the  patient  lies  in  the  early  and  complete 
extirpation  of  the  parts  involved  in  the  disease.  This  may  be  accomplished 
by  the  thorough  application  of  powerful  eschai'otics ;  but  their  action  is  pain- 
ful, slow,  and  uncertain  in  its  results.  Excision  with  cutting  instruments 
is  more  prompt,  more  safe,  and  more  certain,  and  is  attended  with  much 
less  pain  and  discomfort  to  the  patient.  It  is  also  followed  by  a  much 
smaller  deviation  from  the  normal  appearance  of  the  face,  and  is,  therefore, 
on  all  accounts  to  be  preferred.  When  the  disease  involves  less  than  half  of 
the  vermilion  border  of  the  lip,  it  may  readily  be  included  in  the  limits  of  a 
V-incision,  and  the  margins  of  the  wound  may  be  brought  together  with  pin 
sutures  in  such  a  manner  as  scarcely  to  mar  the  appearance  of  the  patient. 
When  a  larger  portion  of  the  lip  is  involved  in  the  disease,  it  may  be  excised 


TELANGEIECTASIS  OF  THE  LIPS. 


863 


by  a  semi-circular,  a  semi-elliptical,  or  a  quadrangular  incision,  and  the 
chasm  thus  produced  may  be  closed  by  an  appropriate  cheiloplastic  operation. 

When  epithelioma  of  the  lip  is  removed  at  a  very  early  period,  there  is 
good  reason  to  hope  for  a  radical  cure,  or,  at  least,  for  a  long  reprieve.  But 
if  the  operation  be  delayed  until  the  lymphatic  system  has  become  involved, 
and  till  the  general  health  has  begun  to  suffer  from  cancerous  cachexia,  little 
or  no  benefit  is  to  be  expected  from  the  excision  of  the  morbid  growth. 

TELANGEIECTASIS  OF  THE  LiPS. 

This  is  usually  a  congenital  affection.  It  may  affect  the  vessels  of  the 
skin  or  mucous  membrane  alone,  or  those  of  the  subjacent  cellular  tissue,  or 
both  tissues  may  be  involved.  When  the  disease  is  of  very  limited  extent  it 
may  be  excised,  and  the  edges  of  the  wound  may  be  united  by  sutures. 

When  it  is  more  extensive,  it  may  be  treated  by  inserting  cauterizing 
needles,  at  a  dull-red  heat,  into  the  tumor  at  a  number  of  points. 

When  the  morbid  growth  is  quite  prominent,  without  a  very  wide  base,  it 
may  be  treated  with  two  pins  traversing  its  base  and  crossing  at  right  angles, 
and  a  strong  ligature  tied  around  the  base  of  the  tumor  under  the  pins, 
with  sufficient  force  to  arrest  the  circulation  and  to  desti'oy  the  vitality  of 
the  included  parts.  After  the  separation  of  the  slough  the  sore  Avill  heal, 
and  the  cicatrix  will  not  much  disfigure  the  patient.  Fig.  1003  shows 
the  pins  iri  situ,  traversing  the  base  of  the  tumor,  and  the  ligature  ready  to 
be  tied.  It  will  sometimes  be  advantageous  to  apply  the  ligature  around  the 
base  of  the  tumor  subcutaneously,  as  represented  in  Fig.  1004.    A  curved 

Fig.  1003.  Fig.  104. 


Telangelectasis  of  Hp  strangnlated  with  pins  and  ligature.  Application  of  subcotaneous  ligature, 

needle  armed  with  a  strong  ligature  is  passed  through  the  integument  at  the 
point  A,  on  one  side  of  the  tumor,  and  is  carried  beneath  the  skin  around 
half  the  circumference  of  the  tumor  to  the  point  B,  on  the  opposite  side.  It 
is  then  re-inserted  at  the  point  B,  and  carried  from  B  to  A  around  the  other 
half  of  the  circumference,  and  thus  the  two  ends  of  the  thread  at  A  may 
be  tied  so  as  to  strangulate  the  tumor  subcutaneousl}^ 

When  the  tumor  is  flat  and  has  a  broad  base,  it  may  be  treated  by  passing 
needles  armed  with  double  ligatures  through  its  base,  at  a  numl)er  of  points, 


864  INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 

and  tying  in  sections  until  the  whole  circumference  is  strangulated.  Or  a 
nuniber  of  parallel  ligatures  may  be  passed  through  the  tumor,  and  intersected 


Fig.  1005. 


Telangeiectasis  of  lip  strangulated  by  ligatures  crossing  each  other  at  right  angles. 

by  others  at  right  angles,  as  represented  in  the  diagram.  (Fig.  1005.)  When 
the  two  ends  of  each  ligature  are  firmly  tied  in  the  direction  of  the  dotted 
lines,  the  whole  mass  will  be  divided  into  quadrangular  segments,  and  the 
vascular  growth  wdll  be  obliterated. 

PoRT-'WiNE  Marks. 

Dark  discolorations  of  the  integument  of  the  face,  forming  circumscribed 
patches  resembling  in  color  the  stains  occasioned  by  port  wine,  are  some- 
times observed  as  a  congenital  affection.  They  are  only  important  as  affect- 
ing the  personal  appearance  of  the  patient.  When  they  are  small,  they  may 
be  excised,  or  the  surface  may  be  destroyed  by  means  of  the  actual  or  potential 
cautery.  In  1876,  a  pamphet  was  published  by  Dr.  Balmanno  Squire,  describ- 
ing his  method  of  treating  port-wine  marks.  His  plan  is  to  freeze  the  part 
by  the  ether-spray  apparatus,  then  scratch  it  with  an  ordinary  cataract 
needle  in  parallel  lines  about  one-sixteenth  of  an  inch  apart,  then  place  a 
piece  of  blotting  paper  on  it  before  it  has  thawed,  pressing  the  paper  firmly 
on  the  scratched  skin  for  five  minutes.  'Next  day  he  repeats  the  operation  if 
necessary,  the  lines  being  in  an  oblique  or  transverse  direction  to  the  original 
scratches.  The  scratches  need  not  divide  the  entii^  thickness  of  the  skin. 
The  part  must  be  well  frozen,  both  that  the  operation  may  be  painless,  and 
to  avoid  any  hemorrhage.  In  applying  the  blotting-paper,  the  pressure 
should  be  absolutely  perpendicular  to  the  surface ;  for  if  the  slightest  lateral 
traction  be  made,  the  miniature  incisions  will  gape  slightly,  and  so  become 
plugged  with  minute,  wedge-shaped  clots  of  blood,  with  resulting,  indelible, 
lin.ear  scars.  After  relaxing  the  pressure,  the  paper  should  be  allowed  to 
remain  for  at  least  half  an  hour.  Then  it  should  be  thoroughly  wetted,  and 
gently  removed,  traction  being  made  in  the  same  direction  as  the  incisions, 
so  as  not  to  tear  them  open.  The  thin  clot  of  blood  which  covers  the  part 
after  removal  of  the  paper,  should  be  gently  washed  off  with  a  camel's  hair 
brush  and  cold  water,  and  then  a  film  of  glycerine  should  be  carefully  applied. 


CfiEILOPLASTIC  OPERATIONS. 


865 


Dr.  Squire  has  since  proposed  to  make  the  linear  incisions  of  the  skin 
oblique  instead  of  perpendicular  to  the  surface,  and  has  devised  an  instrument 
for  the  purpose,  which  he  calls  a  multiple  linear  scarifier.^ 

Cysts  of  the  Lips. 

Cysts,  arising  from  distension  of  the  follicles  and  containing  a  viscid  fluid, 
are  sometimes  found  at  the  margins  of  the  lips.  They  may  be  excised,  or  they 
may  be  laid  open  so  as  to  evacuate  the  fluid,  and  the  surface  may  then  be 
wiped  with  lint  and  cauterized  with  nitric  or  sulphuric  acid. 

Tumors  of  the  Lips. 

Tumors  of  various  kinds  occasionally  present  themselves  in  the  lips,  such 
as  steatomata,  adenomata,  papillomata,  myxomata,  sarcomata,  fl])romata,  and 
lipomata.  Soft  papillomata  may  be  destroyed  by  escharotics,  but  the  other 
varieties  of  tumor  may  more  advantageously  be  excised. 


HiRSUTIES. 

A  growth  of  hair  from  the  lips  and  cheeks,  in  the  female,  is  often  an 
occasion  of  great  annoyance.  When  they  are  not  very  numerous,  the  bail's 
may  be  plucl^ed  individually  with  forceps,  and  the  evulsion  may  be  repeated 
as  often  as  they  are  reproduced.  Dr.  Agnew  recommends,  as  a  depilatory, 
three  parts  of  prepared  chalk  and  one  part  of  sulphide  of  calcium,  mixed  into 
a  paste  with  water,  and  applied  to  the  surface  with  a  brush.  After  it  has 
dried,  it  may  be  rubbed  otf,  and  the  hairs  are  removed  with  it ;  but,  after  a 
while,  they  are  reproduced.  A  radical  cure  may  be  eflTected  by  destroying 
the  hair  follicles,  one  by  one,  by  inserting  into  them  a  platinum  needle 
and  connecting  it  with  the  poles  of  a  galvanic  battery. 

Cheiloplastic  Operations. 

These  operations  consist  in  the  transplantation  of  flaps  to  supply  new 
material  for  the  reconstruction  of  the  lips,  when  a  considerable  portion  of 
their  substance  has  been  destroyed  by  disease  or  by  injury.  The  flaps  em- 
ployed for  this  purpose  are,  for  the  most  part,  taken  from  adjacent  parts  of 
the  face  or  neck,  and  are  left  attached  by  pedicles  to  the  parts  from  which 
they  derive  their  nourishment  until  they  have  become  flrmly  adherent  in 
their  new  position,  and  have  obtained  a  new  vascular  supply  from  the  parts 
into  which  they  have  been  inserted.  The  grafting  of  flaps  without  a 
pedicle  is  not  well  adapted  to  the  supply  of  new  tissue  in  a  part  as  movable 
as  the  lip,  and  which  cannot  well  be  kept  entirely  at  rest  and  subjected  to 
pressure,  on  account  of  the  necessity  of  introducing  food  into  the  mouth.  To 
remove  the  deformity  arising  from  a  loss  of  substance  of  the  lips,  in  such  a 
manner  as  to  restore  the  symmetry  of  the  mouth,  often  taxes  the  ingenuity 
of  the  surgeon  to  its  utmost  limits.  The  operations  which  have  been  devised 
for  this  purpose  present  a  great  variety  of  details,  according  to  the  nature 

'  See  Med.  Record,  Feb.  17,  1877,  p.  107,  and  Jan.  17,  1880,  p.  64;  Med.  Press  and  Circular, 
Nov.  26,  1879  ;  Quarterly  Epitome  of  Pract.  Med.  and  Surg.,  March,  1880,  p.  91. 

VOL.  IV. — 55 


866 


INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


and  extent  of  the  deformity,  and  the  character  of  the  material  of  which  the 
surgeon  can  avail  himself  in  restoring  the  disfigured  features  to  a  condition 
approaching  as  nearly  as  possible  to  their  normal  configuration.  To  obtain 
anything  like  a  satisfactory  result,  it  is  essential  that  the  transplanted 
flaps  should  be  composed  externally  of  skin,  and  internally  of  mucous  mem- 
brane. The  lips  and  cheeks  are  the  only  available  material  for  this  purpose, 
and  the  French  method  of  approximating  the  transplanted  flaps  to  the  part 
to  which  it  is  to  be  attached,  without  twisting  its  pedicle,  is  the  only  method 
of  which  we  can  ordinarily  avail  ourselves.  The  disadvantage  of  this  method, 
in  cases  where  there  is  a  large  chasm  to  be  filled  up,  is  that  the  flaps  cannot 
be  adjusted  to  each  other  without  such  a  degree  of  tension  as  to  endanger  the 
success  of  the  operation.  This  difficulty  may  sometimes  be  overcome  by 
making  free  incisions  beyond  the  base  of  the  flap,  to  relieve  the  tension,  and  by 
allowing  the  space  thus  made  vacant  to  heal  by  granulation  and  cicatrization. 
The  healing  of  this  space  may  sometimes  be  promoted  by  skin-grafting. 

Another  mode  of  relieving  the  tension  of  the  flaps  is  to  give  a  very  consider- 
able curvature  to  their  peduncles.  In  many  cases  the  success  of  the  operation 
will  greatly  depend  on  the  adoption  of  this  expedient.  In  cases  in  which 
there  is  a  very  great  relative  deficiency  of  the  lower  lip  and  superfluity  of 
the  upper  lip,  or  vice  versa^  a  flap  may  be  transplanted  from  the  superfluous 
lip  to  supply  material  to  the  defective  one,  by  one  of  the  ingenious  processes  of 
the  late  Dr.  Gurdon  Buck.  This  seems  to  be  almost  the  only  condition  in 
which  a  cheiloplastic  operation  maybe  advantageously  performed  by  the  Indian 
method.  In  cases  in  which  there  is  a  very  contracted  state  of  the  mouth, 
and  in  which  there  is  no  available  mucous  membrane  in  the  vicinity  to  invest 
the  borders  of  the  lips  which  are  to  be  reconstructed,  it  has  occurred  to  me 
that  the  difficulty  might  be  obviated  by  transplanting  a  flap  of  integument 
from  the  neck,  and  inserting  it  through  an  incision  along  the  base  of  the 
lower  jaw,  so  as  to  line  the  outer  integument,  and  supply  the  place  of  mucous 
membrane.  When  there  is  no  suitable  integument  in  the  immediate  vicinity 
of  the  face,  a  flap  of  integument  may  be  partially  detached  from  the  thorax 
or  abdomen,  and  attached  to  the  margin  of  the  hand  or  forearm,  and  at  a  later 
period  it  may  be  secondarily  transplanted  so  as  to  form  a  mucous  lining  in 
the  lip  or  cheek. 

Cheiloplastic  operations  may  be  divided  into  four  classes,  according  as  they 
are  designed  (1)  to  supply  deficiencies  of  the  upper  lip  ;  (2)  To  supply  defi- 
ciencies of  the  lower  lip ;  (3)  To  supply  deficiencies  of  both  lips  ;  and  (4)  To 
supply  deficiencies  or  correct  malpositions  of  the  angles  of  the  mouth. 

In  cases  of  harelip,  in  which  there  is  a  very  wide  chasm  to  be  filled,  it  is 
sometimes  necessary  to  make  an  incision  outward  and  backward  on  each  side 
from  the  angles  of  the  mouth,  through  the  whole  thickness  of  the  cheeks, 
and  a  parallel  incision  at  the  junction  of  the  lip  with  the  nose,  thus  making 
flaps  from  each  side  to  bridge  the  chasm.  In  such  cases,  a  new  vermilion 
border  to  the  upper  lip  is  made  by  attaching  the  mucous  membrane  to  the 
skin  by  fine  sutures.  If  the  flaps  do  not  meet  without  tension,  the  incisions 
may  be  prolonged  in  a  curved  direction  outward  and  downward,  until  the 
tension  is  entirely  relieved. 

Dieflenbach  proposed  a  plastic  operation  for  the  restoration  of  the  upper 
lip,  by  making  a  vertical  incision  upward  from  the  angle  of  the  mouth  to  a 
point  above  the  level  of  the  nostril,  thence  making  a  horizontal  incision  out- 
ward to  an  extent  fully  equal  to  the  breadth  of  the  space  to  be  occupied  by 
the  reconstructed  lip,  and  thence  a  vertical  incision  downward  nearly  to  the 
level  of  the  angle  of  the  mouth,  thus  making  a  quadrangular  flap  remaining 
attached  below.    This  flap  was  to  be  turned  horizontally  inward,  so  that  its 


CHEILOPLASTIC  OPERATIONS. 


867 


upper  border  should  in  the  median  line  be  secured  by  sutures  to  a  corres- 
ponding flap  on  the  opposite  side.  (Figs.  1006  and  1007.) 

Fig.  1006.  Fig-  1007. 


DiefiFenbach's  operation  for  restoration  of  upper  lip. 

Sedillot  proposed  another  operation  by  which  the  restoration  of  the  upper 
lip  was  to  be  effected  by  means  of  flaps  cut  in  the  reverse  direction  from  that 
proposed  by  Dieffenbach.  The  flap  on  each  side  was  bounded  by  a  vertical 
line,  commencing  at  a  point  midway  between  the  angle  of  the  mouth  and  the 
lower  eyelid  and  ending  midway  between  the  angle  of  the  mouth  and  the 
base  of  the  lower  jaw ;  a  horizontal  line  extending  outward  from  the  lower 
extremity  of  the  vertical  line,  and  another  vertical  line  extending  upward  from 
the  outer  end  of  the  horizontal  line  to  a  point  on  a  level  with  the  nostril. 
These  flaps  were  then  to  be  turned  so  that  their  lower  extremities  should  meet 
and  be  joined  by  sutures  in  the  median  line.    (Figs.  1008  and  1009.) 

Fig.  1008.  Fig-  1009. 


SMillot's  operation  for  restoration  of  upper  lip.  , 

Deficiencies  in  the  lower  lip  are  apt  to  exist  to  a  greater  extent  than  those 
hich  occur  in  the  upper  lip.    Malignant  disease  is  the  most  frequent  cause 


868 


INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


of  these  extensive  deficiencies.  When  a  cancer  of  the  lower  lip  occupies  so 
large  a  portion  of  its  margin  that  it  cannot  be  excised  by  a  V-incision,  allow- 
ing the  opposite  sides  to  be  brought  into  contact  and  secured  by  sutures,  a 
plastic  operation  is  required  for  the  reconstruction  of  the  lip.  When  the 
disease  involves  nearly  the  whole  of  the  vermilion  border,  but  does  not  extend 
very  far  towards  the  chin,  the  operation  proposed  by  Buchanan  may  be  per- 
formed with  advantage.  In  this  operation,  the  morbid  growth  is  removed 
by  a  semicircular  incision,  and  then  a  flap  is  cut  on  each  side,  bounded  above 
by  the  incision  referred  to,  below  by  a  parallel  curved  incision,  and  w^ithin 
by  an  oblique  incision  extending  on  each  side  of  the  median  line  dow^nward 
and  outward  from  the  upper  to  the  lower  curved  incision.  These  flaps  are 
drawn  upward  and  inward  so  as  to  meet  in  the  median  line,  and  their  upper 
margins  are  brought  into  contact  with  the  upper  lip,  leaving  a  considerable 
chasm  to  granulate  between  their  lower  borders  and  the  chin.  (Figs.  1010 
and  1011.)    This  chasm  may  sometimes  be  filled  up  by  making  an  incision 

Fig.  1010.  Fig.  1011. 


Buchanan's  operation  for  restoration  of  lower  lip. 

through  the  integument  of  the  neck,  nearly  parallel  on  the  sides  with  the 
lower  border  of  the  chasm,  but  the  two  lateral  portions  as  they  approach  the 
median  line  extending  downw^ards  and  meeting  at  an  acute  angle  in  the 
median  line.  The  flap  thus  made  may  be  drawn  upward  to  meet  the  upper 
margin  of  the  chasm,  and  the  sides  of  the  triangular  space  below  may  be 
united  by  sutures. 

Instead  of  Buchanan's  operation,  the  tumor  may  be  removed  by  including 
it  in  a  quadrangular  incision,  bounded  above  by  the  free  border  of  the  lip, 
below  by  a  horizontal  line  parallel  with  the  free  border,  and  on  each  side  by 
a  vertical  line  extending  from  the  labial  margin  to  the  lower  horizontal  line. 
The  two  vertical  lines  are  then  extended  downw^ard  below  the  base  of  the  jaw% 
and  the  flaps  thus  formed  are  used  to  fill  up  the  space  which  had  been  occupied 
by  the  excised  portion  of  the  lip.  The  objection  to  this  mode  of  operating  is 
that  it  is  difiicult  to  prevent  the  new  margin  of  the  lip  from  sinking  down 
below  its  proper  level.  I  think  that  this  difficulty  might  be  obviated  by 
dividing  the  base  of  the  flap  into  two  lateral  segments  separated  from  each 
other  by  a  triangular  portion  of  integument,  and  then  curving  these  lateral 
peduncles  outward  and  upward  so  as  to  relieve  the  tension  of  the  flap.  The 
triangular  chasm  between  the  two  peduncles  could  then  be  closed  laterally  by 


CHEILOPLASTIC  OPERATIONS. 


869 


sutures.  Whichever  of  these  methods  may  be  adopted  for  supplying  de- 
ficiencies of  the  lower  lip,  a  new  vermilion  border  should  be  made,  when  it  is 
practicable,  by  uniting  the  mucous  membrane  with  the  skin  by  means  of  fine 
sutures.  When  this  cannot  be  accomplished,  the  free  border  of  the  lip  may 
be  invested  with  skin,  if  this  material  can  be  obtained  for  the  purpose. 

The  operations  of  Dr.  Buck  for  the  transplantation  of  a  i)ortion  of  the 
upper  lip  to  supply  a  deficiency  of  the  lower  lip,  or  of  a  [)ortion  of  the  lower 
lip  to  supply  a  deficiency  of  the  upper  lip,  are  described  in  his  Contributions 
to  Reparative  Surgery,  published  in  1876.^ 

He  first  describes  two  preliminary  operations  for  the  removal  of  extensive 
disease  of  the  lower  lip. 

The  first  of  these  preliminary  operations  is  performed  by  including  the 
diseased  mass  between  two  incisions  extending  downward  and  inward  from 
a  point  on  each  side  near  the  angle  of  the  mouth,  and  meeting  in  the  median 
line  of  the  neck  beneath  the  chin.  The  mucous  membrane  is  then  freely 
divided  on  each  side  at  its  reflection  from  the  cheek  to  the  jaw,  and  the 
margins  of  the  wound  are  drawn  together,  and  united  by  pin  sutures. 

The  second  preliminary  operation,  which  is  adapted  to  cases  in  which  the 
extent  of  the  disease  is  so  great  as  to  forbid  the  first  operation,  consists  in  the 
exsection  of  the  tumor  by  two  vertical  incisions  extending  downwards  froni 
the  commissures  of  the  lips,  and  a  horizontal  incision  extending  from  one  of 
the  vertical  incisions  to  the  other,  below  the  diseased  mass.  The  horizontal 
incision  is  then  extended  to  the  right  and  left,  to  within  a  finger's  breadth  of 
the  angle  of  the  jaw,  and  thence  curved  upward  and  a  little  forward  over  the 
masseter  muscle  to  the  extent  of  about  two  inches.  The  flaps  are  then  dis- 
sected from  the  subjacent  parts,  and  their  edges  brought  together  in  the 
median  line,  and  secured  by  pin  sutures.  The  vacant  spaces  behind  the 
posterior  vertical  incisions  may  be  allowed  to  heal  by  granulation,  or  the 
integument  may  be  dissected  up  from  the  parts  behind,  and  united  by  sutures 
with  the  posterior  margins  of  the  flaps.  After  the  healing  of  the  wounds 
made  by  either  of  these  preliminary  operations,  the  mouth  is  much  disfigured, 
the  angles  being  much  approximated  and  the  upper  lip  being  redundant,  and 
overhanging  the  lower  lip  which  is  extremely  contracted.  The  secondary 
operation,  which  is  designed  to  transfer  the  redundant  portions  of  the  upper 
lip,  so  as  to  relieve  the  contracted  state  of  the  lower  lip,  and  thus  to  restore 
the  symmetry  of  the  mouth,  is  performed  as  follows  :  A  point  is  selected 
about  a  finger's  breadth  below  and  a  little  without  the  angle  of  the  mouth  on 
each  side,  and  this  point  is  marked  by  inserting  a  small  pin  through  the  skin. 
Another  pin  is  inserted  on  each  side  at  the  junction  of  the  vermilion  border 
of  the  upper  lip  with  the  skin,  about  one-fifth  of  the  distance  from  the  angle  of 
the  mouth  to  the  median  line  of  the  lip ;  and  a  third  pin  on  each  side  is  inserted 
into  the  integument  of  the  cheek,  about  an  inch  and  a  half  above  and  Avith- 
out  the  angle  of  the  mouth.  The  points  indicated  by  the  first  and  third  pins 
are  then  to  be  united  by  an  incision  through  the  entire  thickness  of  the  cheek, 
and,  in  like  manner,  the  points  indicated  by  the  second  and  third  pins.  A 
triangular  flap  is  thus  formed,  Avith  its  base  towards  the  angle  of  the  mouth, 
and  from  the  point  indicated  by  the  first  pin  a  vertical  incision  is  made  down 
to  the  base  of  the  jaw.  The  integument  in  this  region  being  in  a  state  of 
great  tension,  the  edges  recede  and  form  a  space  for  the  reception  of  the 
triangular  flap  with  its  apex  towards  the  base  of  the  jaw,  and  its  base, 
including  a  portion  of  the  vermilion  border  of  the  upper  lip,  supplying  the 
deficiency  of  the  corresponding  side  of  the  lower  lip.  When  this  operation 
is  completed  on  both  sides,  it  greatly  improves  the  configuration  of  the  mouth. 


^  Contributions  to  Reparative  Surgery,  chap.  v.  pp.  20-.S0.    New  York,  1876. 


870 


INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


With  slight  modifications,  this  operation  may  be  reversed,  the  redundancy  of 
the  lower  lip  contributing  to  supply  the  deficiency  of  the  upper.  (Figs.  1012 
and  1013.) 

Fig.  1012.  Fig.  1013. 


Buck's  operation  for  restoration  of  lower  lip. 


Dr.  Buck's  second  operation,  which  is  designed,  in  certain  cases  of  defi- 
ciency of  one  side  of  the  upper  lip,  to  supply  material  from  the  lower  lip,  m 
performed  in  the  following  manner :  The  upper  lip  on  the  defective  side  is 
separated  from  the  cheek  by  a  vertical  or  slightly  oblique  incision,  involving 
its  whole  thickness,  and  extending  downward  an  inch  below  the  angle  of  the 
mouth.  From  the  lower  part  of  this  incision,  a  second  incision  is  made, 
extending  inward  almost  to  the  median  line,  and  a  third  incision,  from  the 
inner  extremity  of  the  second,  upward  half  way  to  the  vermilion  border. 
The  opposite  half  of  the  upper  lip  is  to  be  prepared  for  the  reception  of  the 
flap  from  the  lower  lip  by  free  incision  of  the  mucous  membrane  connecting 
it  with  the  jaw,  and  by  paring  its  edge,  so  as  to  leave  a  raw  surface.  The 
flap  from  the  lower  lip  is  then  turned  edgewise  so  as  to  meet  the  opposite 
side  of  the  upper  lip,  the  vermilion  border  of  the  lower  lip  being  reversed 
so  as  to  form  a  part  of  the  border  of  the  upper  lip.  The  flap  is  attached  by 
sutures  in  its  new  position.  When  the  healing  process  has  been  completed^ 
the  commissure  of  the  lips  presents  a  circular  instead  of  an  angular  form,  and 
requires  another  operation  to  give  it  its  proper  shape.  This  operation  is 
performed  in  the  following  manner :  A  curved  incision  is  made  along  the 
line  of  junction  of  the  skin  with  the  vermilion  border,  extending  to  an  equal 
distance  along  the  upper  and  lower  lips.  This  incision  should  divide  the 
skin  and  the  subcutaneous  tissue,  but  should  not  involve  the  mucous  mem- 
brane. A  sharp-pointed  double-edged  knife  is  then  inserted  between  the 
skin  and  mucous  membrane,  and  these  parts  are  freely  separated  from  each 
other,  as  far  outward  as  the  point  where  the  new  angle  of  the  mouth  is  to 
be  constructed.  The  skin  alone  is  then  divided  with  strong  scissors  along 
the  line  which  is  to  separate  the  upper  from  the  lower  lip.  The  mucous 
membrane  is  next  divided  along  the  same  line,  but  not  as  far  outward,  the 
difterence  in  the  length  of  the  two  incisions  being  a  little  less  than  the  thick- 
ness of  the  cheek.  The  mucous  membrane  at  the  outer  extremity  of  the 
incision  is  then  connected  with  the  skin  by  a  suture,  so  as  to  form  the  new 
angle  of  the  mouth,  and  the  borders  of  the  upper  and  lower  lip  are  recon- 


CHEILOPLASTIC  OPERATIONS. 


871 


structed  by  uniting  with  the  sutures  the  skin  and  mucous  membrane,  after 
paring  thin  slices  of  skin  from  the  upper  and  lower  borders  of  the  wound. 

Fig.  1014. 


Buck's  operation  for  restoration  of  upper  lip. 

Cheiloplastic  operations  are  subject  to  great  variety  of  detail,  according  to 
the  nature  and  extent  of  the  deformity,  and  of  the  material  in  the  neighbor- 
hood which  may  be  utilized  for  transplantation. 

Fig.  1015.  Fig.  1016. 


Buck's  operation  for  restoration  of  upper  lip. 

A  number  of  these  operations  are  illustrated  in  the  Atlas  accompanying  a 
work  published  in  1842,  by  M.  Serre.^ 

I  have  selected  a  few  of  these  illustrations,  as  containing  valuable  hints  for 
the  guidance  of  surgeons  in  restoring  the  lips  as  nearly  as  possible  to  a  nor- 
mal condition  after  a  considerable  loss  of  substance.  Fig.  1017  represents  the 
manner  of  removing  a  morbid  growth  involving  nearly  the  whole  of  the 

1  Traite  sur  I'art  de  restaurer  les  Ditformites  de  la  Face,  etc.    Montpellier,  1842. 


872  INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 

vermilion  border  of  the  lower  lip,  by  two  vertical  incisions  extending  down 
from  the  angles  of  the  mouth,  and  a  horizontal  incision  below  the  inferior 
part  of  the  neoplasm.  The  vertical  incisions  are  extended  downwards  below 
the  chin,  and  a  quadrilateral  flap  is  dissected  from  the  subjacent  parts  and 
drawn  up  until  it  comes  in  contact  with  the  upper  lip.  The  mucous  mem- 
brane at  the  upper  extremity  is  united  with  the  skin  by  fine  sutures,  so  as 
to  form  a  new  vermilion  border,  and  the  flap  is  united  on  each  side  with  the 
adjacent  integument  by  pin-sutures,  as  represented  in  Fig.  1018. 

Fig.  1017.  Fig.  1018. 


Cheiloplasty  of  lower  lip,    (After  Serre.^ 

Fig.  1019  represents  a  tumor  involving  three-quarters  of  the  vermilion 
border  of  the  lower  lip,  and  extending  upward  and  outward  beyond  the  left 
angle  of  the  mouth.    The  tumor  is  included  between  two  vertical  incisions 

Fig.  1019.  Fig.  1020. 


Cheiloplasty  of  lower  lip  and  angle  of  mouth.   (After  Serre.) 

joined  by  a  horizontal  incision  below,  and  two  oblique  incisions  including 
the  angle  of  the  mouth  and  terminating  at  an  acute  angle  on  the  left  cheek. 


CHEILOPLASTIC  OPERATIONS. 


873 


Fig.  1020  represents  the  reconstructed  mouth  with  the  flaps  secured  by 
sutures  in  their  new  position. 

Fig.  1021  represents  a  tumor  in  nearly  the  same  situation,  removed  by  ver- 
tical and  horizontal  incisions,  which  are  extended  so  as  to  form  a  transverse 
flap  on  the  right  side,  and  a  vertical  flap  below  the  left  extremity  of  the 
tumor.  Fig.  1022  represents  these  flaps  drawn  into  such  a  position  as  to  fill 
up  the  vacant  space. 

Fig.  1021.  Fig.  1022. 


Cheiloplasty  of  lower  lip  and  angle  of  mouth.    (After  Serre.) 


Fig.  1023  represents  a  tumor  occupying  nearly  the  whole  of  the  vermilion 
border  of  the  lower  lip,  included  between  two  incisions  extending  downward 
and  inward  from  the  angles  of  the  mouth,  and  meeting  at  an  acute  angle  on 

Fig.  1023.  Fig.  1024. 


Restoration  of  lower  lip.    (After  Serre.) 


the  anterior  part  of  the  neck  below  the  chin.  From  the  upper  part  of  these 
lateral  incisions,  a  nearly  transverse  incision  on  each  side  extends  into  the 


874 


INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


corresponding  cheek,  and  thus  two  lateral  flaps  are  formed,  which  are  drawn 
together  so  as  to  meet  in  the  median  line  as  shown  in  Fig.  1024. 

Fig.  1025  exhibits  a  tumor  involving  the  left  half  of  the  vermilion  border  of 
the  lower  lip,  included  between  two  incisions  meeting  at  an  acute  angle 
below  the  base  of  the  jaw.  To  cover  the  vacant  space,  a  quadrangular  flap 
is  cut  on  its  outer  side,  and  drawn  towards  the  median  line,  where  it  is  fixed 
by  sutures,  as  shown  in  Fig.  1026. 

Fig.  1025.  Fig.  1026. 


Restoration  of  left  half  of  edge  of  lower  lip.   (After  Serre.) 

Fig.  1027  exhibits  a  morbid  growth,  extending  from  the  right  commissure 
of  the  lips  downward  and  outward,  and  included  between  incisions  meeting 
at  two  acute  angles,  so  as  to  form  two  triangular  spaces  meeting  at  their 

Fig.  1027.  Fig.  1028. 


Operation  for  growth  involving  right  commissure  of  lips.    (After  Serre.) 

bases,  and  closed  by  drawing  the  adjacent  integuments  together  so  as  to  form 
a  transverse  and  a  vertical  line  of  junction  as  exhibited  in  Fig.  1028. 


CHEILOPLASTIC  OPERATIONS. 


875 


Figs.  1029  and  1030  exhibit  a  similar  proceeding  for  the  removal  of  a  dis- 
tortion of  the  right  angle  of  the  mouth  occasioned  hy  cicatrical  contraction. 

Fig.  1029.  Fig.  1030. 


Operation  for  cicatricial  contraction  of  right  angle  of  mouth.    (After  Serre.) 

^  Figs.  1031  and  1032  represent  the  wound  left  by  removing  a  tumor  of  the 
right  half  of  the  upper  lip,  encroaching  on  the  ala  nasi,  and  the  vacant  space 
covered  by  a  horizontal  flap  with  a  small  triangular  prominence  adapted  to 
the  nasal  deficiency. 

Fig.  1031.  Fig.  1032. 


Restoration  of  upper  lip  and  ala  nasi.    (After  Serre.) 

Fig.  1033  .represents  a  mouth  contracted  to  a  small  ring,  enlarged  by  a 
transverse  incision  on  each  side  into  the  cheek.  Fig.  1034  represents  the  recon- 
struction of  the  buccal  orifice  by  the  attachment  of  the  mucous  membrane  to 
the  skin  on  each  side,  so  as  to  complete  the  vermilion  border  of  the  lips. 

A  very  ingenious  method  of  restoring  the  symmetry  of  the  lips  after  a 


876  INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 

considerable  loss  of  substance  of  the  upper  or  lower  lip,  is  described  by  Carl 
August  Burow.^ 

Fig.  1033.  Fig.  1034. 


Reconstruction  of  buccal  orifice.    C^fter  Serre.) 

Fig.  1035  furnishes  a  representation  of  the  application  of  this  method  to  a 
case  of  deficiency  of  the  left  half  of  the  lower' lip.  The  diseased  portion  of 
the  lip  having  been  excised  by  the  incisions  AB  and  BC,  leaving  a  triano-ular 
chasm  ABC,  a  transverse  incision,  FD,  is  extended  from  the  angle  of  the 
mouth  into  the  cheek,  and  from  the  two  ends  of  this  incision  the  incisions 
FE  and  DE  are  made  so  as  to  excise  the  triangle  FED. 

Fig.  1035.  Fig.  1036. 


Burow's  plastic  operation.  , 

Fig.  1036  represents  the  reconstruction  of  the  mouth  by  joining  the  line 
AB  to  AC,  and  the  line  EF  to  ED.  This  method  of  operating  may  be 
adapted  to  a  considerable  variety  of  deformities  of  the  lips.    The  principal 


^  Reschreibung  einer  neuen  Transplantations-Methode  (Methode  der  seitliclien  Dreiecke)  zum 
Wiedersatz  verlorengegener  Theile  des  Gesichts.    Berlin,  1855. 


CHEILOPLASTIC  OPERATIONS. 


877 


objection  to  it  is  that  it  involves  the  loss  of  a  considerable  portion  of  healthy 
integument.  But  there  are  cases  in  which  the  symmetry  of  the  lips  can  be 
better  secured  by  it  than  by  any  other  method. 

Szymanovvski^  gives  illustrations  and  descriptions  of  a  number  of  ingenious 
operations  for  the  removal  of  deformities  of  the  lips.  I  have  selected  a  num- 
ber of  these  illustrations,  and  I  have  no  doubt  that  many  useful  hints  may  be 
derived  from  their  careful  study.  Fig.  1037  exhibits  a  triangular  chasm  pro- 
duced by  the  excision  of  a  tumor  involving  the  whole  of  the  vermilion  border 
of  the  lower  lip,  and  a  flap  of  integument  on  the  right  side  which  is  designed 
to  be  drawn  upward  and  to  the  left,  so  as  to  fill  the  chasm.  Fig.  1038  repre- 
sents tlie  flap  secured  in  its  new  position  by  sutures. 

Fig.  1037.  Fig.  1038. 


^  ■  , i    ^  ^ 


Restoration  of  edge  of  lower  hp.    (After  Szymanowski-^ 
Fig.  1039.  Fig.  1040. 


Eestoration  of  whole  lower  lip.    (After  Szymanowski.) 

Fig.  1039  represents  a  somewhat  more  extensive  triangular  chasm,  the  apex 
of  which  extends  to  the  chin,  and  a  quadrilateral  flap  on  each  side,  designed 

^  Handbucli  des  operativen  Chiriirgie.    Braunschweig,  1870. 


878  INJURIES  AXD  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


to  be  joined  together  in  the  median  line,  as  represented  in  Fig.  1040,  leaving 
on  each  side  a  narrow  chasm  to  be  filled  by  granulation. 

Fig.  1041  exhibits  a  different  mode  of  forming  flaps  to  close  a  triangular 
chasm  extending  from  the  free  border  of  the  lower  lip  to  the  chin.  The  flaps 
as  seen  in  the  diagram  are  curved,  and  terminate  above  at  acute  angles,  so 
that  when  the  flaps  are  brought  together  in  the  median  line,  the  integument 
above  their  apices  can  be  readily  united  by  sutures  without  puckering.  In 
many  cases,  flaps  constructed  in  this  way  will  close  the  chasm  with  less 
disfigurement  than  when  any  other  method  is  employed.  Fig.  1042  exhibits 
the  appearance  of  the  parts  when  the  flaps  are  adjusted  and  secured  by  sutures. 

Fig.  1041.  Fig.  1042. 


Restoration  of  lower  lip  by  another  method.    (After  Szymanowski.) 
Fig.  1043.  Fig.  1044. 


Another  method  of  restoring  the  lower  lip.    (After  Szymanowski.) 

Fig.  1043  represents  another  mode  of  closing  the  chasm  by  lateral  flaps  on 
each  side,  with  their  bases  above  toward  the  cheeks,  and  their  free  extremities 
below.  These  flaps,  as  represented  in  Fig.  1044,  are  turned  edgewise  so  that 
their  free  extremities  meet  in  the  median  line,  and  the  lower  part  of  the  chasm 
is  filled  by  other  flaps  dissected  from  the  subjacent  parts. 


CHEILOPLASTIC  OPERATIONS. 


879 


Fig.  1045  represents  a  chasm  of  the  form  of  a  parallelogram  produced  b}^ 
the  excision  of  the  lower  lip,  and  two  curved  flaps  extending  below  the  base 
of  the  jaw,  and  with  their  upper  free  extremities  separated  by  a  triangular 
portion  of  integument  which  is  left  above  the  chin.  Fig.  1046  represents 
these  flaps  as  drawn  up  to  form  the  reconstructed  lower  lip,  and  supported  by 
the  triangular  buttress  of  integument  which  was  left  in  situ. 

Fig.  1045.  Fig.  1046. 


Reconstruction  of  lower  lip.    (After  Szymanowski.) 

Fig.  1047  represents  a  chasm  similar  to  that  of  Fig.  1045,  but  with  vertical 
flaps  on  each  side,  with  their  free  extremities  directed  upward,  and  designed 
to  be  turned  edgewise  so  that  their  free  extremities  shall  meet  in  the  median 
line,  as  represented  in  Fig.  1048. 

Fig.  1047.  ■  Fig.  1048. 


Reconstruction  of  lower  lip  by  another  method.    (After  Szymanowski.) 

Fig.  1049  represents  a  case  in  which  the  whole  border  of  the  lower  lip  is 
destroyed,  but  in  which  the  loss  of  substance  does  not  extend  far  down  towards 
the  chin.  Three  portions  of  skin  are  excised,  each  of  the  form  of  a  spherical 
triangle,  the  middle  one  with  its  base  upward  and  its  apex  towards  the  chin. 


880  INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


while  the  two  lateral  triangles  have  their  bases  at  the  commissures  of  the  lips, 
and  their  apices  directed  outwards  upon  the  cheeks.  Fig.  1050  represents  the 
reconstructed  lip,  the  lateral  flaps  being  brought  together  in  the  median  line, 
and  at  the  same  time  being  lifted  up  by  their  attachment  to  the  cheeks. 

Fig.  1049.  Fig.  1050. 


Restoration  of  border  of  lower  lip.    (After  Szymanowski.) 

Fig.  1051  represents  a  much  more  extensive  loss  of  substance,  involving  the 
whole  breadth  of  the  lower  lip  and  the  right  angle  of  the  mouth.  To  cover  the 
deficiency,  two  flaps  of  unequal  size  are  dissected  from  the  cheeks,  the  smaller 
one  on  the  right,  above  and  without  the  right  angle  of  the  mouth,  the  larger 
one  on  the  left,  chiefly  below  and  without  the  left  angle  of  the  mouth,  and 
extending  below  the  base  of  the  jaw.  The  reconstructed  lip  and  the  lines 
of  union  of  the  flaps  are  seen  in  Fig.  1052. 

Fig.  1051.  Fig.  1052. 


Restoration  of  lower  lip  and  angle  of  mouth.    (After  Szymanowski.) 

Fig.  1053  exhibits  a  remarkable  fissure  of  the  upper  lip,  in  which  the  sides 
of  the  fissure  extend  in  a  direct  line  from  the  columna  nasi  to  the  angles  of 
the  mouth.    To  remedy  this  defect,  a  curved  incision  is  carried  on  each  side 


CHEILOPLASTIC  OPERATIONS,. 


881 


around  the  ala  nasi,  separating  the  upper  extremity  of  the  border  of  the  fissure 
from  the  columna,  and  the  flaps  thus  made  are  brought  together  in  the 
median  line,  in  such  a  manner  that  the  edges  of  the  fissure  become  horizontal 
and  form  the  free  border  of  the  reconstructed  upper  lip,  as  shown  in  Fig.  1054. 

Fig.  1053.  Fig.  1054. 


Operation  for  fissure  of  tipper  lip.    (After  Szyraanowski.) 

Fig.  1055  exhibits  a  case  of  destruction  of  the  upper  hp  throuo;hout  its 
whole  extent.  Lateral  flaps,  of  the  full  breadth  of  tlie  lip,  are  cut  on  each 
side ;  their  outer  extremities  are  curved  downwards  so  as  to  relieve  them 
from  tension  ;  and  their  inner  extremities  are  €hen  drawn  together  in  the 
median  line,  as  shown  in  Fig.  1056.  Figs.  1055  and  1056  are  altered  from 
Szymanowski's  drawings  by  curving  the  peduncles  of  the  flaps.  This  change 
in  the  form  of  the  flaps  is  a  matter  of  great  importance  in  relieving  tension, 
and  in  securing  primary  union  with  a  minimum  of  deformity. 

Fig.  1055.  ^  Fig.  1056. 


Restoration  of  upper  lip.    (Modified  from  Szymanowski.) 

Fig.  1057  exhibits  a  cleft  of  the  ui^per  lip,  extending  from  the  angles  of  the 
mouth  to  a  point  in  the  median  line,  one  third  of  th^  distance  from  the  nose 
to  the  incisor  teeth.    A  transverse  incision  is  made  above  the  upper  extremity 
VOL.  IV.— 56 


882 


I^VURIBS  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


of  the  cleft,  so  that  the  lower  border  of  the  lip  can  be  brought  down  to  its 
normal  position,  and  from  the  two  extremities  of  this  transverse  incision  ver- 
tical incisions  are  carried  up  on  each  side  of  the  nose,  and  then  an  oblique, 
curved  incision  is  made  upward  and  outward  on  each  cheek,  and  from  its 
extremity  another  slightly  curved  incision  is  made  downward  and  a  little  out- 
ward. These  incisions  circumscribe  a  flap  on  each  side,  and  these  flaps  are 
turned  downwards  and  inwards  so  that  their  upper  extremities  nieet  in  the 
median  line,  and  fill  up  the  space  between  the  transverse  incision  and  the 

Fig.  1057.  Fig.  1058. 


Operation  for  cleft  of  upper  lip.    (After  Szymanoivski.) 


depressed  margin  of  the  lip,  as  shown  in  Fig.  1058.    The  acute  angles  at  i  and 
k  favor  the  approximation  of  the  edges  of  the  wound  without  puckering. 
Fio-.  1059  represents  the  destruction  of  the  whole  of  the  lower  lip,  and  of 


FiR.  1059. 


Fig.  1060. 


Restoration  of  both  lips.    (After  Szvmanowski.) 

nearly  the  whole  of  the  upper  lip,  only  a  small  portion  of  its  right  extremity 
being  preserved.  To  cover  this  deficiency,  and  reconstruct  the  lips,  a  trans- 
verse incision  is  made  in  each  cheek  along  the  line  which  separates  the  teeth 
of  the  upper  jaw  from  those  of  the  lower  jaw ;  another  transverse  incision  is 


CHEILOPLASTIC  OPERATIONS. 


883 


raade  on  the  right  side  below  the  ala  nasi,  and  a  huge  flap  is  made  on  the 
left  side,  bounded  within  by  the  left  border  of  the  chasm,  above  by  an 
oblique  line  extending  upward  and  outward  from  the  left  upper  angle  of 
the  chasm  to  a  point  in  front  of  the  left  ear,  and  without  by  a  curved  line 
which  extends  along  the  ramus  of  the  jaw  below  its  base  to  the  upper  part  of 
the  neck.  This  large  flap  is  drawn  across  the  median  line  to  meet  the 
smaller  flap  on  the  right  side.  The  vermilion  borders  of  the  upper  and 
lower  lips  are  made  by  uniting  the  mucous  membrane  with  the  skin,  as  seen 
in  Fig.  1060. 

Fig.  1061  exhibits  the  chasm  occasioned  by  the  removal  of  the  right  angle 
of  the  mouth  and  the  adjacent  portions  of  the  upper  and  lower  lips.  The 
chasm  represents  two  triangles  joined  by  their  bases  near  the  angle  of  the 
mouth,  the  apex  of  the  lowest  triangle  extending  down  toward  the  right  side 
of  the  chin,  and  that  of  the  upper  one  extending  outwards  towards  the  ramus 
of  the  jaw.  Fig.  1062  shows  how  the  sides  of  the  triangles  are  approximated 
to  restore  the  contour  of  the  mouth. 

Fig.  1061.  Fig.  1062 


Restoration  of  parts  of  both  lips  and  angle  of  mouth.    (After  Szymanowski.) 

Fig.  1063  exhibits  the  lines  of  incision  by  which  a  diseased  miass  involving 
the  middle  half  of  the  free  border  of  the  lower  lip  has  been  removed.  If  the 
sides  of  this  chasm  were  simply  approximated,  the  edge  of  the  lower  lip 
would  be  very  much  contracted,  and  the  border  of  the  upper  lip  would 
appear  abnormally  full.  To  obviate  this  difficulty,  and  to  cause  the  upper 
lip  to  impart  a  portion  of  its  superfluous  border  to  supply  the  deficiency  of 
the  lower  lip,  a  Y-incision  is  made  transversely  a  little  beyond  each  angle  of 
the  mouth,  and  when  the  lateral  flaps  are  joined  together  in  the  median  line, 
a  portion  of  the  border  of  the  upper  lip  on  each  side  is  raade  to  supplement 
the  border  of  the  lower  lip,  as  seen  in  Fig.  1064. 

Before  concluding  the  subject  of  cheiloplasty,  it  may  not  be  amiss  to  make 
a  few  statements  with  regard  to  the  general  subject  of  plastic  operations. 
The  success  of  these  operations  depends  largely  on  careful  attention  to  cer- 
tain minute  details.  One  of  the  most  important  matters  in  this  connection 
is  the  treatment  of  cicatricial  tissue,  l^one  of  this  tissue  should  be  included 
in  transplanted  flaps,  as  it  will  almost  invariably  lead  to  slouo^hins;  of  the 
flap.  Cicatricial  tissue  may  be  freely  incised,  and  may  even  be  divided  into 
narrow  segments,  without  losing  its  vitality,  if  its  basal  attachments  be  left 
undisturbed.    An  incision  may  be  made  through  a  cicatricial  band,  and  a 


884 


INJURIES  AND  DISEASES  OF  THE  FACE,  CHEEKS,  AND  LIPS. 


flap  of  healthy  integument  may  be  attached  to  it  by  sutures,  and  union  will 
take  place.  In  transplanting  a  flap  of  integument  to  All  up  a  chasm,  great 
care  should  be  taken  to  secure  a  sufficient  vascular  supply  to  maintain  its 
vitality,  by  allowing  ample  breadth  to  its  peduncle,  and  by  including  in  the 

Fig.  1063.  Fig.  1064. 


Mode  of  repairing  deficiency  of  edge  of  lower  lip.    TAfter  Szymanowski.) 

flap  a  suflficient  thickness  of  subcutaneous  cellular  tissue.  The  success  of  a 
plastic  operation  depends  very  much  on  the  absence  of  tension,  and  on  the  free- 
dom w^ith  which  the  flaps  are  brought  into  position.  When  the  transplanted 
flaps  are  of  considerable  thickness,  and  when  they  traverse  an  extensive  space, 
they  should  be  held  in  position  by  pin  sutures  extending  through  nearly 
their  w^hole  thickness.  In  addition  to  these  deep  sutures,  fine  silken  sutures 
should  be  employed  at  short  intervals  to  maintain  a  close  union  of  the  exter- 
nal lips  of  the  wound.  When  a  certain  amount  of  tension  is  unavoidable,  it 
may  be  relieved  in  part  by  the  use  of  bead  sutures,  as  recommended  by  I)r. 
Buck,  in  his  work  on  Reparative  Surgery.  For  this  purpose,  silver  wdre 
should  be  passed  through  the  whole  thickness  of  the  flaps,  entering  on  one 
side  and  emerging  on  the  other  an  inch  or  more  from  their  line  of  union ; 
the  end  of  the  wire  on  one  side  is  passed  through  a  glass  bead,  and  then 
through  a  small  disk  of  leather,  and  tied  into  a  knot,  while  the  other  end  of 
the  wire  is  passed  through  a  bead  and  drawn  so  as  to  bring  the  edges  of  the 
w^ound  into  close  contact,  and  then  twisted  over  a  small  piece  of  wood,  such 
as  the  end  of  a  friction  match.  The  end  of  the  wive  should  be  left  long,  to 
admit  of  its  being  readjusted  if  it  should  become  too  tight  or  too  loose. 
When  one  or  more  bead  sutures  are  employed  to  relieve  tension,  the  edges 
of  the  wound  should  be  accurately  adjusted  to  each  other  by  fine  black  silk 
stitches.  While  the  sutures  are  in  position,  no  adhesive  plasters,  bandages, 
or  compresses,  or  any  other  dressings  should  be  employed,  but  if  the  parts 
become  inflamed,  cooling  and  astringent  lotions  may  be  applied.  After  the 
removal  of  the  sutures,  the  recently  united  parts  may  be  supported  by  means 
of  adhesive  plasters,  or  of  shreds  of  lint  moistened  with  collodion. 

After  the  flaps  have  become  perfectly  united,  if  there  be  at  any  part  a 
superfluity  of  tissue,  a  small  portion  may  be  excised,  being  included  between 
two  semi-elliptical  incisions,  and  the  edges  brought  into  contact  and  secured 
by  fine  sutures.  Under  these  circumstances,  union  will  take  place  more 
rapidly  and  more  perfectly  than  if  similar  incisions  had  been  made  in  parts 
w^hose  natural  relations  had  not  previously  been  disturbed. 


INJURIES  AND  DISEASES  OF  THE  MOUTH,  FAUCES, 
TONGUE,  PALATE,  AND  JAWS. 


BY 

CHRISTOPHER  HEATH,  F.R.C.S., 

HOLME  PKOFESSOR  OF  CLINICAL  SURGERY  IN  UNIVERSITY  COLLEGE,  LONDON,  AND  SURGEON  TO 
UNIVERSITY  COLLEGE  HOSPITAL. 


Injuries  of  the  Mouth,  Fauces,  and  Tongue. 

Wounds  of  the  tongue  caused  by  the  teeth  of  epileptics  are  seldom  severe 
enough  to  require  any  special  treatment,  but  bites  of  the  tongue  caused  by  a 
fall  upon  the  chin  or  a  violent  blow  beneath  the  jaw,  when  the  tongue  is  pro- 
truded, are  often  serious.  The  hemorrhage  may  be  best  arrested  by  the  use 
of  ice,  or,  in  its  absence,  by  exposing  the  part  to  cold  air,  but  any  serious 
arterial  bleeding  should  be  controlled  with  a  ligature,  which,  though  apt  to 
be  soon  sucked"  off,  usually  sufficiently  accomplishes  its  purpose  if  tied 
tightly.  When  only  the  margin  of  the  tongue  is  bitten  through,  no  stitches 
will  be  required,  but  when  a  large  portion  of  the  tip  is  hanging  loose,  it  will 
be  necessary  to  put  silk  sutures  deeply  into  the  substance  of  the  tongue,  in 
order  to  bring  the  parts  into  apposition.  I  have,  on  more  than  one  occasion, 
had  to  pare  the  edges  of  a  bitten  tongue  in  which  this  had  been  neglected, 
and  then  bring  the  parts  together  again  w^ith  stitches.  Wounds  of  the 
tongue  by  the  stem  of  a  pipe  or  a  crochet-needle,  held  in  the  mouth,  occa- 
sionally occur,  and  a  piece  of  broken  tobacco-pipe  has  been  found  imbedded 
in  the  tongue  many  months  after  the  accident.  In  the  case  of  a  crochet- 
needle  or  fish-hook  which  may  have  been  accidentally  driven  into  the  tongue, 
it  will  be  necessary  to  force  the  barbed  point  completely  through  the  organ,  in 
order  that  its  removal  with  cutting-pliers  may  permit  the  withdrawal  of  the 
shaft  of  the  instrument. 

Wounds  of  the  fauces  may  be  due  to  accident  or  to  surgical  interference. 
Accidental  wounds  are  mostly  caused  by  the  forcible  thrusting  backwards  of 
a  tobacco  pipe,  and  are  unimportant,  unless,  as  has  happened,  the  stem  should 
have  been  driven  obliquely  outwards  into  the  internal  carotid  artery.*  In 
such  a  case  the  withdrawal  of  the  stem  must  lead  to  fatal  hemorrhage,  and 
it  may  be  doubted  whether,  if  the  injury  could  be  diagnosed,  the  fatal  event 
.  could  be  averted.  A  case  of  deep  arterial  wound  by  the  point  of  a  parasol, 
in  which  the  common  carotid  Avas  successfully  tied,  is  recorded  by  Mr.  Dur- 
ham,2  but  it  was  probably  some  branch  of  the  external  carotid  which  was 
wounded.  The  hemorrhage  following  a  puncture  of  an  inflamed  tonsil  is  often 

'  See  cases  by  Mr.  Vincent  (Medico-Chirurgical  Transactions,  vol.  xxix.),  and  Mr.  Charles  Moore 
(Lancet,  Sept.  10,  1864). 

*  Holmes's  System  of  Surgery,  3d  ed.,  vol.  i.  p.  745. 

(885) 


886  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

severe,  and  depends  upon  a  wound  of  an  unusually  large  tonsillar  artery  ;  or, 
possibly,  if  the  puncture  has  been  very  deep,  the  blood  may  come  from'  the 
ascending  pharyngeal  artery.  The  fear  of  wounding  the  internal  carotid 
artery  by  any  reasonable  incision  is  chimerical,  and  in  fatal  cases  of  ligature 
of  the  common  carotid,  for  supposed  wound  of  the  internal  carotid,  that 
vessel  has  been  found  intact.  Several  illustrations  of  this  statement  will  be 
found  in  a  list  of  fifty  cases  of  wound  of  the  throat  in  which  the  common 
carotid  was  tied,  appended  to  a  paper  by  Mr.  Harrison  Cripps,i  in  which  the 
author  advocates  ligature  of  the  external  rather  than  of  the  common  carotid 
in  similar  cases. 

_  Wounds  or  the  pharynx  by  bodies  swallowed,  such  as  fish-bones,  needles, 
pms,  or  pieces  of  grass  (Moore),  give  rise  to  serious  abscesses  in  the  cellular 
tissue  behind  the  pharynx.  In  tw^o  cases  I  have  known  torticollis  produced 
by  a  pin  which  I  w^as  able  to  extract  with  a  horse-hair  probang. 

Foreign  bodies,  such  as  portions  of  insufiaciently  masticated  meat,  may 
lodge  in  the  pharynx  and  give  rise  to  serious  symptoms,  and  even  death,  by 
obstructing  the  windpipe.^  Unfortunately,  in  these  cases  the  urgent  symp- 
toms are  often  misinterpreted  and  the  patient  thought  to  be  suffering  from 
apoplexy,  for  the  prompt  removal  of  the  foreign  tody  w^ith  the  finger  is  a 
sufiiciently  obvious  and  simple  mode  of  treatment.  A  case  is  recorded  by 
Mr.  Pollock^  in  which  a  set  of  displaced  artificial  teeth  caused  death  by  being 
impacted  in  the  pharynx  and  pressing  on  the  epiglottis ;  but,  on  the  other  hand. 
Sir  James  Paget^  removed  a  large  plate,  with  nine  artificial  teeth  attached, 
from  the  pharynx  of  an  old  gentleman  four  months  after  they  had  been 
swallowed. 

Tooth-plates  may  in  most  cases  be  withdrawn  from  the  pharynx  with 
ordinary  curved  forceps ;  but  when  they  have  projecting  metal  points,  these 
are  apt  to  become  entangled  in  the  wall  of  the  pharynx  and  prevent  with- 
drawal. In  these  circumstances  it  will  be  necessary  to  open  the  pharynx,  as 
in  two  successful  cases  recorded  by  Mr.  Cock.*  The  foreign  body  being  fixed 
at  the  point  where  the  pharynx  and  oesophagus  join,  an  incision  along  the 
inner  edge  of  the  left  sterno-mastoid  muscle,  with  its  centre  opposite  the  cri- 
coid cartilage,  will  allow  of  a  careful  dissection  to  the  inner  side  of  the  carotid 
sheath,  until  the  projecting  wall  of  the  pharynx  is  reached.  The  gullet  hav- 
ing been  opened  and  the  foreign  body  extracted,  the  opening  may  be  advan- 
tageously closed  with  carbolized  catgut  sutures. 


Diseases  of  the  Mouth  and  Fauces. 

Inflammatory  affections  of  the  mouth  and  fauces  may  be  due  to  local  or 
constitutional  causes.  A  scald  of  the  mouth  from  imbibing  hot  fluids,  or 
hot  steam  (as  not  unfrequently  occurs  in  the  case  of  the  children  of  the  poor 
from  drinking  out  of  a  teakettle),  will  produce  a  sodden  condition  of  the 
mucous  membrane  of  the  mouth,  with  possibly  vesication.  Inflammatory 
action  supervenes  in  due  course,  and  may  lead  to  fatal  oedema  of  the  larynx 
and  fauces,  but  in  the  mouth  comparatively  little  harm  will  be  done  except  ' 
by  the  local  destruction  of  epithelium,  which  may  be  seen  forming  a  dense 
white  membrane  closely  resembling  that  found  in  diphtheria. 

*  Medico-Chirurgical  Transactions,  vol.  Ixi.  1878. 

2  Beale,  Pathol.  Soc.  Trans.,  vol.  iii.  8  Lancet,  April  3,  l^m. 

*  British  Journal  of  Dental  Science,  vol.  v. 

»  Guy's  Hospital  Reports,  3d  series,  vols,  iv,  and  xiii. 


DISEASES  OF  THE  MOUTH  AND  FAUCES. 


887 


The  imbibition  of  strong  mineral  acid  or  of  strong  carbolic  acid,  is  usually 
immediately  fatal  from  injury  to  the  stomach,  but  in  cases  in  which  the  fluid 
has  been  ejected,  the  mucous  membrane  of  the  mouth  will  be  charred,  and 
deep  sloughing  will  ensue. 

Stomatitis,  or  inflammation  of  the  mouth,  is  a  disease  of  childhood,  except 
when  it  is  the  result  of  the  action  of  mercury  upon  the  system.  In  badly 
fed  and  ill-nourished  children,  it  is  common  to  meet  with  an  inflammatory 
condition  of  the  mouth  (stomatitis  follicular  is),  coupled  with  small  vesicles 
rapidly  developing  into  ulcers.  Added  to  this  is  commonly  found  the  condi- 
tion known  as  "  thrush,"  due  to  the  development  of  a  grayish-white  pellicle 
containing  the  o'idium  albicans,  a  parasitic  fungus. 

A  more  important  form  of  the  disease  is  the  stomatitis  gangrenosa,  wdiich 
if  unchecked  may  develop  into  the  formidable  cancrum  oris.  Beginning 
usually  in  the  gum,  close  to  the  necks  of  the  teeth,  the  disease  appears  as  a 
line  of  unhealthy  ulceration,  which  rapidly  extends  along  the  neigliboring 
gum,  and  into  the  sulcus  of  mucous  membrane  between  the  teeth  and  the 
cheek.  Owing  to  the  destruction  of  the  gums  and  the  extension  of  inflam- 
mation into  the  sockets  of  the  teeth,  these  soon  become  loosened,  and  drop 
out ;  there  is  a  profuse,  purulent,  oftensive  discharge,  by  swallowing  which 
the  patient  is  poisoned,  besides  being  worn  out  by  the  irritation  and  want 

of  food.  .  . 

The  slightest  cases,  whether  of  simple  or  gangrenous  stomatitis,  are  best 
treated  by  attention  to  feeding,  and  especially  to  hygiene ;  and  locally  by  the 
use  of  the  solid  nitrate  of  silver,  and  the  constant  application  of  the  glycerine 
of  carbolic  acid,  combined  with  the  internal  administration  of  chlorate  of 
potassium,  which  seems  to  be  almost  a  specific  remedy  in  these  cases.  The 
more  severe  cases  of  gangrenous  stomatitis  must  be  arrested  by  the  applica- 
tion of  strong  nitric  acid  or  the  actual  cautery— by  preference  Paquelin's 
thermo-cautere  —while  the  patient  is  under  the  influence  of  chloroform. 

Cancrum  oris^  is  thought  by  some  authors  to  be  a  separate  disease,  and  to 
orio-inate  in  the  cheek,  which  rapidly  becomes  gangrenous  and  sloughs  away, 
causino-  a  hideous  deformity,  and  rapidly  proving  fatal  in  the  majority  of 
cases.  "^The  treatment  is  the  same  as  for  the  more  severe  forms  of  gangrenous 
stomatitis,  but  the  disease  is  apt  to  leave  terrible  deformity  in  cases  which 
recover,  and  to  lead  to  permanent  closure  of  the  jaws  by  cicaTnee^i. 

Tonsillitis,  or  acute  inflammation  of  the  tonsils,  commonly  results  from 
exposure  to  cold  in  the  case  of  delicate  young  people  who  have  susceptible 
throats.  Towards  evening  the  throat  feels  swollen  and  painful,  and  both 
speech  and  deglutition  become  diflicult,  the  voice  having  a  peculiar,  thick 
tone,  which  is  very  characteristic.  On  inspection,  the  fauces  will  be  seen  deeply 
iniected,  and  the  tonsils  swollen  and  bulging  both  towards  the  median  line  and 
behind  the  anterior  pillars  of  the  fauces.  There  is  great  tenderness  in  the 
submaxillary  region  and  behind  the  jaw^  and  occasionally  acute  pam  m  the 
ear  from  extension  of  inflammation  along  the  Eustachian  tube.  There  is, 
besides,  considerable  fever,  the  temperature  rising  three  or  four  degrees,  and 
the  tono-ue  being  coated  with  a  white  fur;  but  the  pulse,  though  rapid,  has 
little  force,  and  is  very  compressible.  In  from  twelve  to  twenty-four  hours, 
and  either  with  or  without  a  rigor,  matter  forms  in  one  or,  seldom,  both  ton- 
sils •  and  if  not  relieved  gives  rise  to  great  distress  from  the  embarrassment 
caused  to  the  breathing,  the  patient  sitting  up  in  bed  and  constantly  hawking 


'  See  Vol.  I.,  page  802. 


2  Vide  infra. 


888  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

up  viscid  mucus,  until  at  last  in  some  straining  efFort  the  abscess  bursts,  when 
immediate  relief  with  rapid  convalescence  follows. 

In  the  premonitory  or  early  stage,  a  mustard  emetic  often  acts  as  a  charm 
and  produces  immediate  resolution ;  but,  failing  thus,  recourse  may  be  had 
to  warm  inhalations,  the  application  of  hot  poultices  below  the  ear,  and  the 
administration  of  belladonna  internally,  in  small  and  frequent  doses,  coupled 
with  plenty  of  liquid  food.  Salicylate  of  sodium  has  also  been  held  to  act  as  a 
specific  m  these  cases.  An  early  puncture  of  an  inflamed  tonsil  is  much  to 
be  recommended  if  the  surgeon  will  use  a  bistoury  covered  except  for  a  quarter 
of  an  inch  from  the  point,  and  will  thrust  it  boldly  through  the  soft  palate 
where  it  is  made  prominent  by  the  tonsil.  The  hemorrhage  should  be  en- 
couraged by  gargling  with  hot  milk  and  water,  and  much  greater  relief  will 
thus  be  given  than  by  the  application  of  leeches  externally.  The  same 
method  should  be  adopted  in  opening  an  abscess  in  the  tonsil,  and  thus  all 
risk  of  doing  damage  to  important  structures  will  be  avoided. 

A  more  chronic  form  of  tonsillitis  is  familiar  to  residents  in  hospitals 
under  the  name  of  "  hospital  sore-throat,"  and  is  met  with  among  persons 
exposed  to  bad  air,  particularly  if  tainted  with  sewer-gas.  It  consists  in  a 
subacute  inflammation  of  the  tonsils,  with  injection  and  ulceration  of  the 
fauces,  sometimes  going  on  to  abscess,  but  more  frequently  subsiding  if  the 
patient  is  put  upon  a  stimulant  and  tonic  plan  of  treatment,  and  removed 
from  the  depressing  influences  to  which  he  has  been  exposed.  The  occurrence 
of  frequent  sore-throats  in  a  household  should  direct  immediate  attention  to 
the  condition  of  the  drainage,  and  to  the  probable  escape  of  sewer-gases  into 
the  house. 

Pharyngitis. — Acute  inflammation  of  the  pharynx  may  occur  in  conjunction 
with  tonsillitis,  or  alone,  and  its  chief  symptom  is  the  difficulty  in  swallow- 
ing. The  disease  ends  ordinarily  in  resolution,  but  may  occasionally  lead  to 
suppuration  in  the  cellular  tissue  behind  the  gullet,  thus  causing  a  post- 
pharyngeal abscess.  The  bulging  forward  of  the  posterior  wall  of  the  pharynx 
by  an  elastic  swelling  which  impedes  deglutition  and  may  interfere  with  res- 
piration, clearly  marks  the  case,'  and  a  puncture  in  the  median  line  will 
readily  evacuate  the  pus.  It  should  not  be  forgotten  that  post-pharyngeal 
abscess  is  often  connected  with  caries  of  the  cervical  vertebrae,  in  which  case 
it  has  been  proposed  by  Mr.  Cheyne  to  open  the  abscess  externally  with 
antiseptic  precautions. 

Erysipelas  occasionally  attacks  the  fauces  and  pharynx,  and  appears  to 
lead  to  complete  temporary  paralysis  of.the  muscles,  so  that  not  only  is  deglu- 
tition suspended,  but  it  is  impossible  to  excite  reflex  action  in  the  muscles 
by  irritating  the  throat  mechanically.  The  affection  is  a  very  serious  one, 
and  likely  to  prove  rapidly  fatal  from  depression  of  the  vital  powers,  both  by 
the  poison  and  by  the  want  of  food,  unless  ample  nourishment  be  administered 
by  the  rectum  until  the  power  of  swallowing  is  restored.  A  much  more 
chronic  form  of  paralysis  of  the  throat  is  that  following  diphtheria,  but  here 
It  is  the  palate  which  is  principally  aflfected,  the  voice  being  thick  for  weeks. 

Hypertrophy  of  the  tonsils  is  common  in  children  and  young  persons  of  a 
strumous  diathesis,  and  in  rachitic  patients  is  apt  to  lead  to  the  deformity 
known  as  "  pigeon-breast,"  from  interference  with  the  full  expansion  of  the 
lungs.  The  thick  speech,  open  mouth,  and  stertorous  breathing,  which  in  sleep 
develops  into  sonorous  snoring,  are  sufficiently  marked  in  extreme  cases; 


»  C.  Fleming,  Cases  Occurring  in  Children,  Dublin  Journ.  of  Med.  Science,  vol.  xvii. 


DISEASES  OF  THE  MOUTH  AND  FAUCES. 


889 


whilst  in  milder  cases  the  constant  tendency  to  sore  throat  and  the  general 
failure  of  health  and  strength  without  ohvious  cause  should  direct  attention 
to  the  tonsils.  On  inspection,  the  tonsils  will  be  seen  as  large,  white,  glistening 
masses,  often  meeting  in  the  middle  line,  and  presenting  yellow  spots  due  to 
inspissated  mucous  secretion.  Ilypertrophied  tonsils  may  project  into  and 
down  the  pharynx,  but  can  never  reach  up  to  and  obstruct  the  Eustachian  tubes ; 
the  deafness  so  commonly  found  in  these  cases  is  due  to  the  generally  con- 
gested condition  of  the  mucous  membrane,  Avhich  is  relieved  by  the  removal  of 
the  glands.  The  application  of  local  sty  j,  lies  in  the  form  of  a  solution  of  nitrate 
of  silver  (gr.  x  to  f  or  the  glycerine  of  tannin  ;  the  use  of  catechu  or  kra- 
meria  lozenges,  or  the  employment  of  a  spray  of  sulphate  of  zinc  (gr.  x 
to  f^j),  are  all  useful  in  slight  cases  by  keeping  the  disease  in  check,  while  the 
patient's  health  is  improved  by  sea  air  and  tonics.  In  severe  cases,  removal 
of  the  projecting  portion  of  the  tonsil  is  the  best  remedy,  and  is  much  less 
painful  and  infinitely  more  satisfactory  than  drilling  the  tonsil  with  a  sharp 
stick  of  nitrate  of  silver,  or  caustic  potassa,  as  has  been  recommended.  The 
simplest  form  of  guillotine,  used  with  a  pair  of  volsella  forceps  (Fig.  1065),  by 


Fig.  1065. 


Volsella  forceps. 


which  the  tonsil  can  be  drawn  thoroughly  into  the  ring  with  the  opposite  hand, 
is  preferable  to  the  complicated  guillotines  fitted  with  a  fork,  which  are  apt  to 
get  out  of  order,  and  which  require  considerable  practice  for  their  successful  em- 
ployment. The  patient  being  seated  in  a  good  light,  with  the  head  thrown  back 
and  the  hands  held  by  assistants,  the  guillotine  can  be  slipped  into  the  mouth, 
which  it  immediately  gags.  The  forceps  then  grasping  the  tonsil  through 
the  ring  of  the  guillotine,  draws  it  well  forward,  and  a  sharp  movement  oftlie 
thumb  drives  home  the  blade  of  the  guillotine  and  cuts  a  large  portion  off. 
Without  withdrawing  the  guillotine,  it  is  turned  round  and  the  other  tonsil 
is  similarly  treated  by  changing  hands,  before  the  little  patient  has  really  time 
to  cry.  It  is  quite  sufficient  to  remove  a  large  portion  of  a  tonsil,  and  any 
attempt  to  remove  the  whole  is  likely  to  be  followed  by  sharp  bleeding;  but  at 
the  same  time  it  is  necessary  to  pull  the  piece  to  be  removed  well  into  the  ring, 
80  as  to  avoid  notching  the  pillar  of  the  fauces,  from  which  the  mucous  mem- 


Fig.  1066. 


Fahnestock's  tonsillotome. 


brane  is  continued  directly  on  to  the  tonsil,  occasionally  holding  it  very 'firmly. 
Ordinarily,  the  sucking  of  ice  for  a  few  minutes  staunches  all  bleeding,  but 
if  not,  the  bleeding  surface,  and  that  only,  should  be  painted  with  the  solution 


890  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 


of  the  persulphate  of  iron.  After  removal  of  the  tonsils,  ice  may  be  sucked 
for  a  few  hours,  and  a  warm  poultice  under  the  jaw  gives  great  comfort.  Care 
should  be  taken  to  give  food  cool  enough  to  be  easily  swallowed,  and  for  a 
few  days  hard  substances,  such  as  crusts,  should  be  avoided.  [Figs.  1066  and 
1067  represent  convenient  tonsil  guillotines,  devised  respectively  by  the  late 
Dr.  Fahnestock  and  Dr.  Billings,  U.  S.  A.  Fig.  1068  illustrates  the  tonsil 
ecraseur  employed  by  Prof.  Gross.] 


Fig.  1067. 


Gross's  tonsil  icraseur. 


Hypertrophy  of  the  uvula  may  be  met  with  in  the  same  class  of 
patients  as  hypertrophied  tonsils,  the  whole  uvula  being  swollen  from  over- 
development of  the  adenoid  tissue  contained  in  it.  This  must  not  be  con- 
founded with  the  cedematous  uvula  due  to  inflammation,  and  commonly 
found  in  any  acute  inflammation  of  the  throat.  A  more  common  form  is  the 
elongated  uvula  found  in  persons  of  relaxed  habit,  who  sufl:er  from  irritable 
throat  and  constant  cough,  the  result  of  the  irritation  of  the  fauces  by  the 
uvula.  Astringent  gargles  may  be  usefully  employed  in  such  cases,  but  if 
obstinate,  these  should  be  treated  like  those  of  chronic  hypertrophy,  by  abscis- 


Fig.  1069. 


Uvula  scissors. 


sion.  This  little  operation  may  be  performed  with  the  tonsil  guillotine,  or 
more  simply  with  scissors,  which  must  be  very  sharp  at  the  edge  but  blunt 


DISEASES  OF  THE  MOUTH  AND  FAUCES. 


891 


at  the  points.  The  uvula  should  be  caught  with  a  pair  of  hooked  forceps  to 
prevent  its  being  swallowed,  and  will  be  found  thicker  on  section  than 
might  have  been  anticipated.  [A  convenient  form  of  uvula  scissors  is  repre- 
sented in  Fig.  1069.] 

Ulceration  of  the  tonsils  of  a  superficial  character  is  common  in  inflam- 
matory aftections  of  the  throat,  and  the  ulcers  are  often  covered  with  aph- 
thous patches  in  patients  whose  vitality  is  low.  The  deep,  excavated  ulcer 
of  the  tonsils,  nearly  circular  in  shape  and  covered  with  a  thin  gray  slough, 
is  symptomatic  of  secondary  syphilis,  and  will  only  yield  to  constitutional 
treatment. 

Irregukr,  excavated  ulcers  presenting  a  yellow  slough,  seen  upon  the  uvula 
and  soft  palate,  or  on  the  posterior  wall  of  the  pharynx,  are  almost  always  due 
to  tertiary  or  inherited  syphilis,  and  will  heal  rapidly  under  the  administra- 
tion of  iodide  of  potassium  in  full  doses. 

As  the  result  of  this  form  of  ulceration,  adhesions  of  the  soft  palate  to 
the  pharynx,  with  narrowing  of  the  pharynx  and  nasal  intonation,  owing  to 
the  shutting  off  of  the  nose,  are  occasionally  met  with.  Interference  with 
the  cicatrices  is  ordinarily  to  be  avoided,  as  no  good  result  is  likely  to  follow 
the  division  of  the  adhesions  between  the  palate  and  pharynx  ;  but  where  the 
cicatrization  leads  to  narrowing  of  the  pharynx,  division,  and  subsequent 
dilatation  with  bougies,  may  be  advantageously  undertaken.^ 

Tumors  of  the  tonsils,  as  distinguished  from  glandular  hypertrophy,  are 
rare.  In  general  lymphadenoma  of  the  neck,  the  tonsils  may  be  similarly 
affected,  and  may  in  the  later  stages  ulcerate,  as  in  a  lad  of  seventeen  under 
the  author's  care.  A  few  instances  of  distinct  jibro-cellular  tumor  of  the  ton- 
sil have  been  met  w^ith,  one  of  the  most  recent  being  that  recorded  by  Mr. 
Fitzgerald,^  Surgeon  to  the  Melbourne  Hospital,  which  occurred  in  a  boy  of 
fifteen,  and  had  been  present  four  years,  gradually  blocking  up  the  fauces. 
It  was  successfully  removed,  and  was  of  irregular,  ovoid  form,  distinctly  en- 
capsuled  and  lobulated.  "  Its  measurements  w^ere :  Length  2J  inches  :  breadth 
If  inches ;  thickness  1 J  inches.  Under  the  microscope,  sections  were  found, 
unless  very  thin,  to  have  a  confused  fibro-cellular  appearance,  not  cleared  up 
at  all  by  acetic  acid.  When  traced  out,  the  growth  was  found  to  consist  of 
small  cells,  rounded,  oval,  or  spindle-shaped ;  the  spindles,  as  a  rule,  were 
nucleated,  and  the  round  cells  destitute  of  nuclei."  According  to  Butlin^ 
round-celled  sarcoma  is  the  most  common  of  all  malignant  tumors  of  the  tonsil. 

Cancer  of  the  tonsil  is  rare ;  it  may  be  primary,  in  which  case  it  is  encepha- 
loid,  or  more  rarely  scirrhous ;  or  secondary,  from  extension  of  epithelioma, 
from  the  tongue  and  pillars  of  the  fauces. 

Cases  of  encephaloid  cancer  of  the  tonsils  in  connection  with  development 
of  cancer  in  the  lymphatic  glands  of  the  neck  and  in  the  spleen,  have  been 
recorded  by  Carswell,  Sydney  Jones,  and  Moxon ;  such  cases  are  clearly  be- 
yond surgical  treatment,  but  when  the  disease  is  confined  to  the  tonsil  it  has 
been  successfully  removed. 

Mr.  Poland,^  in  an  exhaustive  article  upon  "  Cancer  of  the  Tonsil  Glands," 
shows  that  the  diagnosis  of  cancer  in  the  early  stag-e  is  very  difiicult,  it  being 
confounded  with  chronic  hypertrophy  or  syphilitic  gumma.  Its  rapidity 
of  growth  and  tendency  to  involve  surrounding  structures,  including  particu- 
larly the  lymphatic  gland  at  the  angle  of  the  jaw,  will  afterwards  serve  to  dis- 

•  See  a  Case  of  Extreme  Pharyngeal  Stenosis,  with  resume  of  subject,  by  Smith  and  Walsham. 
Medico-Chirurgical  Transactions,  vol.  Ixiii.  1880. 
2  Australian  Medical  Journal,  September  15,  1880. 
8  British  and  Foreigji  Medico-Chirurgical  Review,  April,  1872. 


892  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

tinguish  its  nature.  Removal  of  portions  of  the  growth  hy  the  knife,  wire- 
snare,  and  ecraseur,  have  given  unsatisfactory  results  in  the  hands  of  several 
surgeons,  and,  if  any  operation  is  resorted  to,  total  extirpation  of  the  tonsil 
should  be  performed.  This  operation,  though  said  to  have  been  employed 
by  Langenbeck  and  Hueter,  in  1865,  was  first  described  by  Dr.  Cheever,^  of 
Boston,  who  performed  it  successfully  in  1869,  and  again  in  1878.^  In  both 
cases,  the  operation  was  done  through  an  external  incision  below  the  angle  of 
the  jaw ;  and  in  the  second  case,  the  jaw  was  divided  and  turned  up  so  as  to 
gain  sufficient  room  without  dividing  the  digastric,  stylo-hyoid  and  stylo- 
glossus muscles,  as  had  been  done  in  the  first  case.  In  both  instances  the 
tonsil,  when  reached  by  dividing  the  superior  constrictor  of  the  pharynx, 
was  enucleated  with  less  trouble  and  hemorrhage  than  might  have  been 
anticipated. 

Dr.  Cheever's  first  patient  was  lost  sight  of;  in  the  second  case  the  history 
may  thus  be  summarized.  The  primary  growth  began  in  the  tonsil  in  August. 
Lymphatic  poisoning  occurred,  and  a  bubo  formed,  in  JsTovember.  ^The 
tumor  and  the  bubo  were  removed  by  the  knife,  early  in  January.  Early  in 
February,  a  second  bubo  had  formed  and  was  removed.  In  March,  the  origi- 
nal growth  was  sprouting  again,  and  w^as  twice  burnt  away,  the  bubo  not 
recurring.  In  May,  the  pharyngeal  tumor  was  larger  than  ever,  and  the  bubo 
w^as  recurrent  in  an  enormous  growth.  As  Dr.  Cheever  remarks,  "  the  ques- 
tion remains  whether,  in  view  of  such  rapid  and  persistent  recurrence  as  in 
the  second  case,  it  is  w^orth  while  to  interfere  with  cancer  of  the  tonsil  at  all 
by  operation." 

In  Dr.  Cheever's  second  case,  and  also  in  Mr.  Fitzgerald's  case  of  fibro-cel- 
lular  tumor,  already  described,  tracheotomy  was  done,  and  the  upper  aper- 
ture of  the  larynx  was  plugged  to  prevent  the  entrance  of  blood  into  the 
lungs ;  and  it  w-ould  appear  that  if  this  were  etfectually  done,  enucleation  of 
the  entire  growth  from  within  the  mouth  might  be  fairly  attempted,  the  dis- 
eased lymphatic  gland  being  dissected  out  separately.  Mr.  Fitzgerald, ^  in- 
deed, says  that,  had  he  known  as  much  as  he  did  afterwards,  he  would  not 
have  made  an  incision  through  the  cheek,  ^' for  after  free  division  of  the 
muscles  that  bind  the  lips  to  the  bone,  the  mouth  can  be  opened  to  almost 
any  extent  that  may  be  required." 

In  October,  1882,  Mr.  Golding-Bird  and  Mr.  Clement  Lucas,  of  Guy's 
Hospital,  communicated  to  the  Clinical  Society  of  London  cases  of  epithe- 
lioma of  the  tonsil,  removed  by  the  former  gentleman  from  the  outside,  by 
Cheever's  operation,  and  by  the  latter  from  within  the  mouth,  portions  of 
the  soft  palate  and  tongue  being  at  the  same  time  taken  away.  The  results, 
though  not  leading  to  a  permanent  cure,  w^ere  encouraging. 

Follicular  DISEASE  of  the  pharynx  is  commonly  met  with  as  an  accompani- 
nent  of  chronic  glandular  laryngitis,  or  clysphonia  clericorum-.  The  pharynx 
and  fauces  are  seen  to  be  injected  and  roughened,  owing  to  hypertrophy  of 
the  glandular  structures  of  the  mucous  membrane.  The  patient  complains 
of  dryness  of  the  throat,  and  is  constantly  clearing  it,  and  hawking  up  small 
quantities  of  viscid  mucus.  The  hoarseness  of  the  voice  after  use  for  a 
short  time  is  a  marked  feature  of  the  disease,  and  depends  upon  a  similarly 
congested  condition  of  the  laryngeal  mucous  niembrane.  In  slight  cases, 
much  good  may  be  done  by  proper  elocutional  instruction,  and  particularly 
by  teaching  the  patient  to  use  his  lips  and  tongue  rather  than  his  throat  in 
vocalizing.  The  use  of  soft  astringent  lozenges  (catechu  or  rhatany),  which 
are  to  be  slowly  sucked  at  intervals,  and  the  use  of  a  spray  with  a  solution 


-  Surgical  Cases,  Boston,  1869. 

2  Boston  Med.  and  Surg.  Journal,  August  1,  1878. 


*  Log.  cit. 


DISEASES  OF  THE  TONGUE. 


893 


of  sulphate  of  zinc  (gr.  x  to  f§j),  night  and  morning,  will  eftect  much  good. 
In  more  confirmed  cases,  the  application  of  a  strong  solution  of  nitmte  ot 
silver  (o-r.  xxx  to  fsj),  with  a  hrush,  or  painting  with  the  tincture  of  iodine  or 
solution  of  the  perchloride  of  iron,  will  be  necessary,  combined  with  atten- 
tion to  the  general  health ;  but  the  improvement  is  always  slow,  and  the 
remedies  must  be  varied  to  suit  hidividual  cases. 

Tumors  of  the  pharynx  are  of  rare  occurrence,  and  usually  of  congenital 
orio-in ;  thev  are  mostly  pendulous,  with  a  narrow  neck.  The  most  remark- 
able case  known  is  one  in  which  a  fatty  tumor,  now  in  the  museum  of  the 
Westminster  Hospital,  occurred  in  an  old  man  whose  history  is  recorded  by 
Mr  llolt.i  Here  the  pedicle  was  attached  to  the  epiglottis,  so  that  when  the 
tumor  was  projected  into  the  mouth  the  patient  was  suffocated.  Other  cases 
in  which  smaller  pedunculated  growths  have  been  successfully  removed,  are 
recorded,  and  in  any  case  of  difficulty  from  impending  asphyxia,  the  opera- 
tion of  laryngotomy  would  relieve  all  embarrassment  during  the  removal  of 

the  tumor.  ,     -,      .  -        x-  ^v. 

A  pulsating  tumor  of  the  pharynx  may  be  due  to  an  aneurism  ot  the 
internal  carotid  artery,  ii^  in  cases  recorded  by  Porter  and  Syme ;  and  Mr. 
Barnes,^  of  Bolton,  has  recorded  a  case  of  pulsating  tumor  of  the  back  of  the 
pharynx,  in  a  woman  aged  seventy-three,  in  which  the  pulsation  was  entirely 
arrested  by  pressure  upon  the  external  carotid. 

Diseases  of  the  Tongue. 

Tongue-tie  is  a  common  congenital  affection,  but  more  often  imagined^  by 
the  mother  or  nurse  than  actually  present.  Any  slight  difiiculty  in  sucking, 
soon  after  birth,  or  in  talking  at  a  later  period,  is  apt  to  be  put  down  to 
"  tono-ue-tie,"  and  though  in  some  cases  the  frsenum  is  shorter,  and  extends 
nearer  the  tip  of  the  tongue,  than  in  others,  it  may  be  doubted  whether,  ex- 
cept in  extreme  examples,  it  ever  really  interferes -with  the  movement  of  the 
organ.  I  have,  however,  recently  had  to  divide  the  frpenum  in  a  young  man 
of  "^twenty-eight,  whose  speech  was  certainly  interfered  with.  The  operation 
of  division  is  very  simple  if  a  blunt-pointed  pair  of  scissors  be  used,  and  if 
the  points  be  directed  downwards  so  as  not  to  injure  the  tongue  itself,  or  the 
ranine  artery,  which  may  be  protected  with  the  fingers,  or  vvith^  the  split 
handle  of  a  director.  A  small  snip  is  quite  suflicient,  and  the  point  of  the 
finger  may  tear  the  fr?enum  a  little  farther  if  necessary. 

Ranula  is  the  term  applied  to  cysts  beneath  the  tongue,  but  these  vary  con- 
siderably in  character.  The  simplest  is  a  thin-walled  cyst  having  a  bluish 
look,  and  containing  clear  mucus.  This  is  due  to  the  obstruction  and  dilata- 
tion of  one  of  the  numerous  mucous  follicles  of  the  floor  of  the  mouth,  and 
never  to  dilatation  of  the  Whartonian  duct  of  the  submaxillary  gland,  which 
does  not  undergo  dilatation  except  when  its  orifice  is  obstructed,  as  some- 
times happens,  by  a  salivary  calculus.  Occasionally  a  ranula  is  multilocular, 
a  second  cyst  lying  behind  the  superficial  one. 

The  treatment  consists  either  in  snipphig  out  a  piece  of  the  cyst  wall  with 
scissors,  or  in  passing  a  fine  seton  through  the  cyst.  The  seton  may  be  intro- 
duced with  an  ordinary  curved  needle,  and  should  be  of  fine  silver  wire,  the 
ends  of  which  can  be  twisted,  and  will  lie  under  the  tongue  without  absorb- 
ing putrid  material,  as  would  be  the  case  with  silk.    As  a  rule,  the  wire  does 

I  Path.  Soc.  Trans.,  vol.  v  *  Lantiet,  October  30,  1875. 


894  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

not  cut  its  way  out,  and  will  require  removal  when  the  cyst  has  become 
obliterated. 

A  rarer  form  of  cyst  is  the  congenital  cyst  of  the  floor  of  the  mouth 
which  contains  inspissated,  sebaceous  material,  closelv  resembling  putty  in 
appearance,  and  having  an  offensive,  cheesy  odor.  Being  of  slow  growth  it 
seldom  gives  trouble  until  early  adult  life,  when  an  unsi^-htly  swelling;  below 
the  chm  IS  noticed  externally,  and  the  tongue  is  pushed^up  so  as,  in  extreme 
cases,  to  interfere  with  speech. 

This  form  of  cyst  is  confined  to  the  floor  of  the  mouth,  but  often  has  a 
portion^  reflected  around  the  posterior  edge  of  the  mylo-hyoid  muscle  and 
presenting  m  the  digastric  triangle.  This  fact  makes  the  treatment  'very 
diflacult,  as  graphically  described  by  Sir  Wm.  Fergusson,i  who  met  with  two 
cases  of  the  kind,  one  of  which  he  treated  by  excision,  and  the  other  by 
inducing  suppuration  in  the  cyst.  In  one  case  I  succeeded  in  removing 
the  cyst  through  the  mouth,  after  dividing  the  mylo-hyoid  so  as  to  alio! 
of  the  withdrawa  of  the  portion  superficial  to  the  muscles.  Should  removal 
not  be  feasible,  the  use  of  a  seton,  passed  from  below  the  jaw  through  the 
mouth,  after  evacuation  of  the  contents,  would  probably  set  up  sufficient 
action  to  produce  a  cure.  The  diagnosis  of  these  cases  is  always  obscure, 
and  they  are  usually  mistaken,  until  opened,  for  examples  of  ordinary  ranula. 

Inflammatory  swelling  beneath  the  tongue,  leading  to  the  formation  of 
pus  wliich  IS  apt  to  find  its  way  between  the  muscles  of  the  throat  may 
arise  from  abscess  connected  with  a  tooth,  and  should  be  opened  early 

Hypertrophy  with  prolapse  of  the  tongue,  or  macroglossia,  though 
usually  a  congenital  affection,  is  not  invariably  so.  In  some  of  the  recorded 
cases  It  appears  to  have  been  the  result  of  inflammation  occurring  in  early 
life,  and  m  one  case  to  have  followed  the  application  of  a  leech.  It  has  been 
reo:arded  by  some  surgeons  as  primarily  a  prolapse  due  to  deficiency  of  mus- 
cular power,  and  by  others  as  an  hypertrophy  leading  to  prolapse  by  the 
weight  of  the  organ  ;  and  undoubtedly,  in  the  later  stages,  the  whole  or4n  is 
enormously  enlarged  and  hangs  out  of  the  mouth.  In  Dr.  Humphry's^  case 
m  a  girl  aged  eleven,  the  prolapsed  portion  of  the  tongue  measured  from  the 
upper  hp  to  the  tip  three  and  one-half  inches,  and  the  circumference  of  the 
widest  part  of  the  organ  was  six  and  one-half  inches.  The  papillse  were 
greatly  enlarged  and  separated  by  deep  clefts,  but  no  record  is^iven  of  the 
condition ^of  the  portion  removed.  Mr.  H.  Arnott^  has,  however,  recorded  a 
case  in  which  there  was  actual  hypertrophy  of  the  muscular  substance,  as 
we  l  as  enlargement  of  the  bloodvessels  and  lymphatics,  and  thickening 
and  induration  due  to  inflammation.  In  addition  to  the  discomfort  caused 
by  the  prolapse,  m  all  the  recorded  cases  an  alteration  in  the  position  of  the 
teeth  and  alveolus  of  the  lower  jaw,  due  to  the  constant  pressure  of  the 
tongue,  has  been  observed.  In  the  treatment  of  this  affection,  pressure  by 
bandaging  and  the  use  of  styptics  seem  to  have  given  good  results  in  some 
cases  and  Syme*  speaks  highly  of  the  use  of  a  solution  of  sulphate  of  cop- 
per Qj  to  f5j).  Failing  to  get  relief  in  this  way,  removal  of  the  protrudinp- 
portion  with  the  knife,  as  in  Syme's  and  Humphry's  cases,  or  with  the 
ecraseur,  as  in  Erichsen  s,  offers  the  only  method  of  treatment  available  *  In 
the  case  of  an  idiot  boy,  aged  ten,  recently  under  my  care,  with  macroglossia 
ot  congenital  origin,  I  removed  the  anterior  portion  of  the  tongue  by  a 

1  System  of  Practical  Surgerj,  p.  514.  2  Medico-Chirurgical  Trans.,  vol.  xxxvi. 

*  Path  Soc.  Trans.,  vol.  xxiii  4  Observations  in  Clinical  Surgery.  1861. 

*  List  of  cases  m  F.  Clarke's  Diseases  of  the  Tongue,  p.  72. 


DISEASES  OF  THE  TONGUE. 


895 


V-shaped  incision,  bringing  the  two  sides  together  with  stitches ;  but  these 
soon  cut  through,  and  the  result,  though  eventually  satisfactory,  was  not 
better  than  that  gained  by  the  simpler  method. 

Atrophy  of  one  side  of  the  tongue  is  never  a  congenital  affection,  but 
the  result  either  of  cerebral  disease  or  of  injury  to  the  hypoglossal  nerve,  as 
in  a  case  of  aneurism  of  the  external  carotid  artery,  recently  under  my  care, 
in  which  the  nerve  was  stretched  and  atrophied.^  Sir  James  Pagct^  has 
recorded  a  case  in  which  removal  of  necrosed  bone  from  the  skull  relieved 
the  nerve  and  led  to  restoration  of  the  tongue,  but  this  is  a  favorable  result 
which  can  seldom  be  anticipated. 

IST^vus  OF  the  tongue  is  another  congenital  affection  occasionally  met 
with.  If  superficial  it  may  be  treated  with  nitric  acid,  the  tongue  being 
previously  dried  and  held  out  of  the  mouth  with  a  towel  so  as  to  prevent 
injury  to  the  surrounding  parts.  In  more  extensive  nievi,  the  application 
of  a  ligature,  which  must  be  passed  into  the  substance  of  the  tongue  and 
tied  very  firmly,  is  the  best  mode  of  treatment. 

Congenital  Tumor  of  the  Tongue. — A  very  rare  form  of  congenital  tumor 
of  the  tongue  is  recorded  by  Dr.  Hickman^  as  occurring  in  a  new-born  child, 
who  died  a  few  hours  after  birth  from  suftbcation  induced  by  the  tumor. 
Immediately  in  front  of  the  epiglottis  was  a  tumor  projecting  half  an  inch 
from  the  surface  of  the  tongue,  and  measuring  three-quarters  of  an  inch  by 
one-half  inch.  It  proved  to  be  an  hypertrophy  of  the  normal  racemose 
glandular  structures  of  the  part.  Congenital  Jibro-celhdar  tumors  of  the 
tono-ue  are  occasionally  met  with,  and,  being  usually  pedunculated,  are  easily 
removed.  Mr.  F.  Mason  has  recorded  two  examples  of  the  kind,  which 
were  allowed  to  remain  in  situ  till  adult  life.'* 

Lymphangeioma  is  a  very  rare  congenital  affection  of  the  tongue,  and  is  a 
variety  of  hypertrophy  in  which  the  lymphatics  are  principally  affected.  In 
1876, 1  had  a  young  woman  aged  twenty-three  under  my  care,  suffering  from 
this  affection,  the  tongue  being  enlarged  and  indurated  so  as  to  interfere  with 
speech,  but  not  being  prolapsed,  and  the  surftice  being  tubercalated  and 
marked  with  whitish  lines  which  were  evidently  enlarged  lymphatics.  With 
the  hope  of  producing  some  effect  I  passed  setons  into  the  tongue,  the  only 
result  of  which  was  to  set  up  severe  inflammation  with  great  temporary  dis- 
tress of  breathing,  but  without  any  permanent  benefit. 

Glossitis,  or  inflammation  of  the  tongue,  in  the  acute 'form,  is  an  affection 
rarely  met  with  at  the  present  time,  and  then  is  apparently  of  spontaneous  origin. 
In  former  days,  when  the  administration  of  mercury  was  ordinarily  pushed 
to  salivation,  the  occurrence  of  glossitis  was  common,  and  the  swollen  tongue 
protruding  from  the  mouth  was  looked  upon  as  a  proof  of  successful  treat- 
ment. As  some  individuals  seem  to  be  peculiarly  liable  to  be  rapidly  afiected 
by  small  doses  of  drugs,  it  may  be  well  to  bear  in  mind  that  iodide  of  potas- 
sium and  its  allies,  no  less  than  mercury,  may  rapidly  induce  salivation.  The 
swollen,  (edematous  condition  of  the  tongue  in  glossitis,  may  interfere  with 
respiration  sufiiciently  to  demand  tracheotomy,  but  as  a  rule  the  inflammation 
rapidly  yields  to  leeching,  or  to  a  free  incision  on  each  side  of  the  median  line. 


1  Medico-Cliirurg.  Trans.,  vol.  Ixvi. 

»  Pathological  Society's  Trans.,  vol.  xx. 


«  Clinical  Soc.  Trans.,  vol.  iii. 
*  Ibid.,  vols.  XV.  and  xviii. 


896  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC.  • 

In  milder  cases  the  use  of  chlorate-of-potassium  and  borax  ^are-les,  and  the 
free  purgation  of  the  patient,  will  give  relief.  &   &  ' 

Abscess  of  the  ToNGUE.-Abscess  is  not  unfrequently  the  result  of  glossitis 
and  should  be  opened  as  soon  as  the  presence  of  matter  can  be  detected  In 
all  niflamniatory  affections  in  which  the  tongue  is  protruded  beyond  the 
jaws,  the  effects  of  the  presence  of  the  incisor  teeth  upon  the  orP-an  must  be 
borne  m  mind,  for  a  deep  groove  is  apt  to  be  cut  in  the  under  surface  of  the 
tongue  by  the  teeth,  and  thus  the  swelling  and  cedema  are  increased.  The 
teeth  may  be  conveniently  guarded  by  a  metal  or  gutta-percha  shield,  and  if 
necessary,  a  support  for  the  tongue  may  be  easily  adapted  to  such  a  con- 
trivance.^ ^ 

GuMMATA  OF  THE  ToNGUE.-^Closely  resembling  abscess,  since  in  its  later  stao-es 
It  breaks  down  and  contains  fluid,  is  the  gumma  due  to  tertiary  syphiTis 
Situated  near  the  base  or  in  the  centre  of  the  tongue,  gummata  or  muscular 
nodes  slowly  increase  in  size  without  pain,  and  then;  when  the  patient  has 
got  out  of  health  from  the  syphilitic  poison  in  his  system,  they  rapidly  soften 
and  discharge,  leaving  deep  excavated  ulcers.^  A  very  similar  nodule  occur- 
ring m  the  tongue  of  a  strumous  child,  and  running  much  the  same  course  as 
a  gumma,  would  by  some  surgeons  be  considered  tubercular  in  its  origin,  but 
It  may  be  doubted  whether  most  of  the  recorded  examples  are  not  cases  of 
inherited  syphilis.  The  occurrence  oi  jibro-cellular  or  fibroid  tumors,  or  of 
scirrhous  or  medullary  cancer,  in  the  substance  of  the  tongue,  is  extremelV  rare 
and  as  it  is  impossible  to  diagnose  their  nature  in  an  early  sta^e,  it  is  safer  to 
look  upon  all  tumors  of  the  substance  of  the  tongue  as  gummatous,  and  to 
treat  them  with  full  doses  of  iodide  of  potassium.  The  great  majority  will 
be  tound  to  disappear  rapidly  under  this  treatment,  and  certainly  no  harm 
will  be  done  by  the  drug  in  cases  of  other  forms  of  growth,  which  are  not 
amenable  to  its  influences. 

Chronic  glossitis,  leading  to  serious  alterations  in  the  superficial  struc- 
tures of  the  tongue,  may  be  due  simply  to  too  stimulating  food  or  drink,  or, 
much  more  frequently,  to  the  over-use  of  tobacco.  It  may  also  depend  upon 
syphilis,  or  may  be  caused  by  prolonged  mercurial  treatment.  In  the  early 
stage  the  tongue  is  reddened  and  irritable,  being  much  more  sensitive  than  iii 
health,  and,  possibly  patches  of  similarly  affected  mucous  membrane  may  be 
found  m  the  cheeks.  It  unchecked,  patches  of  white,  hypertrophied  epithelium 
will  be  formed  over  the  most  irritable  spots,  and  these  may  be  thrown  off  from 
tmie  to  time,  constituting  the  so-called  -psoriasis  linguoe. 

The  treatment  of  this  chronic  form  of  glossitis  consists  in  removing  all 
sources  of  local  irritation,  and  in  attending  to  the  general  health.  Frequent 
painting  with  a  five-grain  solution  of  chromic  acid,  in  the  non-syphilitic 
forms  and  with  a  two-grain  solution  of  bichloride  of  mercury  in  the  syphi- 
litic forms  of  the  disorder,  seems  to  be  useful,  combined  with  the  use  of 
demulcent  lozenges,  slowly  sucked. 

A  more  serious  result  of  chronic  glossitis  is  the  formation  of  a  permanent 
loliite  patc^h  (leucoplakia.leucoma)  in  which  destruction  of  the  papillary  struc- 
ture IS  brought  about  with  more  or  less  infiltration  of  granulation-cells. 
I  hese  patches  may  remain  quiescent  for  years,  and  may  then  develop  true 
epithelioma,  and  they  are  therefore  always  causes  for  anxiety  and  watching, 
with  a  view  to  early  operative  interference  should  any  growth  beo-in  to  de- 
velop.   It  is  remarkable,  as  pointed  out  by  Hutchinson,  that  we  do^'occasion- 

»  Lancet,  January  22,  1881.  2  yide  infra. 


DISEASES  OF  THE  TONGUE. 


897 


ally  see  patches  on  the  tongue  and  cheeks  in  association  with  non-syphilitic 
skin-diseases,  viz.  psoriasis  and  pityriasis. 

Alterations  in  the  cuticle  of  the  tongue  are  likely  to  attract  attention 
in  an  early  stage,  and  their  prompt  recognition  and  treatment  are  important. 
Before  examining  the  surface  of  a  tongue,  care  should  be  taken  to  dry  it 
thoroughly,  since  the  presence  of  saliva  masks  many  of  the  characteristic 
appearances. 

The  ordinary  furred,  red,  or  glazed  tongues,  which  are  only  evidences  of 
gastric  irritation  or  general  fever,  can  hardly  be  considered  surgical,  but  when 
one  side  of  the  tongue  only  is  covered  with  "  fur,"  there  nmst  be  some  local 
cause  for  irritation,  which  will  probably  be  found  in  a  decayed  molar  tooth 
of  the^  upper  jaw.  Hilton^  has  shown  that  occasionally  a  one-sided,  furred 
condition  of  the  tongue,  may  be  symptomatic  of  injury  to  the  hfth  nerve 
in  fracture  of  the  base  of  the  skull. 

Mucous  tuhercles  of  the  ordinary  flat  form  are  occasionally  met  witli  on 
the  tongues  of  prostitutes,  and  others  suffering  from  secondary  syphilis,  and 
in  these  cases  confirmatory  evidence  will  be  found  about  the  lips  and  inside 
the  cheek.  A  warty  condition  of  some  of  the  papillae  of  the  dorsum  of  the 
tongue,  occasionally  occurs  in  perfectly  healthy  children  and  adults,  and  is  best 
treated  by  paring  down  the  growth  and  applying  nitrate  of  silver. 

True  papilloma  occurs  occasionally  upon  the  dorsum  of  the  tongue,  consist- 
ing in  a  patch  of  thickened  mucous  membrane  covered  with  hypertrophied 
and  prominent  papillae.  In  its  early  stage  it  is  quite  superlicial,  and  may  be 
readily  removed  with  the  knife,  but  at  a  later  period  it  is  apt  to  invade  the 
deeper  layers  of  the  corium,  and  to  present  an  appearance  closely  resembling 
epithelioma,  but  without  any  lymphatic  enlargement.  Possibly,  in  some  o'f 
the  successful  cases  of  removal  of  portions  of  the  tongue  for  epithelioma, 
the  disease  really  may  have  been  papilloma. 

A  loss  of  epithelium  in  patches  on  the  dorsum  of  the  tongue,  by  which  a 
smooth,  bluish  surface  is  left,  undergoing  no  alteration  for  many  weeks 
together,  is  generally  due  to  syphilis,  and  may  be  combined  with  a  fissured 
and  scarred  condition  of  the  sides  and  tip  of  the  organ.  There  is  a  form  of 
smooth  tongue  which  is  apt  to  end  in  cancer,  but  here  the  loss  of  epithelium 
is  more  uniform  and  extensive,  and  there  is  submucous  induration.  This 
latter  form  has  been  specially  investigated  by  Mr.  Butlin,^  who  regards  the  dis- 
ease as  a  chronic  inflammation  of  the  mucous  membrane,  and  not  the  result 
of  cicatrization,  but  probably  allied  to  psoriasis  and  ichthyosis ;  this  view, 
however,  is  contested  by  Mr.  Jonathan  Hutchinson.  ' 

A  more  formidable  condition  is  that  known  as  ichthyosis  lingucc,  in  which 
not  only  is  the  epithelium  hypertrophied,  but  the  papillae  are  greatly  enlarged, 
the  surface  ot  the  tonj_^ue  being  rough,  hard,  and  fissured.  This  is  a  chronic 
affection,  lasting  for  many  years,  but  tending  eventually  to  develop  into  epi- 
thelioma. Mr.  Hulke,3  who  originally  described  the  disease,  says :  Ichthyosis 
is  characterized  by  tough,  white,  raised  patches  on  the  surface  of  the  tongue. 
Their  color  is  not  unlike  that  of  a  thin  film  of  boiled  white  of  e^^-o*,  or  wet 
kid  leather.  They  are  clinically  distinguishable  from  syphilitic  condylomata 
by  their  thick  epithelium  and  their  wide  superficial  extent ;  and  from  syphi- 
litic nodes  and  cancerous  tumors  by  their  restriction  to  the  mucosa,  by  their 
exact  circumscription,  by  the  natural  softness  of  the  underlying:  muscular 
tissue  (showing  the  absence  of  infiltration),  and  by  the  absence  of^  ulceration 
and  of  infection  of  the  lymphatics." 

1  Lectures  on  Rest  and  Pain.  2  Medico- Chirurgical  Transactions, vol.  Ixi. 

^  Transactions  of  the  Clinical  Society,  vol.  ii.  »     •  • 

VOL.  IV. — 57 


898  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

The  prominent  patches  may  be  reduced  by  paring  or  by  excision,  but  the 
disease  tends  to  run  so  surely,  though  slowly,  into  epithelioma,  that  early 
and  complete  removal  of  the  affected  portion  of  the  tongue  should  be  urged 
upon  the  patient  before  positive  evidence  of  cancer  is  developed. 

Ulceration  of  the  tongue  may  be  simple,  syphilitic,  tubercular,  or  can- 
cerous. 

The  simple  ulcer  is  often  caused  by  the  irritation  of  a  sharp  tooth  or  the 
end  of  a  cigar  ;  or  it  may  be  due  to  dyspepsia.  It  is  small  and  superficial,  and, 
unless  due  to  local  irritation,  is  generally  multiple,  and  is  often  found  beneath 
the  tongue.  It  is  painful,  and  interferes  with  the  movements  of  the  tongue, 
but  yields  readily  to  treatment.  The  removal  of  the  sharp  corner  of  a 
decayed  tooth  with  a  file,  or  the  employment  of  an  amber  mouth-piece,  and 
the  subsequent  application  of  a  stick  of  nitrate  of  silver  to  the  ulcer,  are  gen- 
erally sufi5«ient  to  effect  a  cure,  w^hen  the  cause  is  local.  When  it  is  consti- 
tutional, a  brisk  purge  with  the  local  use  of  the  glycerine  of  tannin,  or  any 
astringent  gargle,  will  be  sufficient  treatment. 

Syphilitic  ulceration  may  appear  during  the  secondary  stage  of  the  dis- 
order along  the  edges  of  the  tongue,  and  will  almost  alw^ays  be  found  to  have 
a  corresponding  white  patch  on  the  mucous  membrane  of  the  cheek.  These 
ulcers  have  no  induration  at  their  bases,  but  when  healed  leave  an  irregular 
fissured  border,  w^"hich  is  very  characteristic.  A  later  form  of  ulceration  is 
found  in  fissures  of  the  dorsum,  which  leave  irregular  furrow^s  in  healing. 

The  deep  syphilitic  ulcer  is  due  to  the  breakipg  down  of  a  gumma,  and  it 
is  this  kind  which  is  apt  to  be  confounded  with^'cancerous  ulceration.  The 
ulcer  is  irregular,  with  everted  edges,  and  presents  a  yellowish  slougb  at  its 
base,  in  which  a  varying  amount  of  induration  can  be  detected.  It  is  often 
in  the  central  portion  of  the  tongue,  whereas  epithelioma  is  more  commonly  at 
the  sides ;  and  careful  investigation  will  show  that  a  lump  has  been  noticed 
in  the  organ  before  the  ulceration  commenced,  and  that  the  induration  dimin- 
ishes as  the  ulcer  grows ;  whereas  in  cancer  the  induration  follow^s  the  ulcer, 
and  steadily  increases  in  extent.  Still,  it  must  be  admitted  that  cases  occur 
in  which  it  is  impossible  to  give  an  accurate  diagnosis  without  having  re- 
course to  the  tentative  administration  of  iodide  of  potassium,  and  that  even 
then  it  is  not  always  possible  to  be  sure  that  epithelioma  has  not  begun  in  an 
old  tertiary  lesion.  Eecourse  may  be  had  with  advantage  to  the  microscopic 
examination  of  scrapings  from  a  doubtful  ulcer,  when  epithelial  elements 
characteristic  of  epithelioma  may  possibly  be  obtained.* 

In  the  treatment  of  syphilitic  ulceration  of  the  tongue,  regard  must  be  had 
to  the  stage  of  syphilis  in  which  it  occurs,  and  to  the  previous  treatment 
undergone.  In  the  superficial  form  of  ulceration,  mercury,  in  the  shape  of  the 
bichloride  or  the  iodide,  is  much  more  efiectual  than  the  alkaline  iodides 
alone,  and  should  be  had  recourse  to,  unless  the  patient's  health  has  been 
shaken  by  previous  courses  of  the  drug.  In  the  tertiary  form  of  ulcerated 
gumma,  iodide  of  potassium  will  certainly  effect  a  rapid  cure  if  the  ulceration 
is  recent,  provided  it  be  given  in  sufficient  doses,  beginning  with  not  less  than 
10  grains,  thrice  daily,  and  being  increased  to  30-grain  doses,  if  smaller  ones 
are  not  efiectual.  In  all  forms  of  syphilitic  ulceration  the  local  application  of 
mercury  is  useful,  but  it  must  be  applied,  not  in  the  form  of  gargles,  which 
are  used  and  spat  out  at  once,  but  as  a  lotion,  to  be  held  in  the  mouth  for  five 
minutes,  so  as  to  "pickle"  the  tongue.  A  lotion  containing  the  bichloride  of 


^  See  a  paper,  with  drawings,  by  Mr.  H.  T.  Butlin.    British  Medical  Journal,  Feb.  18,  1882. 


DISEASES  OF  THE  TONGUE. 


899 


mercury,  gr.  ss  to  f^j  of  water,  with  a  little  glycerine  or  honey,  is  a  very  good 
preparation,  and  its  strength  may  be  increased  after  a  time  with  advantage. 
Care  must,  of  course,  be  taken  that  none  of  the  fluid  be  swallowed. 

Tubercular  ulceration  occurs,  for  the  most  part,  at  the  tip  of  the  tongue. 
At  first  superficial,  and  often  multiple,  the  ulcer  is  apt  to  spread  into  the 
organ,  leacling  to  a  splitting  of  the  tip,  which  becomes  bitid  as  the 
ulceration  proceeds.  This  form  occurs  in  patients  who  are  distinctly  tuber- 
cular, or  on  the  border-land  of  tuberculosis ;  and  the  tongue  improves  if  the 
general  health  can  be  reestablished,  or  becomes  more  deeply  excavated  pari 
passu  with  the  progress  of  the  disease  of  the  lungs  or  other  organs.  Locally, 
I  have  found  benelit  from  the  use  of  weak  lotions  of  chromic  acid,  and  have 
fancied  that  capping  the  lower  incisor  teeth  with  gutta-percha,  so  as  to 
obviate  the  constant  friction  of  the  ulcer,  has  done  good.  Mercurial  and 
all  anti-s3'philitic  remedies  are  extrismely  harmful  to  cases  of  tubercular 
ulceration. 

Cancerous  ulceration  is  always  of  the  epitheliomatous  type.  Attacking 
the  side  of  the  tongue,  in  patients  usually  over  forty  years  of  age,  the  onset 
of  the  disease  is  so  insidious  as  to  attract  little  attention,  the  ulcer  being  often 
attributed  (and  perhaps  correctl}^  as  to  origin)  to  the  irritation  of  a  tooth. 
When  well  developed,  the  ulcer  is  usuallj^  oval  in  shape,  with  sharply  cut  edges, 
and  a  marked  induration  beneath  it  when  the  parts  are  grasped  by  the  finger 
and  thumb.  The  pain  of  cancerous  ulceration  is  a  well-marked  and  early 
symptom,  being  lancinating  and  acute,  and  shooting  up  into  the  ear.  The 
irritation  causes  a  great  flow  of  saliva,  and  the  tongue  is  moved  with  diffi- 
culty, at  first  because  of  the  pain  produced,  and  afterwards  because  it  is  bound 
down  by  the  infiltration  of  all  the  structures.  The  submaxillary  lymphatic 
glands  become  involved  early  in  the  disease,  being  at  first  swollen  and  tender,  and 
subsequently  apt  to  suppurate  and  break  down,  causing  large  openings  beneath 
the  jaw.  Should  the  disease  spread  towards  the  base  of  the  tongue,  death  may 
occasionally  follow  hemorrhage  from  one  of  the  lingual  arteries,  but  in  cases 
where  the  anterior  part  of  the  tongue  is  involved,  this  not  unfrequently  be- 
comes adherent  to  the  incisor  portion  of  the  low^er  jaw,  and  the  disease  ulti- 
mately infiltrates  that  bone.  In  these  cases,  the  patient  has  generally  a  longer 
life,  but  one  of  great  misery,  and  dies  at  length  exhausted  by  pain  and  dis- 
charge, from  numerous  open  sores  about  the  chin  and  angles  of  the  jaw. 

In  the  treatment  of  epithelioma  of  the  tongue,  all  surgeons  of  experience 
are  agreed  as  to  the  inutility  of  medication,  whether  topical  or  general,  and 
the  advisability  of  early  and  complete  removal  of  the  disease.  A  recent 
discussion  at  the  Societe  de  Chirurgie,^  of  Paris,  has  shown  that  all  the  leading 
surgeons  of  that  city  are  agreed  with  those  of  other  countries,  that  the  admin- 
istration of  iodide  of  potassium  in  true  epithelioma  is  useless,  and  that  the 
constant  application  of  nitrate  of  silver  is  harmful.  The  difficulty  in  practice 
is  to  induce  a  patient  to  take  a  sufficiently  grave  view  of  his  case  at  an  early 
stage,  when  an  operation  may  be  undertaken  with  advantage,  and  with  a  fair 
prospect  of  relief,  prolonged  if  not  permanent.  In  the  later  stages,  w^hen  the 
lymphatic  glands  are  involved,  it  becomes  a  question  w^hether  any  inter- 
ference is  advisable,  and  many  surgeons  would  refuse  an  operation ;  but  it 
appears  to  me  that  in  many,  even  of  the  worst  cases,  temporary  relief  may 
often  be  given  by  operating,  provided  that  the  patient  is  prepared  to  run  the 
immediate  risk  of  the  proceeding,  which  is  undoubtedly  great ;  and  Mr.  Stokes, 
of  Dublin,  has  recently  brought  before  the  Clinical  Society  of  London,  cases 


*  Medical  Times  and  Gazette,  January  8,  1881. 


900  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

in  which  he  had  removed  the  enlarged  and  infiltrated  lymphatic  glands  with 
good  results.  Really,  life  prolonged  in  misery  is  worse  than  death  following 
close  upon  the  operation,  and  I  have  been  thanked  more  than  once  by  dying 
patients  for  having  given  relief  during  the  few  days  for  which  they  survived. 
Anaesthetics,  moreover,  have  robbed  operations  of  so  much  of  their  horror, 
that  patients  may  nowadays  be  induced  to  submit  to  extensive  mutilations 
which  would  have  been  impossible,  or  at  least  unadvisable,  without  chloroform. 
Chloroform  is  necessarily  the  anaesthetic  to  be  employed  in  operations  upon 
the  tongue,  for  ether  is  inadmissible,  first  because  of  the  difficulty  of  keeping 
the  patient  under  its  influence  when  atmospheric  air  necessarily  gains  free 
admission  ;  and  secondly  because  if,  as  often  happens,  a  cautery  is  required  in 
the  course  of  the  operation,  a  dangerous  explosion  and  conflagration  in  the 
patient's  mouth,  may  be  caused  by  the  inflammable  vapor  of  the  ether. 

Ligature  of  the  lingual  artery  has  been  advocated  by  both  Demarquay  and 
Moore,^  in  order  to  check  the  growth  of  cancer  of  the  tongue,  as  well  as  for 
the  arrest  of  hemorrhage,  but  has  not  yielded  the  results  anticipated.  I  have 
on  two  occasions  tied  the  lingual  artery,  once  for  hemorrhage  occurring  in  the 
course  of  a  case  of  cancer,  and  once  with  the  view  of  checking  the  2:rowth 
which  was  rapidly  extending,  but  in  neither  case  did  the  ligature  appear  to 
have  any  influence  in  staying  the  course  of  the  disease. 

Division  of  the  lingual  nerve  is  another  palliative  operation,  recommended 
by  Hilton  and  Moore,  and  this  certainly  is  efficacious,  for  a  time  at  least,  in 
relieving  the  pain  of  a  cancer  involving  the  side  and  tip  of  the  tongue. 
The  operation  is  not  a  difficult  one,  and  has  the  negative  advantage  of  doing 
no  harm  if  it  effects  little  good.  The  operator  feels  for  the  mylo-hyoid  ridge 
of  the  lower  jaw,  immediately  below  the  last  molar  tooth,  and  a  sharp-pointed 
curved  bistoury,  pushed  through  the  mucous  membrane  at  this  point,  will 
readily  divide  the  nerve  against  the  lower  edge  of  the  ridge,  with  little  or  no 
bleeding.  The  side  of  the  tongue  will  bie  thoroughly  numbed  for  some  days^ 
and  then  sensation  slowly  returns  from  union  of  the  divided  nerve,  when  the 
operation  may  be  repeated. 

Removal  of  ^portions  of  the  tongue _  loith  the  knife  is  an  operation  which  has 
fallen  into  disuse,  owing  to  the  hemorrhage  ordinarily  accompanying  it. 
Sir  William  Fergusson,  who  advocated  the  practice,  and  who  thus  removed 
more  than  one-half  of  the  tongue  in  the  case  of  the  late  Dr.  John  Reid, 
maintained  that  the  fear  of  hemorrhage  in  these  cases  was  exaggerated,  and 
in  his  account  of  that  particular  operation,  says  "  The  bleeding  for  a  minute 
or  two  looked  formidable ;  several  vessels  were  speedily  secured,  and  there 
was  no  further  trouble  in  this  respect."  It  must  be  noted  that  the  operation 
was  performed  without  an  anaesthetic,  the  patient  being  a  man  of  great  moral 
courage  and  physical  endurance,  and  that  only  one  lingual  artery  was  divided. 
With  an  unconscious  patient  in  whom  both  arteries  have  been  divided  far 
back,  I  have  seen  the  very  greatest  difficulty  arise  in  securing  the  vessels, 
which  play  across  one  another,  and  obscure  the  operator's  view  in  the  dark 
cavity  of  the  throat. 

In  such  cases,  and  in  cases  of  secondary  hemorrhage  after  removal  of  large 
portions  of  the  tongue,  I  have  found  that  it  is  practicable  to  arrest  all 
bleeding  in  the  following  way.  The  fore-finger,  passed  well  down  to  the 
epiglottis,  is  made  to  hook  forward  the  hyoid  bone,  and  drag  it  up  as  far 
as  practicable  towards  the  symphysis  menti.  The  effect  of  this  is  to  stretch 
the  lingual  arteries  so  as  to  completely  control  for  the  time  the  flow  of  blood 
through  them,  and  in  this  way  portions  of  the  anterior  part  of  the  tongue 


'  Medico-Chirurgical  Transactions,  vol.  xlv. 
*  System  of  Practical  Surgery,  p.  517. 


DISEASES  OF  THE  TONGUE. 


901 


may  be  cut  off  almost  bloodlessly.  Mr.  Walter  AVhitehead,  of  Manchester, 
has  adopted  the  use  of  scissors  only,  for  the  removal  of  the  tongue,  drawing 
the  organ  well  forward,  and  dividing  the  tissues  beneath  by  a  series  of  snips 
on  alternate  sides,  each  lingual  artery  being  secured  as  soon  as  divided. 

The  ligature^  formerly  used  for  strangulating  portions  of  the  tongue,  has 
fallen  into  disuse  because  of  the  practical  dilhculty  of  'keeping  it  sutiiciently 
tight  to  insure  continuous  strangulation  of  the  part  to  be  removed,  and  also 
because  of  the  suffering  caused  by  the  presence  of  a  sloughing  mass  of  tissue 
in  the  mouth.  It  is  unnecessary  therefore  to  consider  the  various  modes 
devised  for  applying  the  ligature  in  former  years. 

The  ecraseur  has  been  extensively  employed  for  removal  of  portions,  or  the 
whole,  of  the  tongue,  with  very  satisfactory  results.  The  wire  ecrascdv  (Fig. 
1070)  answers  the  purpose  better  than  the  chain  instrument  (Fig.  1071)  at 


Fig.  \m. 


Wire  Ecraseur. 


Fig.  1071. 


Chain  icraseur. 


first  employed,  in  which  portions  of  the  tongue  were  apt  to  be  twisted  up. 
In  order  to  effectually  remove  a  diseased  portion  of  the  tongue  with  the 
ecraseur^  it  is  necessary  to  isolate  the  growth  by  passing  well  beyond  it 
curved  needles  set  in  handles,  around  which  the  wire  of  the  ecraseur  may 
be  passed  and  be  thus  kept  in  its  proper  position.  Without  this  precaution, 
the  wdre  as  it  is  tightened  is  certain  to  encroach  upon  the  disease,  and  lead  to 
an  incomplete  operation,  and  no  forceps  are  sufficient  alone  to  obviate  the 
occurrence. 

The  galvanic  ecraseur used  in  the  same  way,  has  the  advantage  of  cutting 
more  readily  through  the  tissues,  which  it  sears  at  the  same  time,  thus  pre- 
venting all  hemorrhage  at  the  moment.  It  has  however  the  drawback  that 
the  separation  of  the  slough  necessarily  formed  by  the  cautery,  is  very  a[)t  to 
lead  to  secondary  hemorrhage  some  days  after  the  operation,  and  hence  the 
use  of  this  instrument  has  been  abandoned  by  many  surgeons  who  formerly 
employed  it. 

Paqiielin's  thermo-cauth^e^  is  a  very  convenient  instrument  for  removing 
small  portions  of  the  tongue,  since  it  is  not  necessary  in  using  it  to  pass  pins 
beyond  the  growth.  It  "is  liable  however  to  the  same  drawback  as  the  gal- 
vanic cautery,  viz.,  secondary  hemorrhage. 

Removal  of  one-half  of  the  tongue  is  an  operation  yielding  satisfactory^ 
results,  and  comparative!}^  easy  of  performance.  It  was  recommended  by  Dr. 
Buchanan,  of  Glasgow,  who  however  divided  the  symphysis  menti,  a  com- 


i  See  Vol.  1.  page  530,  Fig.  94. 


2  See  Vol.  I.  page  510,  Fig.  77. 


902  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

plication  which  is  unnecessary  in  the  majority  of  cases,  as  shown  by  Mr. 
Morrant  Baker.^  A  thread  being  passed  through  each  side  of  the  tip  of  the 
tongue,  and  the  mouth  gagged,  the  operator  divides  the  frsenum  linguae  and 
subjacent  muscles  with  curved  scissors,  which  he  runs  along  the  floor  of  the 
mouth  on  the  diseased  side,  so  as  to  divide  the  mucous  membrane  near  the 
jaw,  as  far  back  as  the  disease  reaches.  Taking  one  thread  in  his  left  hand, 
and  the  other  being  held  by  an  assistant,  the  operator  then  with  a  blunt- 
pointed  straight  bistoury  divides  the  tongue  strictly  in  the  median  plane,  being 
particularly  careful  to  divide  the  tough  corium  of  the  dorsal  aspect  well 
beyond  the  disease.  Any  bleeding  vessel  on  the  surface  of  the  section  is 
easily  seen  and  secured,  and  with  the  fore-finger  the  operator  then  tears 
through  any  remaining  muscular  structure  of  the  tongue  or  sublingual  tissues, 
so  as  to  isolate  the  half  of  the  tongue  to  be  removed.  The  wire  loop  of  the 
ecraseur  can  then  be  easily  slipped  over  the  apex  of  the  tougue  to  the  base, 
through  which,  if  necessary,  needles  may  be  inserted,  and  the  diseased  half 
of  the  organ  removed  as  far  back  as  may  be  desired.  Should  the  disease  be 
so  extensive  as  to  require  removal  down  to  the  hyoid  bone,  it  may  be  neces- 
sary to  resort  to  the  plan  suggested  by  the  late  Mr.  Collis,  of  Dublin,  viz.  to 
lay  open  the  cheek  by  a  horizontal  incision  carried  from  the  angle  of  the 
mouth.  This  would  of  course  bring  the  parts  more  thoroughly  into  view, 
but  with  the  drawback  df  increased  hemorrhage  and  permanent  deformity. 
By  employing  an  ecraseur  ^'lih  the  end  slightly  curved,  I  have  been  able,  in 
several  cases  in  which  I  have  removed  half  the  tongue,  to  dispense  with  any 
external  incision. 

Bemoval  of  the  whole  breadth  of  the  tongue  may  be  readily  performed  with  the 
ecraseur  when  the  disease  involves  only  the  anterior  portion  of  the  organ,  but 
when  it  extends  further  back,  free  division  of  the  sublingual  tissues,  as  recom- 
mended by  Sir  James  Paget,  will  be  necessary,  in  order  to  allow  of  the  satis- 
factory application  of  the  wire-loop  to  the  base  of  the' organ.  Mr.  Baker  has 
recommended  that,  in  cases  requiring  removal,  the  tongue  should  be  split, 
and  the  halves  removed  by  two  ecra.sewr^  simultaneously,  and  both  methods  are 
for  all  practical  purposes  identical,  i^unneley's  method  of  applying  the 
ecraseur  for  removal  of  the  entire  tongue  is  as  follows :  An  incision  is  made 
in  the  median  line,  between  the  chin  and  the  hyoid  bone,  and  is  carried  up 
between  the  genio-hyo-glossi  muscles  into  the  mouth,  the  chain  of  2in  ecraseur 
being  then  carried  through  this.  The  base  of  the  tongue  being  next  transfixed 
from  above  downwards  by  three  pins,  the  chain  is  passed  behind  them,  and  the 
ecraseur  is  worked  from  beneath  the  chin.  The  objection  to  this  method  is 
that  the  tongue  is  necessarily  cut  obliquely,  notwithstanding  the  use  of  the  pins. 
Its  advantage  is  that  a  useful  drain  for  discharges  is  maintained  from  the 
floor  of  the  mouth.  Mr.  Barwell  has  modified  ^^^unneley's^  method  by 
making  a  small  supra-hyoid  wound,  and  carrying  a  thread  into  the  mouth  by 
means  of  a  handled  needle  much  farther  back  than  in  the  older  method.  The 
needle  is  made  to  enter  the  mouth  close  to  the  last  molar  tooth  on  each  side, 
and  the  wire  of  the  ecraseur  is  drawn  by  the  thread  through  the  supra-hyoid 
wound  and  around  the  base  of  the  tongue.  A  handled  needle  is  then  passed 
from  before  backwards  through  the  tongue  at  the  point  where  the  section  is 
to  be  made,  and  the  wire  slipped  behind  it.  When  the  tongue  has  been 
thus  divided  transversely,  a  second  ecraseur  is  applied  in  the  mouth  to  divide 
the  sublingual  tissues  which  have  been  left.  Mr.  Barwell  claims  for  this 
method  that  it  leaves  a  painless  stump,  because  the  lingual-gustatory  nerves 
are  divided  close  to  the  lower  jaw ;  but  this  result  is  not  peculiar  to  this  par- 
ticular operation,  which  does  not  appear  to  possess  any  special  advantages  over 


1  Lancet,  vol.  i.  1880. 


2  Lancet,  April  19, 1879. 


DISEASES  OF  THE  TONGUE. 


OOP, 


that  in  which  the  sublingual  tissues  are  divided  before  the  section  of  the 
tono:ue,  whilst  if  hemorrhage  should  occur  on  completion  of  thesecticm  of  the 
tono-ue,  that  organ  would  be  very  much  in  the  way  of  the  api)lication  of  a 
lio;ature.  .      .  , 

'Mr.  Barwell  has  introduced  into  practice  a  form  of  wire  tor  the  ecraseur 
which  promises  to  be  very  serviceable.  It  consists  of  a  strand  of  Newall's 
patent  wire  rope,  made  of  untempered  steel,  with  a  thread  in  its  centre,  and 
is  more  flexible  than  any  steel  wire.  ^  ^ 

Regnoli,  in  1838,  devised  a  submental  operation  which  consists  in  dividing 
the  fl'oorof  the  mouth  close  to  the  lower  jaw,  from  one  facial  artery  to  the 
other,  so  as  to  allow  of  the  tongue  being  drawn  down  and  fully  exposed. 
It  may  then  be  removed  with  the  knife  or  ecraseur;  but  if  the  knife  be 
employed,  care  should  be  taken  to  divide  only  one  lingual  artery  at  a  time. 
I  have  assisted  in  the  performance  of  this  operation  more  than  once,  and 
think  that  for  slight  cases  it  is  an  unnecessarily  severe  proceeding,  and  has 
no  advantage  over'^the  intra-buccal  method  ;  while  for  the  more  serious  cases 
in  which  it  is  necessary  to  go  close  to  the  liyoid  bone,  it  has  the  drawback 
that  the  surgeon  is  working  in  a  hole  where  it  is  very  difficult  to  see  and 
secure  a  bleeding  artery. 

Sedillot  and  Syme  were  the  first  to  divide  the  lower  jaw  in  order  more 
thoroughly  to  extirpate  the  tongue.  The  operation  is  a  very  severe  one,  but 
affords'the  only  satisfactory  method  of  dealing  with  cases  of  extensive  disease 
of  the  tono;ue,  in  which  the  floor  of  the  mouth  is  involved.  An  incision  in 
the  median  line  of  the  lower  lip,  prolonged  to  the  hyoid  bone,  will  allow  of 
the  dissection  of  the  lip  from  the  lower  jaw  for  about  a  quarter  of  an  inch  on 
each  side.  With  a  drill  the  bone  can  then  be  perforated  on  each  side  of  the 
median  line,  and  about  midway  in  the  depth  of  the  jaw,  so  as  to  admit  of 
the  two  halves  being  subsequently  drawn  together  with  wire.  The  jaw  is 
next  to  be  divided  exactly  in  the  median  line  with  a  fine  saw,  which  may 
advantageously  have  its  handle  raised  above  the  level  of  the  blade,  so  as  to  be 
out  of  the  way  of  the  patient's  chest.  The  advantage  of  dividuig  the  bone 
in  the  median  line  is  that  the  teeth  are  not  interfered  with,  whereas  m  Se- 
dillot's  method  of  dividing  the  jaw  by  a  >  cut,  it  is  necessary  to  sacrifice  all 
the  incisor  teeth.  In  addition  to  the  wire  employed  to  bind  the  halves  of  the 
jaw  together,  the  action  of  the  muscles  tends  to  maintain  the  parts  in  relation 
and  to'press  the  halves  of  the  jaw  together,  rendering  the  notching  of  the 
bone  an  unnecessary  complication.  If  the  section  be  completed  with  ^  the 
bone-forceps  when  about  half  the  thickness  of  the  bone  has  been  divided 
with  the  saw,  the  slight  irregularity  thus  produced  assists  also  in  maintaining 
the  parts  in  apposition.  The  halves  of  the  jaw  being  held  asunder  with  h()oks, 
the  operator  cuts  the  genio-hyo-glossi  muscles  from  the  jaw  with  a  pair  of 
scissors,  leaving  the  attachments  of  the  genio-hyoid  muscles.  With  the  fore- 
finger and  scissors,  the  tongue  can  then  be  dissected  up  from  the  floor  of  the 
moTith,  with  the  sublingual  glands  and  mucous  membrane,  until  the  hyoid 
bone  is  reached,  firm  tractioirbeing  made  with  a  stout  string  passed  through 
the  tip.  The  tongue  being  then  drawn  down,  the  palato-glossi  muscles  form- 
ing the  anterior  pUlars  of  the  fauces  will  be  put  on  the  stretch,  and  must  be 
divided  w^ith  scissors,  after  which  a  handled  needle  should  be  passed  through 
the  tongue  close  to  the  hyoid  bone,  and  the  wire  of  the  ecraseur  then  adjusted. 

The  surgeon  should  be  prepared  with  a  handled  needle  and  stout  thread, 
to  transfix^and  hold  the  small  remnant  of  tissue  left  attached  to  the  hyoid 
bone,  should  the  breathing  be  embarrassed  by  the  epiglottis  and  base  of  the 
tongue  falling  backward.  In  my  experience  this  is  much  more  likely  to  happen 
when  a  considerable  portion  of  the  tongue  is  left,  than  when  the  section  is. 
made  far  back,  and  the  difficulty  seems  to  arise  from  the  weight  of  the  piece 


904  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

left,  forcing  back  the  epiglottis  when  the  sublingual  muscles  have  been 
divided. 

All  hemorrhage  having  been  checked,  the  two  halves  of  the  jaw  are  to  be 
brought  together  with  a  piece  of  stout  silver  wire.  This  may  be  passed  from 
before  backwards  readily  enough  through  the  hole  in  one  side  of  the  jaw,  but 
it  is  not  easy  to  pass  it  back  again  on  the  opposite  side,  unless  a  loop  of  thin  wire 
be  passed  from  before  backwards  through  the  hole  already  made,  into  which 
the  end  of  the  wire  can  be  bent,  andlhus  drawn  forward.  The  two  halves  of  the 
jaw  should  be  brought  into  close  and  correct  apposition,  and  the  ends  of  the 
wire  twisted  and  brought  up  beneath  the  lip.  The  lip  is  then  to  be  brought 
together  with  hare-lip  pins,  and  a  fine  silk  stitch  in  the  mucous  membrane, 
but  care  should  be  taken  to  leave  the  lower  part  of  the  incision  open,  so  that 
there  may  be  a  free  drain  for  the  saliva  and  discharges  from  the  mouth.  In 
removing  the  wire  from  the  jaw,  at  the  end  of  three  weeks  or  more,  it  will  be 
found  convenient  to  cut  the  wire  close  to  the  jaw  on  each  side,  and  then 
with  a  blunt  hook  to  pull  out  the  loop  from  behind.  When  the  disease 
hivolves  the  anterior  part  of  the  tongue,  it  is  by  no  means  uncommon  to  find 
the  tongue  adherent  to  the  incisive  portion  of  the  jaw,  and  the  bone  more  or 
less  infiltrated,  as  shown  by  the  loosening  of  the  teeth  and  softening  of  the 
bone.  Under  these  circumstances,  it  is  necessary  after  clearing  the  bone  to 
apply  the  saw  on  each  side  of  the  diseased  portion,  as  far  from  the  median 
line  as  may  be  necessary  to  reach  healthy  bone.  After  removal  of  the  por- 
tion of  bone  with  the  diseased  tongue,  it  is  quite  useless  to  attempt  to  wire  the 
remaining  portions  of  the  jaw  together,  since  it  is  impracticable  to  draw  them 
m  apposition  at  the  time.  And  yet  it  will  be  found,  in  a  few  weeks,  that  as 
the  wound  heals  the  two  sides  of  the  jaw  are  gradually  approximated  by  the 
action  of  the  muscles,  and  will  eventually  in  many  cases  unite  firmly.^  " 

In  all  operations  for  removal  of  the  tongue,  it  is  well  to  be  prepared  for 
unexpected  hemorrhage,  which  may  be  very  urgent.  Blood  collecting 
in  the  pharynx  may  embarrass  the  breathing  very  much,  and,  by  the  conges- 
tion produced,  keep  up  venous  bleeding.  Under  these  circumstances  it  is 
well  to  perform  laryngotomy  at  once,  and  if  blood  has  entered  the  lungs,  as 
is  very  apt  to  happen  when  the  tongue  is  dragged  forward,  to  suck  out  the 
blood  through  the  tube.  I  have  twice  seen  patients  rescued  from  imminent 
danger  of  sufifocation  in  this  way,  and  ultimately  make  good  recoveries. 

With  the  view  of  obviating  all  risk  of  sufi:bcation  during  the  operation, 
and  also  to  facilitate  the  administration  of  the  anaesthetic,  recourse  may  be 
had,  before  commencing  the  operation  of  removal  of  the  tongue,  to  laryngo- 
tomy or  tracheotomy,  and  the  use  of  Trendelenburg's  tampon.  This  consists 
of  an  India-rubber  tube,  which  covers  the  tracheal  canula,  and  which  can  be 
inflated  so  as  to  plug  the  trachea  and  prevent  the  admission  of  blood ;  but  an 
equally  satisfactory  method  is  to  plug  the  pharynx  with  a  sponge  to  which  a 
string  has  been  attached.  A  flexible  tube  attached  to  the  ordinary  tracheal 
canula  allows  of  the  ready  administration  of  chloroform  vapor.  I  have 
employed  this  method  on  one  occasion,  and  have  seen  it  employed  on  others, 
but  it  appears  in  most  cases  to  be  an  unnecessary  complication. 
^  The  after-treatment  of  cases  of  removal  of  the  half  or  entire  tongue,  con- 
sists in  maintaining  the  strength  of  the  patient  by  judicious  feeding,  and 
m  keeping  the  mouth  sweet.  Feeding  is  best  accomplished  with  the  ordi- 
nary earthenware  feeder,  having  a  spout  to  which  an  India-rubber  tube  may 
Ixi  fitted,  if  It  IS  necessary  to  carry  the  food  very  far  back.  In  this  way,  suffi- 
cient milk,  beef-tea,  and  brandy  may  be  administered  until  the  patient  pre- 


'  For  cases,  see  Lancet,  vol.  i.  1876. 


DISEASES  OF  THE  TONGUE. 


005 


fers  to  take  nourishment  from  a  cup,  which  he  often  does  earlier  than  might 
be  expected.  Should  the  feeding  by  the  mouth  be  insufficient,  recourse 
should  be  had  to  nutrient  enenuita. 

With  regard  to  cleanliness  and  prevention  of  fetor,  it  is  very  desirable 
that  at  the  time  of  the  operation  all  divided  tissues  should  be  thoroughly 
mopped  with  a  forty-grain  solution  of  chloride  of  zinc,  or  be  freely  powdered 
with  Iodoform,  either" of  which  applications  not  only  obviates  fetor,  but  tends 
powerfully  to  prevent  the  absorption  of  septic  matter.  The  frequent  wash- 
ing out  of  the  mouth  with  a  lotion  of  permanganate  of  potassium  or  lime 
(the  latter  by  preference),  is  most  readily  accomplished  with  a  siphon  douche 
fitted  with  a  soft-rubber  nipple,  which  the  patient  can  direct  himself  without 
risk  of  hurting  the  mouth.  After  each  washing,  the  mouth  should  be 
brushed  out  with  the  glycerine  of  carbolic  acid  or  "  terebene,"  either  of  which 
answers  admirably  in  preventing  fetor. 

It  has  been  suo;gested  that  the  lobular  pneumonia  which  occasionally  proves 
fatal  in  some  cases  of  removal  of  the  tongue,  is  due  to  septic  influence  conse- 
quent upon  the  state  of  the  mouth.  The  cases  which  end  fatally  occur  how- 
ever amono;  elderly  patients,  who  have  become  greatly  reduced  by  the  disease, 
and  who  would  be  likely  under  any  circumstances  to  suffer  from  lung  _conii)li- 
cations  of  a  low  type.  With  the  view  of  obviating  this  supposed  septic  influ- 
ence, my  colleague  Mr.  Arthur  Barker^  has  in  a  few  cases  allowed  the  patient 
to  wear  a  tracheotoniy  tube  for  some  days,  and  to  breathe  only  through  it,  the 
mouth  and  nostrils  being  carefully  covered  with  cotton-wool,  and  a  drain  for 
saliva  being  established  1:hrough  the  floor  of  the  mouth. 

In  cases  of  recurrence  after  removal  of  the  tongue  for  epithelioma,  the  dis- 
ease shows  itself  in  the  stump  or  in  the  submaxillary  lymphatic  gland,  or  more 
frequently  I  think  in  both,  though  I  have  known  both  to  escape,  and  the  disease 
to  re-appear  in  the  lymphatic  gland  beneath  the  sterno-mastoid,  first  on  one 
side  and  then  on  the  other.  The  infiltration  of  the  glands  always  spreads  to 
those  beneath  the  sterno-mastoid,  should  the  patient  survive  sufficiently  long, 
but  death  usually  surpervenes  after  a  few  months  from  general  asthenia  and 
exhaustion,  the  sufferer  being  worn  out  by  pain  and,  should  the  submaxil- 
lary lymphatic  glands  suppurate  and  open  externally,  as  they  frequently  do, 
by  the  constant  discharge.  In  cases  w^here  recovery  is  permanent,  and  the 
patient  remains  well  for  years,  one  is  almost  tempted  to  suspect  a  mistaken 
diagnosis;  and  it  must  be  acknowledged  that  mistakes  have  been  made  by 
good  surgeons  in  removing  tongues,  the  subject  of  gumma,  for  examples  of 
epithelioma.  I  am  able,  however,  to  record  the  survival  for  over  twelve  years 
of  a  patient  from  whom  I  removed  what  w^as  believed  to  be  a  tongue  afiected 
by  medullary  cancer.  The  patient  was  sixty  years  of  age,  and  the  disease 
had  existed  six  months.  On  looking  into  the  mouth,  there  w^as  between  the 
tongue  and  the  lower  jaw  on  the  left  side,  a  ragged,  ulcerated  surface,  occupy- 
ing'^the  floor  of  the  mouth.  This  was  prolonged  to  the  side  of  the  tongue, 
and  ^viih  the  finger  a  large  mass  could  be  felt  in  the  substance  of  the  organ, 
extending  beyond  the  median  line,  and  to  about  two  inches  from  the  tip. 
The  patient  complained  of  constant  pain  in  the  tongue,  but  was  otherwise  in 
good  health.  There  was  a  slight  enlargement  of  one  of  the  submaxillary 
lymphatic  glands.  After  section  of  the"  lower  jaw^  in  the  median  line,  I 
removed,  with  the  ecraseiir,  the  anterior  half  of  the  tongue,  in  September,  1868. 
The  patient  made  a  good  but  slow  recovery,  and  called  on  me  in  1880,  nearly 
twelve  years  after  the  operation,  perfectly  well.  The  part  removed  was 
exhibited  to  the  Pathological  Society  of  London,  and  w^as  submitted  to  the 
Committee  on  Morbid  Growths.    To  the  naked  eye  the  tumor  presented  the 

*  Lancet,  August,  1879. 


906  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 


appearance  of  medullary  cancer,  and  was  reported  by  the  committee  to  con- 
sist of  cells  and  nuclei.  The  conclusion  drawn  was  as  follows  :  "  The  opinion 
we  formed  is  that  the  tumor  was  essentially  a  cell-growth  invading  and  dis- 
placing the  normal  tissues,  the  cell-growth  forming  equally  the  more  obvious 
cell-structure  of  the  tumor  and  its  fibrous  portion.  We  may  add  that  it 
seemed  to  us  most  probable  that  the  larger  forms  of  cells  Avere  developed  out 
of  the  smaller  forms,  and  that  therefore  the  spongy  portion  of  the  tumor  in 
which  the  larger  cells  were  most  abundant  represented  a  later  phase  of  devel- 
opment than  the  homogeneous  portion."^  In  this  case  I  noticed  particularly 
a  pomt  which  is  not  often  seen,  viz.,  the  extent  to  which  the  portion  of  ton2:ue 
left  behind  grows  or  becomes  stretched.  In  the  case  in  question,  notwith- 
standing the  extensive  removal,  the  man  some  years  after  appeared  to  have  a 
tongue  of  ordinary  size,  but  rather  more  sessile  in  the  mouth  than  normal. 

_  "When  recurrence  of  cancer  takes  place,  the  case  is  generally  beyond  sur- 
gical aid,  the  disease  usually  infiltrating  the  tissues  of  the  mouth  and  of  the 
neck  to  an  extent  which  forbids  any  interference.  It  seems  to  me,  however, 
that  occasionally  an  attempt  should  be  made  to  rescue  the  suflerer  from  an 
early  and  miserable  death,  as  in  the  following  instance:  

A  man,  aged  sixty-two,  was  sent  to  me  in  1875,  with  very  extensive  cancerous  disease 
of  the  tongue  and  subhngual  tissues.  In  January,  1874,  he  noticed  a  swelling  of  one  of 
the  submaxillary  o^lands,  and  soon  after  a  sore  beneath  the  tongue.  The  sore  healed, 
and  the  gland  subsided  under  treatment.  In  September,  1874,  the  gland  began  again 
to  swell,  and  at  last  broke.  At  the  same  time  he  found  that  he  had  difficulty  in  articu- 
lating, as  the  tongue  was  fixed  to  the  floor  of  the  mouth,  and  eventually  the  tip  of  the 
tongue  became  fixed  to  the  jaw.  The  latter  condition  was  temporarily  relieved  by  an 
operation  at  another  hospital.  On  admission  to  University  College  Hospital,  the  patient 
was  unable  to  protrude  his  tongue  or  move  it  in  his  mouth,  the  saliva  constantly  trickled 
away,  and  articulation  was  very  imperfect.  He  complained  of  great  pain  in  the  occi- 
pital region,  but  of  none  in  the  tongue.  The  gums  of  the  incisor  region  were  swollen 
and  ulcerated,  and  the  teeth  loose.  The  tongue  was  fixed  to  the  back  of  the  incisive 
portion  of  the  jaw,  which  was  softened.  All  the  tissues  beneath  the  tongue  were  indu- 
rated, but  the  skin  was  not  involved. 

On  September  29,  I  removed  the  tongue,  centre  of  the  jaw,  and  all  the  sublingual 
tissues,  by  dividing  the  chin  in  the  middle  line,  then  sawing  the  jaw  through  on  each 
side,  and,  having  isolated  the  tongue  somewhat  on  each  side,  inclosing  the  whole  of 
the  disease  with  the  wire  of  the  galvanic  ecraseur.  The  parts  removed  consisted  of  the 
middle  three  inches  of  the  lower  jaw,  nearly  the  whole  of  the  tongue,^  and  the  subhn- 
gual muscles  and  glands  en  masse.  At  the  posterior  end,  the  mass  measured  two  and  a 
half  inches  in  depth,  and  slightly  more  from  side  to  side.  The  tongue  appeared  to  be 
healthy  except  at  the  anterior  part ;  and  on  the  left  side,  just  behind  the  tip,  was  a 
nodule  of  the  size  of  a  pea.  Beneath  the  tongue  was  a  mass  of  yellowish-white,  firm 
tissue,  with  a  granular  surface,  which  w^as  continued  quite  up  to  the  cut  margin.  This 
tissue,  on  microscopical  examination,  proved  to  be  epithelioma. 

The  patient  made  a  good  recovery,  and  was  alive  and  well  six  years  after  the  opera- 
tion. He  recovered  a  surprising  amount  of  power  of  deglutition,  and  of  speech,  due  prin- 
cipally to  the  growth  of  the  stump  of  the  tongue  already  noticed.  The  occipital  pain 
complained  of  by  this  patient  is  difficult  of  explanation,  but  it  was  entirely  relieved  by 
the  operation.    I  have  noticed  it  in  other  cases  of  cancer  of  the  tono-ue.^ 

My  friend  and  former  pupil,  Mr.  Rushton  Parker,  of  Liverpool,  has  recorded^ 
two  cases  in  which  he  performed  almost  as  extensive  operations  as  in  the 
foregoing  case.  In  one  patient,  aged  fifty-eight,  he  removed,  in  1876,  half 
the  tongue,  parts  of  the  upper  and  lower  jaws,  the  submaxillary  glands,  and 
a  portion  of  the  pharynx,  for  extensive  epithelioma,  the  patient  recovering, 


'  Pathological  Society's  Transactions,  vol.  xx. 
3  Medical  Times  and  Grazette,  December  1,  1877. 


f  Lancet,  vol.  i.  1876. 


MALFORMATIONS  AND  DISEASES  OF  THE  PALATE. 


907 


and  being  perfectly  well  in  1880.  In  the  other  patient,  aged  fifty-four,  he 
removed  one-half  of  the  tongue,  half  the  soft  palate,  the  side  of  the  pharynx, 
the  submaxillary  glands,  and  part  of  the  lower  jaw,  for  epithelioma,  but  un- 
fortunately a  recurrence  of  the  disease  took  place  in  the  neck. 

Malformations  and  Diseases  of  the  Palate. 

Cleft  Palate.— Cleft  palate  occurs  in  infants  otherwise  well  formed,  or  in 
combination  with  harelip,  and  in  either  case  may  affect  the  soft  palate  only, 
or  both  the  hard  and  the  soft  palates.  When  harelip  is  present,  the  fissure 
usually  extends  from  the  lip  through  the  alveolus  and  the  entire  palate ;  but 
there  are  many  exceptions,  a  fissure  of  the  soft  palate  alone  freciuently  accom- 
panying a  single  harelip.  That  both  affections  are  the  result  of  arrest  of 
development  in  the  early  wrecks  of  fcjctal  life,  cannot  be  doubted,  and  that  they 
are  hereditary  cannot  be  denied.  Still,  cases  of  cleft  palate  occur  in  families 
not  known  to  inherit  the  malformation,  and  in  the  great  majority  of  cases  it 
will  be  found  that  the  mother  has  been  much  out  of  health  in  the  early  weeks 
of  pregnancy,  or  that  the  pregnancy  has  followed  very  closely  upon  a  previous 
one,  or  has  occurred  during  lactation. 

The  experience  of  Professor  Ilaughton,  of  Dublin,  first  showed,  in  the  case 
of  the  larger  carnivora,  the  effect  of  diet  upon  the  production  of  cleft  palate ; 
and  it  is  very  desirable  in  the  case  of  a  parent  the  subject  of  the  deformity  her- 
self, or  having  already  given  birth  to  a  child  with  cleft  palate,  that  in  subse- 
quent pregnancies  every  care  should  be  taken  to  improve  her  health,  and  to 
administer  food  and  medicines  calculated  to  promote  the  formation  of  l)one. 

When  a  harelip  and  cleft  palate  are  continuous,  the  latter  deformity  is 
sufiiciently  obvious ;  but  when  a  cleft  palate  occurs  alone,  it  may  be  easily 
overlooked  for  the  first  few  hours  of  life,  and  the  earliest  intimation  of  the 
malformation  may  be  given  by  the  inability  of  the  infant  to  suck,  and  by  the 
fact  that  milk  introduced  into  its  mouth  with  a  spoon  returns  through  the 
nostrils.  Under  these  circumstances,  infants  are  often  allowed  to  pine  away 
through  insufiGlcient  feeding,  but  with  proper  care  this  may  generally  be 
obviated. 

A  large-sized,  India-rubber  .teat,  or  an  ordinary  covered  spoon,  such  as  is 
used  for  the  administration  of  nauseous  medicines,  may  be  used  to  convey  the 
milk  to  the  gullet ;  but  a  much  less  troublesome  and  more  effectual  method 
is  that  adop'ted  by  Mr.  Oakley  Coles,i  who  attaches  a  fiap  of  elastic  India- 
rubber  to  the  nipple  of  a;n  ordinary  feeding-bottle.  This  overlies  the  nipple, 
and  is  introduced  into  the  mouth  with  it,  and,  when  the  infant  is  suckled, 
rises  up  against  the  cleft  and  enables  the  child  to  swallow.  The  India-rubber 
is  undoubtedly  the  cleanest  and  most  effectual  fiap  which  can  be  employed, 
but  I  have  often  directed  the  use  of  a  leaf-shaped  piece  of  kid  leather  with 
advantage,  when  the  India-rubber  could  not  be  readily  procured.  Mr.  Francis 
Mason^  has  employed  a  very  thin  plate  of  soft  metal,  moulded  to  the  patient's 
mouth,  but  acknowdedges  that  the  instrument  is  not  available  in  -all  cases. 
If  no  other  plan  is  adopted,  the  mere  closing  of  the  nostrils  by  the  nurse's 
finger  and  thumb,  at  each  effort  of  deglutition,  will  give  material  assistance 
to  successful  sw^allowing. 

The  question  of  surgical  interference  in  cases  of  cleft  palate  is  one  which 
must  be  considered  as  still  suh  Judice.    That  it  is  possible  to  close  the  entire 

1  Deformities  of  the  Moutli,  Congenital  and  Acquired,  with  their  Mechanical  Treatment.  Lon- 
don, 1881. 

2  On  Harelip  and  Cleft  Palate.    London,  1877. 


908  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

length  of  a  cleft,  extending  .through  both  hard  and  soft  palates,  at  an  early 
age,  IS  undoubted  ;  but  it  may  be  questioned  whether  in  many  of  these  cases 
a  better  result,  as  regards  articulation,  would  not  have  been  obtained  by  the 
use  of  some  form  of  apparatus.  It  is  most  satisfactory  to  the  parents  of  a 
child  suffering  from  any  congenital  malformation,  that  the  deformity  should 
be  repaired  by  operation  as  soon  as  possible,  but  grave  disappointment  is  apt 
to  follow  when,  as  years  go  on,  the  power  of  articulation  fails  to  improve  in 
the  ratio  anticipated.  The  sufferer  is  inclined  to  complain  that  the  operation 
has  not  improved  his  voice  as  much  as  his  power  of  eating  comfortably,  and 
is  sometimes  annoyed  to  find  that  no  mechanical  contrivance  can  be  subse- 
quently worn,  without  undoing  what  was  effected  with  so  much  trouble  and 
suffering  some  years  before. 

^  In  deciding,  therefore,  as  to  the  propriety  of  an  operation  for  cleft  palate,  it 
IS  necessary  to  take  into  account  not  merely  the  mechanical  difficulty  of 
bringing  the  soft  tissues  on  each  side  of  the  median  line  into  sufficiently  close 
proximity  to  unite,  but  also  the  length  of  the  palate,  and  the  probability  that 
It  will  sufficiently  shut  off'  the  mouth  from  the  nose  to  prevent  the  nasal 
intonation  which  is  commonly  met  with,  both  before  and  after  these  opera- 
tions. In  no  case  of  successful  operation  for  cleft  palate,  I  believe,  is  the 
palate  sufficiently  in  contact  with  the  back  of  the  pharynx  to  allow  water  to 
be  injected  from  one  nostril  into  the  other  without  entering  the  pharynx 
when  the  mouth  is  open,  as  is  the  case  in  well-formed  throats.  And  yet 
many  of  these  patients  have  very  little  nasal  intonation,  which  is  to  be  ex- 
plained, I  believe,  by  the  hypertrophied  condition  of  the  muscles  forming 
the  pillars  of  the  fauces,  which  may  be  seen  when  the  patient  attempts  to 
swallow  with  the  mouth  open,  acting  powerfully  to  narrow  the  fauces,  and 
thus  make  up  for  the  deficient  length  of  the  palate. 

Before  deciding  therefore  as  to  the  advisability  of  an  operation  upon  the 
soft  palate,  it  is  well  to  grasp  the  chin  of  the  patient  and  hold  the  mouth 
open  so  as  to  aid  his  efforts  at  swallowing,  when  if  the  two  halves  of  the  soft 
palate  come  in  contact  in  nearly  their  whole  length,  while  the  superior  con- 
strictor and  palato-pharyngeal  muscles  closely  approximate  the  palate  and 
pharynx,  the  case  is  one  in  which  union  may  almost  certainly  be  obtained, 
and  probably  a  fair  result  as  regards  phonation. 

^  In  the  case  of  the  hard  palate,  there  is  an  undoubted  disposition  for  the  two 
sides  of  the  cleft  to  approach  one  another  for  some  years  after  birth  ;  and  this 
is  particularly  seen  in  cases  complicated  with  harelip,  in  which  the  successful 
closing  of  the  lip  tends  powerfully  to  approximate  the  divided  edges  of  the 
alveolus  and  pakte.  But  success  in  closing  the  fissure  in  a  hard  palate  depends 
in  no  small  degree  upon  the  mode  in  which  the  palate  is  arched.  As  was 
pointed  out  by  Sir  W.  Fergusson,  in  cases  of  highly  arched  palates,  which  in 
section  would  resemble  a  Gothic  arch,  it  is  comparatively  easy  to  dissect  down 
the  muco-periosteum  sufficiently  to  make  the  flaps  approximate ;  while  in 
palates  but  slightly  arched,  and  the  section  of  which  could  resemble  a  I^or- 
man  arch,  it  is  difficult  to  get  the  flaps  together,  and  the  tension  must  neces- 
sarily be  severe. 

It  is  quite  true  that  these  cases  of  slightly  arched  palate  give  the  best 
results  as  regards  the  voice,  when  the  operation  is  successful,  and  that  the 
high  palates,  when  most  successfully  closed,  are  apt  to  lead  to  disappointment ; 
but  this  might  well  be  anticipated,  since  it  is  by  no  means  uncommon  for  a 
person  with  a  healthy,  high  palate,  to  speak  with  a  nasal  intonation  closely 
resembling  that  of  one  suffering  from  a  congenital  cleft,  or  from  perforation 
by  disease. 

The  effort  involuntarily  made  by  all  patients,  the  subjects  of  cleft  palate,  to 
shut  off'  the  nose  from  the  mouth  in  speaking,  is  aided  as  they  grow  up  by  a 


MALFORMATIONS  AND  DISEASES  OF  THE  PALATE. 


909 


Fig.  1072. 


voluntary  closure  of  the  nostrils  which  is  very  remarkable.  Ordinarily,  in 
man,  the  nostrils  are  perfectly  quiet  in  tranquil  respiration,  and  it  requires 
considerable  effort  to  close  them,  as  when  plunging  the  face  into  water.  A 
patient  with  cleft  palate,  on  the  contrary,  may  be  noticed  to  put  his  comipres- 
sores  narium  into  strong  action  every  time  he  speaks  or  swallows,  and  it  is 
very  difficult  to  overcome  the  habit  when  the  necessity  for  it  has  passed  away, 
throuo;h  either  a  successful  operation  or  the  adaptation  of  well-fitting  apparatus. 

Staphylora'ph),  or  the  operation  for  closure  of  a  cleft  palate,  was  up  to  the  last 
fifteen  years  almost  invariably  postponed  until  the  period  of  puberty,  or  later, 
so  that  the  suro:eon  miglit  have  the  patient's  self-control  to  aid  him  m  his 
troublesome  and  tedious  operation.  A  few  cases  had  no  doubt  been  operated 
upon  in  childhood,  with  indifi:erent  success,  by  Mason  Warren  and  others,  but 
to  Mr.  Thomas  Smith,  of  St.  Bartholomew's  and  the  Children's  Hospital,  is 
mainly  due  the  credit  of  showing  that  it  is  possible  to  operate  in  infancy 
under  chloroform,  not  only  without  risk  but  with  very  great  success.  In  his 
paper  in  the  Medico-Chirurgical  Transactions  (1868),  Mr.  Smith  described  a 
o-ao-  by  which  the  mouth  of  the  patient  can  be  kept  sufficiently  open,  and 
which,  in  some  form  or  other,  is  essential  for  the  due  performance  of  the 
operation,  now  performed  by  him  as  follows.  [Fig.  1072  illustrates  a  conve- 
nient form  of  mouth-gag  and  tongue-depressor  combined.] 

The  patient  is  placed  on  a  table  of  convenient  height,  facing  the  window, 
and  if  possible  a  northern  light.    The  head  is  supported  by  an  air-cushion, 
and  is  firmly  held  by  an  assistant  standing  be- 
hind, while  the  arms  and  legs  are  strapped 
down  to  prevent  struggling.     The  operator 
stands  on  the  right  of  the  patient  and  the 
chloroformist  on  his  left.    The  patient  being 
thoroughly  narcotized,  the  gag  is  introduced 
and  the  mouth  screwed  open,  the  rings  of  the 
gag  being  held  by  the  thumbs  of  the  assistant 
supporting  the  patient's  head.    The  edges  of 
the  cleft  are  then  pared  with  a  slender,  double- 
edged  knife,  which  is  thrust  through  the 
margin  of  one  side  of  the  soft  palate,  held  tense 
with  forceps,  and  made  to  cut  up,  and  then 
down  to  the  end  of  the  uvula.    The  margin 
thus  separated  is  caught  with  the  forceps,  and 
the  section  completed  up  to  the  angle  of  the 
cleft,  if  possible  as  one  sweep,  or,  if  not,  by  a 
reappli cation  of  the  knife.    The  same  process 
is  repeated  on  the  other  side,  and  in  favorable 
cases  it  is  both  possible  and  satisfactory  to  re- 
move the  parings  of  both  sides  of  the  palate 
in  one  piece. 

The  closure  of  the  soft  palate  is  then  pro- 
ceeded with,  fine  silver  wire  being  used,  with 

horse-hair  or  silk  for  the  uvula.  Mr.  Smith  employs  a  sharply-curved,  tubular 
needle,  for  the  wire,  which  is  carried  on  a  wheel  in  the  handle  of  the  instru- 
ment (Fio'.  1073),  and  which  can  be  projected  when  the  point  has  traversed  both 
side^<  of  the  palate.  A  twister  (Fig.  1074)  is  employed  to  twist  the  wire  up,  but 
the  last  few  turns  are  more  conveniently  given  at  the  conclusion  of  the  ope- 
ration with  a  pair  of  torsion-forceps.  The  horse-hair  is  softened  in  warm 
water,  and  is  introduced  with  a  small  curved  or  rectangular  needle  set  in  a 
handle,  being  passed  through  both  sides  of  the  palate,  and  caught  with  a 
catcher"  or  forceps.    The  horse-hair  is  simply  tied  with  three  knots  so  as 


Mears's  mouth-gag  for  staphyloraphy. 


910 


INJURIES   AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 


not  to  slip.  Should  there  be  a  fissure  of  the  hard  palate,  the  operator  pro- 
ceeds to  detach  the  muco-periosteum  by  a  modification  of  Langenbeck's 
urano-plastic  method;  making  a  puncture  near  the  alveolus,  he  introduces  a 
palatal  raspatory  of  small  size,  and  brings  the  point  out  in  the  fissure.  Then 


Fig.  1073. 


Tubular  needle. 

Fig.  1074. 


Coghill's  wire-twister. 


meeting  this  with  a  strong  aneurism-needle,  he  replaces  the  raspatory  with 
the  needle,  withdrawing  the  former  altogether,  and  working  with  the  needle 
from  the  fissure  towards  the  alveolus.  In  this  way,  aided,  if  necessary,  by  the 
leverage  of  strong,  curved  scissors,  the  muco-periosteum  of  the  hard  palate  is 
sufiiciently  detached,  the  hemorrhage,  il*  troublesome,  being  controlled  from 
time  to  time  by  a  small  sponge  pressed  against  the  palate.  With  the  curved 
scissors,  the  soft  palate  is  then  detached  from  the  bone  of  the  hard,  one  blade 
being  passed  beneath  the  muco-periosteum,  and  the  other  above  the  soft 
palate  so  as  to  divide  the  tissue  transversely  close  to  the  horizontal  plate  of 
the  palate  bone.  The  muco-periosteal  flaps  of  the  hard  palate  are  now  closed 
by  a  sufiicient  number  of  fine  wire  sutures,  and  lastly  an  incision,  as  recom- 
mended by  Dieflfenbach,  is  made  on  each  side  of  the  soft  palate,  so  as  to  tho- 
roughly loosen  It  and  take  all  tension  o&  the  stitches,  which  are  then  finally 
adjusted  with  torsion  forceps. 

In  this  operation,  no  formal  division  of  the  levator  palati  muscles,  as  recom- 
mended by  Sir  W.  Fergusson,  is  undertaken,  but  it  is  probable  that  the  lateral 
incisions  m  the  soft  palate  divide  to  a  great  extent  the  insertions  of  the 
levators,  while  the  detachment  of  the  soft  from  the  osseous  hard  palate  must 
necessarily  divide  the  insertion  of  the  tensors  of  the  palate. 

Many  operators,  myself  among  them,  have  found  that  they  have  obtained 
good  union  of  the  soft  palate  without  even  lateral  incisions ;  but  where  the 
tension  is  great  these  should  not  be  omitted,  and  in  cases  of  great  muscular 
irritability  of  the  palate,  the  systematic  division  of  the  levators  may  be  under- 
taken with  advantage.  Whether  the  division  be  performed  as  recommended 
by  Sir  W.  Fergusson,  with  a  lancet-shaped  blade  set  at  right  angles  to  the 
shaft  of  the  knife,  and  introduced  above  the  soft  palate,  or  with^a  straio-ht 
knife  thrust  through  the  palate  as  proposed  by  Mr.  Pollock,  the  division 
should  be  performed  after  the  introduction  of  the  stitches,  which  both  serve 
to  render  the  muscles  tense,  and  also  are  more  readily  introduced  before  the 
hemorrhage  which  is  caused  by  the  myotomy,  and  which  is  sometimes  severe, 
obscures  the  view. 

The  material  for,  and  the  method  of  introducing,  the  stitches,  vary  in  the 
hands  of  diflPerent  surgeons.  Sir  W.  Fergusson  preferred  purse  silk,  and  em- 
ployed the  method  devised  by  Mr.  Avery  for  introducing  it,  as  follows :  An 
ordinary  palate-needle,  carrying  the  silk,  was  passed  froni  before  backwards 
through  the  margin  of  the  soft  palate,  and  the  loop  caught  with  forceps  and 
drawn  out  of  the  fissure.    This  being  repeated  on  the  opposite  side,  one  silk 


MALFORMATIONS  AND  DISEASES  OF  TTIE  PALATE. 


was  looped  through  the  other,  and  drawn  by  this  means  across  the  fissure 
and  tlirough  both  sides  of  the  palate.  In  tying  the  silk  it  is  convenient  to 
use  a  slidino;-knot,  that  is,  one  end  is  simply  knotted  firmly  upon  the  other, 
when  by  pulling  the  silk  the  knot  is  slid  up  to  the  palate  and  will  keep 
its  place  while  a  second  knot  is  m^de  over  it.  _ 

In  the  after-treatment  of  a  case  of  cleft-palate  operation,  it  is  essential  that 
plenty  of  liquid  nourishment  should  be  given  in  the  first  day  or  two,  and 
be  followed  up  by  semi-solid  food,  so  that  the  patient's  strength  may  be 
well  supported,  and  the  process  of  healing  accelerated.  The  idea  that  any 
effort  at  swallowing,  even  of  the  saliva,  must  necessarily  tear  open  the 
wound,  was  shown  by  Sir  Wm.  Fergusson  to  be  fallacious,  and  the  practice  of 
starving  the  patient,  first  decried  by  Sir  Philip  Crampton,  is  now  universally 
abandoned.  Talking  should  be  forbidden  for  the  first  few  days,  and  it  is 
undesirable  that  the"  patient  should  be  exposed  to  any  chance  of  taking  cold 
by  exposure  to  draught  or  east  wind. 

The  time  for  removing  the  stitches  after  an  operation  for  cleft  palate  has 
been  greatly  modified  of  late  years,  and  it  has  come  to  be  thought  by  the 
most  experienced  operators  that  the  longer  they  are  left  the  better.  In  most 
cases,  silk  or  horse-hair  sutures  should  be  removed  in  from  ten  days  to  a 
fortnight,  but  fine  wire  sutures  may  be  left  for  weeks  or  even  months,  as  long 
as  they  do  not  scratch  the  tongue.  . 

In  order  to  imp'rove  the  voice,  in  cases  of  successful  staphyloraphy  m 
which  the  nasal  tone  persi&ts,  Mr.  Francis  Mason^  has  proposed  to  divide  the 
united  soft  palate  on  each  side  by  a  longitudinal  incision,  so  that  the  soft 
palate  may  be  loosened  and  made  more  flexible.  ^  The  results  are,  however, 
disappointing,  as  the  cicatrization  which  necessarily  ensues  leaves  the  parts 
much  as  before. 

M.  Passavant,  with  the  same  object  in  view,  proposed  to  make  a  trans- 
verse incision  in  the  soft  palate,  which  could  then  be  drawn  forward  and 
reversed.  A  portion  of  the  mucous  membrane  of  the  upper  surface  was  then 
to  be  dissected  off,  and  a  corresponding  portion  of  the  mucous  membrane  of 
the  pharynx,  and  the  two  raw  surfaces  were  to  be  brought  together  with  a 
few  sutures.  As  Sedillot  remarks,  however,  it  is  difficult  to  understand  how 
the  two  surfaces  could  be  brought  in  contact ;  and  the  experience  of  all  sur- 
geons goes  to  show  that  permanent  separation  of  the  posterior  nares  and 
pharynx  by  cicatricial  tissue  is  certain  to  produce  nasal  intonation. 

Uranoplasty.— Ill  describing  the  operation  usually  performed  by  Mr.  T. 
Smith,  it  will  be  noticed  that  the  entire  fissure  in  both  hard  and  soft  palates 
is  closed  by  the  same  operation.  This  practice  is  not  followed  by  some  sur- 
geons, who  content  themselves  with  closing  the  soft  palate  first,  hoping  thus 
to  influence  the  approximation  of  the  two  halves  of  the  hard  palate;  or,  in 
cases  too  wide  for  closure,  to  employ  an  artificial  palate.  It  seems  to  me, 
however,  that  it  is  very  undesirable  to  close  the  soft  palate  when  the  hard 
palate  cannot  be  closed,  for  in  these  severe  cases  the  soft  palate  is  both  small 
and  short,  and  the  results,  therefore,  as  regards  the  voice,  are  most  unsatis- 
factory, even  after  the  gap  in  the  hard  palate  has  been  filled  artificially. 
Again,  if  the  patient  is  to  be  subjected  to  the  inconvenience  of  wearing  an 
artificial  palate  at  all,  he  may  as  well  be  fitted  with  one  to  fill  up  the  whole 
cleft,  and  thus  improve  the  voice,  which  will  be  impossible  if  the  scanty  soft 
palate  has  been  united. 

The  late  Dr.  Mason  Warren, ^  of  Boston,  was  the  pioneer  in  closing  fissures 
of  the  hard  palate  by  dissecting  down  a  flap  of  mucous  membrane,  and  his 
success  was  such  as  to  encourage  other  surgeons  to  imitate  his  practice.  He 


1  Lancet,  vol.  ii.  1869. 


2  American  Journal  of  the  Medical  Sciences.  1848. 


912  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

woi;ked  /rom  the  margin  of  the  deft,  using  sharp  knives  bent  at  a  rig-ht 
angle  to  detach  the  periosteum,  which  was  then  united  with  sutures  Mr 
Avery  was  the  first  to  follow  his  example  in  England. 

In  1862,Langenbeck  published  his  experience  o1' operating  from  the  alveolus 
towards  the  margin  of  the  cleft,  and  laid  ^special  stress  upon  detaching  the 
periosteum  by  means  of  blunt  raspatories,  to  form  part  of  the  thickness  of 
the  flap  Having  performed  this  operation  on  several  occasions  with  ^ood 
success,  I  can  speak  well  of  it,  notwithstanding  that  the  incision  near  the 
alveolus  may,  it  earned  too  far  back,  give  rise  to  troublesome  hemorrhage 
1  wo  instances  m  which  nearly  fatal  hemorrhage  occurred  from  the  posterior 
palatine  artery,  have  been  recorded  by  Mr.  Howard  Marsh,'  in  both  of  which 
the  bleeding  was  successfully  arrested  by  plugging  the  palatine  canal  with 
a  wooden  plug,  pushed  through  the  palate. 

In  1874,  Sir  William  Fergusson  brought  forward  what  was  then  believed  to 
?  P^oP^s^l'  but  was  afterwards  shown  to  be  a  revival  of  a  suggestion 

of  Dieffenbach  s— VIZ.,  to  detach  the  bony  edge  of  the  hard  palate  with  a 
chisel,  and  to  push  the  two  portions  of  the  hard  palate  toward  the  median 
line  In  his  early  cases  Fergusson  used  silk  sutures,  but  he  subsequently  found 
that  he  gained  sufiicient  approximation  by  stopping  the  gap  made  on  each 
side  with  lint.  In  this  proceeding,  the  damage  done  to  the  parts  is  con- 
siderable, and  necrosis,  with  some  exfoliation,  is  apt  to  follow  Mr  Mason^ 
has  proposed  to  limit  the  action  of  the  chisel  by  boring  holes  in  the  line  of 
incision  with  a  bradawl,  before  the  chisel  is  applied;  but  even  with  this 
modilication  the  operation  is  one  of  limited  application,  which  has  not  found 
tavor  with  many  surgeons. 

Although  the  surgeon  will  not  undertake  to  supply  artificial  aid  himself  in 
cases  of  deformity  ot  the  mouth,  it  is  essential  that  he  should  be  able  to  advi.e 
his  patient  m  the  matter,  and  possibly  direct  the  dentist  or  mechanician  as 
to  the  method  to  be  adopted.  In  Mr.  James  Salter's^  and  Mr.  Oakley  Coles's^ 
"^^1^  '/i^^^®  ^'^^^  ^^""^  complete  historical  accounts  of  the  methods 
adopted  by  successive  practitioners  to  obviate  mechanically  the  deformities  of 
the  palate ;  but  for  surgical  purposes,  it  will  be  sufiicient  to  say  that  as  regards 
congenital  cleft  palate,  it  is  only  during  the  last  sixty  years  that  anything 
like  success  has  been  attained.  In  1820,  M.  He  la  Barre  seems  first  to  have 
employed  ''elastic  gum"  in  making  artificial  palates;  and  in  1828,  Mr  Snell 
made  a  palate  of  gold  with  a  movable  velum,  which  was  subsequently  im- 
proved by  Stearn  (1845),  Sercombe  (1857),  and  Parkinson  (1867).  All  these 
palates  acted  simply  as  obturators— that  is,  were  placed  below  the  palate  and 
overlapped  the  margins  of  the  cleft,  thus  more  or  less  completely  shuttins:  oft' 
the  nose  from  the  mouth.  In  1864,  Dr.  J^orman  Kingsley,  of  New  York 
brought  before  the  Odontological  Society  of  Great  Britain  an  artificial  palate 
made  entirely  of  vulcanized  rubber,  cast  in  moulds  of  metal  taken  from  impres- 
sions in  plaster-of-Paris.  The  velum  of  soft  rubber  had  the  great  peculiarity 
that  It  fitted  between  the  halves  of  the  split  palate,  and  moved  with  them  at 
^''^f  between  the  palate  and  back  of  the  pharynx. 

With  this  palate  adapted  by  Mr.  Coles,  I  have  seen  very  remarkable  results; 
but  the  method  has  the  drawback  that,  if  applied  to  patients  whose  growth  is 
not  complete,  frequent  alterations  are  required,  in  addition  to  the  fact  that 
the  sott  rubber  wears  out  and  requires  renewal.  A  palate  on  a  totally  dif- 
ferent principle,  contrived  originally  by  Dr.Wilhelm  Swersen,  of  Berlin,  and 
lately  brought  to  my  notice  by  Mr.  Oakley  Coles,  appears  in  many  cases  to 

»  Clinical  Society's  Transactions,  vol.  xi.  2  Lancet,  Oct.  24,  1874 

3  Dental  Pathology  and  Surgery.    London,  1874. 
<  Deformities  of  the  Mouth.    London,  1881. 


MALFORMATIONS  AND  DISEASES  OF  THE  PALATE. 


913 


afford  the  most  satisfactory  means  of  treating  cases  of  wide  congenital  cleft  of 
the  palate.  It  consists  entirely  of  hard  rubber,  the  posterior  part  being  much 
thicker  than  the  hard  palate,  to  which  it  is  attached  by  a  narrow  stem ;  this 
posterior  part,  which  is  triangular  in  shape,  is  set  at  an  angle  so  as  to  pass 
above  the  soft  palate  and  till  up  the  cavity  of  the  pliarynx,  the  edges  of  the 
soft  palate  coming  in  contact  with  it  in  deglutition  and  i)honation.  Mr.  Coles 
has  found  that  the  tone  of  the  voice  is  improved  by  substituting  gold  in  the 
hard  palate.  Having  induced  a  highly  intelligent  medical  student  to  try  one 
of  these  i)alates,  after  having  worn" one  of  Kingsley's,  he  informs  me  that  he 
has  no  hesitation  in  giving  the  preference  to  the  former,  whilst  I  am  able  to 
testify  personally  to  the  iniprovement  of  his  voice. 

Whatever  method  of  treating  a  congenital  cleft  palate  may  be  adopted,  the 
im[)rovement  in  the  voice  must  be  gained,  to  a  great  degree,  by  education. 
A  patient  has  in  the  first  few  years  of  life  acquired  vicious  habits  of  speak- 
ing,  and  particularly  a  guttural  and  nasal  tone,  which  requires  great  care 
to  overcome.  It  is  essential  that  he  should  be  taught  to  speak  with  his  lips, 
and  to  throw  the  voice  forward.  With  proper  teaching  and  diligent  prac- 
tice, he  will  in  time  speak  as  distinctly  as  the  majority  of  healthy  persons. 

Ulceration  of  the  palate  is  usually  of  syphilitic  origin.  Mucous  patches 
with  superficial  ulceration,  more  or  less  circular  in  shape,  are  not  infrequent 
in  the  secondary  stage  of  syphilis,  but  the  well-marked  ragged  ulcers,  with 
a  yellow  base,  are  found  either  in  tertiary  or  congenital  syphilis.  The  mu- 
cous patches  jdeld  readily  to  ordinary  anti-syphilitic  treatment,  but  the 
tertiary  ulcers  are  apt  to  perforate  the  soft  palate  and  eat  into  the  uvula,  or 
may  destroy  the  muco-periosteum  of  the  hard  palate,  and  lead  to  exfoliation 
of  bone.  The  existence  of  so-called  strumous  Or  tubercular  ulceration  of  the 
palate  may  be  doubted,  since  in  these  cases  a  rapid  cure  is  effected  by  the 
administration  of  the  iodides  in  full  doses,  exactly  as  in  cases  of  recognized, 
tertiary  syphilis.  The  adhesions  of  the  palate  to  the  pharynx  which  are 
apt  to  follow  extensive  tertiary  ulceration  are  best  let  alone,  since  any  sur- 
gical interference  is  not  likely  to  improve  the  intonation.  When  the  soft 
palate  is  destroyed,  or  the  hard  perforated,  an  obturator  may  be  w^orn  with 
advantage. 

IS'odes  of  the  hard  palate  are  not  infrequent  in  constitutional  syphilis, 
and  iu  the  recent  state  are  apt  to  be  confounded  w^ith  abscess.  An  abscess 
always  extends,  from  the  alveolus,  and  usually  that  of  the  incisor  teeth, 
which  will  be  found  to  be  painful  and  loosened ;  and  on  applying  pressure 
to  the  swelling,  pus  exudes  by  the  sides  of  the  teeth.  A  node,  on  the  other 
hand,  is  less  rapid  in  formation  tlian  an  abscess,  and  is  isolated  from  the 
alveolus,  the  teeth  being  firm,  although  possibly  tender.  The  distinction 
between  the  two  affections  is  important,  since  the  early  incision,  w^hich  is 
essential  in  the  cure  of  the  abscess,  in  order  to  prevent  necrosis,  will  in  all 
probability  lead  to  this  very  result  if  the  node  be  incised,  whereas  the  latter 
will  rapidly  subside  under  the  free  administration  of  the  iodides. 

^Tecrosis  of  the  hard  palate,  when  it  occurs,  is  followed  by  very  slow  exfo- 
liation, and  nothing  can  be  done  to  hasten  the  process.  The  use  of  detergent 
mouth-washes  to  keep  down  the  fetor,  and  the  removal  of  sequestra  as  they 
form,  constitute  the  whole  treatment. 

Fortunately,  exposed  portions  of  the  hard  palate  do  not  always  necrose, 
but  have  a  singular  power  of  recuperation,  due  doubtless  to  the  abundant 
vascular  supply  to  both  surfaces  of  the  palate.  In  order  that  bare  bone  may 
thus  recover,  it  is  essential,  however,  that  it  should  be  protected  from  the  con- 
VOL.  IV. — 58 


914 


INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 


stant  contact  of  the  tongue,  and  the  lodgment  of  particles  of  food.  For  this 
purpose,  a  metallic  or  vulcanite  plate  niust  be  fitted  to  the  mouth,  so  as  to 
cover  without  pressing  against  the  affected  part.  This  is  even  more  impor- 
tant when  a  small  exfoliation  with  perforation  has  taken  place,  for  even  then 
if  the  parts  are  healthy  a  cure  may  thus  be  effected.  Any  attempt  to  pluo- 
SLich  an  aperture  must  inevitably  lead  to  its  rapid  enlargement,  and,  if  per- 
sisted in,  will  cause  absorption  of  the  entire  palatine  process,  as  in  a  specimen 
in  the  museum  of  St.  Bartholomew's  Hospital,  London. 

Tumors  of  the  Palate.— A  case  of  jpapillary  tumor  of  the  hard  palate  has 
been  described  by  Salter,  which,  as  it  recurred,  was  probably  an  example  of 
true  papilloma. 

A  few  cases  of  congenital  tum.or  of  the  palate  are  recorded,  one  of  the  most 
recent  being  an  example  of  dermoid  tumor,  springing  from  the  upper  surface 
of  the  soft  palate,  in  a  child  of  three  years.  It  was  removed  by  Mr.  Morrant 
Baker,  and  was  exhibited  at  the  Pathological  Society  of  London,  in  April, 
1881,  by  Dr.  Hale  White,  who  described  the  tumor  as  two  inches 'in  length' 
with  a  wide  base,  and  consisting  of  epidermis,  papillae,  corium,  and  fat,  and 
having  on  one  surface  a  plate  of  cartilage.  In  the  museum  of  St.  Bartholo- 
mew's Hospital,  is  a  section  of  a  boy's  head  with  a  large  lobed  tumor  of 
myxomatous  structure  in  the  soft  palate,  which  suffocated  the  patient  by 
obstructing  the  larynx. 

The  glandular  structure  of  the  soft  palate,  which  in  health  forms  a  consider- 
able portion  of  its  thickness,  may  become  hypertrophied  and  form  a  tumor; 
and  this,  from  its  position,  may  give  rise  to  great  inconvenience  by  inter- 
fering with  the  voice  and  deglutition.  A  case  of  the  kind  was  under  my 
notice  for  some  months,  in  tlie  person  of  a  married  lady  aged  thirty-four, 
otherwise  in  good  health.  As  the  tumor  slowly  increased  and  interfered 
with  her  professioi^  as  a  vocalist,  I  thought  it  right  to  interfere,  and  in  July, 
1879,  having  taken  the  precaution  to  perform  tracheotomy,  and  to  introduce 
Trendelenburg's  tampon  to  obviate  the  entry  of  blood  into  the  windpipe,  I 
incised  the  tumor,  and  was  agreeably  surprised  to  find  that  I  was  able  to  turn 
out  with  the  finger,  from  between  the  layers  of  the  palate,  a  soft  mass  of  gland 
structure,  distinctly  encapsuled,  afterwards  withdrawing  the  containing'cyst. 
The  patient  made  a  good  recovery,  and  has  remained  well  since.  Encysted 
tumors,  probably  of  the  same  nature,  have  been  met  with  in  the  hard  palate. 

Sarcoma  of  the  round-celled  variety  affects  both  the  hard  and  soft  palate. 
I  had  recently  under  my  care  a  child  of  seven,  with  a  tumor  of  the  right  side 
of  the  soft  palate,  which  had  been  punctured  under  the  idea  that  it* was  an 
abscess.  It  closely  resembled  the  tumor  in  the  preceding  case,  externally,  but 
upon  cutting  into  it  I  found  it  extensively  attached,  and  a  small  portion 
removed  for  examination  proved  it  to  be  a  round-celled  sarcoma.  The  child 
survived  six  months.  In  a  woman  aged  forty-eight,  who  had  a  tumor  of 
the  hard  palate,  the  size  of  a  horse-chestnut,  which  had  been  noticed  from 
childhood  but  had  latterly  increased  rapidly,  I  succeeded  in  removing  the 
growth,  which  proved  to  be  a  round-celled  sarcoma,  and,  by  the  application 
of  the  actual  cautery  to  the  bone  from  which  it  sprang,  induced  a  superficial 
exfoliation  with,  I  believe,  a  permanent  cure.^  A  similar  specimen,  removed 
by  Sir  Wm.  Fergusson,  is  in  the  museum  of  the  Eoyal  College  of  Surgeons. 
Dr.  David  Foulis,^  of  Glasgow,  has  recorded  the  case  of  a  man  aged  thirty, 
from  whom  he  successfully  removed  a  round-celled  sarcoma  involving  the 
right  side  of  the  soft  palate  and  tonsil,  through  an  incision  carried  horizon- 
tally froni  the  angle  of  the  mouth,  with  division  of  the  angle  of  the  lower  jaw. 


1  Lancet,  November  18,  1876. 


2  British  Medical  Journal,  Oct.  12,  1878. 


DISEASES  OF  THE  GUMS. 


915 


The  hard  palate,  which  resemhles  the  gum  in  structure,  is  like  it  liable  to 
epdoid  growths  of  a  fibrous  nature,  closely  connected  with  the  periosteum 
and  bone,  and  therefore  requiring  free  removal.  The  trephine  was  advan- 
tao-eously  employed  by  Syme  in  a  case  of  this  kind,  but,  in  the  majority  of 
instances,  a  superficial  exfoliation  produced  with  the  cautery  will  give  com- 
plete immunity  from  return,  without  causing  subsequent  deformity. 

Epithelioma  may  invade  the  palate  primarily,  but  more  frequently  it  extends 
from  the  gums  or  tonsil.  In  the  latter  case  its  nature  is  readily  recognized, 
but  in  primary  epithelioma  of  the  palate  it  may  be  difiicult  to  disthiguish  it 
in  the  earlier  stages,  and  the  disease  is  often  more  extensive  than  at  first 
sight  appears.  In  a  man  lately  under  my  care,  who  presented  an  epithelial 
ulcer  confined  apparently  to  the  palate,  which  I  destroyed  with  the  actual 
cautery,  I  found  extensive  mischief  spreading  into  the  antrum,  and  recurring 
after  free  removal.  When  the  disease  begins  in  the  alveolus,  it  spreads 
upwards  into  the  antrum  and  along  the  palate,  in  the  form  of  an  out-standing 
growth  and  not  in  that. of  an  ulcer.  Hence  the  nature  of  the  case  is  some- 
times overlooked  at  first,  and  attention  is  apt  to  be  concentrated  upon  the 
oftensive  discharge  from  the  nostril,  and  other  symptoms  suggestive  of  sup- 
puration in  the  antrum.  Nothing,  however,  less  than  early  and  free  removal 
of  the  whole  disease  can  be  of  any  service,  and  even  then  recurrence  cannot 
always  be  prevented. 


Diseases  of  the  Gums. 

Hypertrophy  of  the  gums  occurs  as  a  congenital  affection,  and  cases  of  it 
have  been  recorded  by  Gross,  Salter,  MacGillivray  and  others.  In  the 
Transactions  of  the  Royal  Medical  and  Chirurgical  Society ,i  is  a  record  of 
three  children  of  one  family  who  all  presented  hypertrophy  of  the  gums,  and 
who  were  also  the  subjects  of  molluscwn  Jibrosum.  All  these  children  were  of 
weak  intellect.  I  brought  before  the  Odontological  Society  of  Great  Britain,  in 
1878,  two  remarkable  cases  of  hypertrophy  of  the  , gums,  one  in  a  child  of  five 
years,  and  the  other  in  a  young  man  of  twenty-six.  In  the  child  the  hyper- 
trophy was  general,  involving  the  whole  of  the  gums  of  both  jaws,  but  ni 
the  young  man  it  was  partial,  being  confined  to  the  gum  and  alveolus  of 
the  right'^side  of  the  lower  jaw,  from  the  right  wisdom  tooth  to  the  left 
caninS  A  cure  was  eftectedin  both  cases  by  removing  the  aftected  alveolus 
with  the  contained  teeth,  by  means  of  powerful  cutting  forceps ;  and  nothing 
less  severe  is  effectual,  since  it  has  been  shown  by  Mr.  Charles  Tomes  that  in 
these  cases  the  disease  dips  into  the  socket  of  the  teeth,  and  that  therefore 
mere  paring  away  of  the  redundant  gum  does  not  eflect  a  cure. 

A  N.EVOiD  CONDITION  OF  THE  GUM  is  occasionally  met  with  as  a  congenital 
afl:ection,  and  I  have  known  it  to  coexist  with  an  extensive  port-wine  stain 
of  the  face.  In  this  patient,  an  otherwise  healthy  young  woman,  the  neevoid 
growth  appeared  to  take  on  greater  activity  with  each  pregnancy,  and  I  re- 
moved the  vascular  outgrowth  on  two  or  three  occasions,  applying  the  actual 
cautery  freely  for  the  arrest  of  hemorrhage.  ... 

A  vascular,  non-congenital  tumor  of  the  gum  may  originate  from  irritation 
of  the  teeth,  especially  in  the  region  of  the  incisors.  When  small,  these 
growths  may  be  treated  with  caustics,  but  if  large  and  causing  hemorrhage, 
they  should  be  removed,  and  the  surface  from  which  they  grow  should  be 
touched  with  the  actual  cautery. 

1  Medico-Chirurgical  Transactions,  vol.  Iri. 


916  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

Polypus  of  the  gum,  or  simple  hypertrophy  due  to  irritation,  is  not  uncom- 
mon in  the  neighborhood  of  decayed  teeth,  or  where  an  accumulation  of  tartar 
has  been  allowed  to  take  place.  The  affection,  when  of  considerable  size,  may 
resemble  epulis,  but  differs  from  it  in  being  unconnected  with  the  periosteum  ; 
and  hence  it  requires  much  milder  treatment.  The  removal  of  the  tartar  or 
the  decayed  teeth,  and  the  use  of  an  astringent  wash,  are  sufficient  in  most 
cases ;  if  the  growth  is  large,  it  is  generally  pedunculated,  and  therefore 
readily  snipped  off  with  scissors,  or,  if  sessile,  it  may  be  cut  off  and  cauterized 
with  Paquelin's  cautery.  Salter  describes  a  true  warty  affection  of  the  gums, 
and  also  a  condyloinatous  condition  occurring  in  constitutional  syphilis. 

Gingivitis,  or  inflammation  of  the  gums,  is  a  common  affection  in  infants 
who  are  cutting  their  teeth.  The  mouth  is  hot  and  tender,  there  being  a  con- 
stant dribbling  of  saliva,  and  the  child's  health  is  interfered  with  by  the  loss 
of  rest,  and  by  diarrhoea,  and  possibly  convulsions,  caused  by  the  irritation  of 
the  system.  Free  lancing  of  the  gums  is  the  only  trustworthy  remedy,  and 
should  be  had  immediate  recourse  to  in  all  cases  of  severity,  although  in 
slight  cases  rubbing  the  gums  with  the  syrupus  croci^  or  with  one  of  the  numer- 
ous but  dangerously  narcotic    soothing-syrups,"  may  be  sufficient. 

A  SPONGY  CONDITION  OF  THE  GUMS,  often  Called  scurvy,  but  which  differs  en- 
tirely from  the  gum  of  true  scurvy,  is  common  in  persons  w^ho  neglect  the 
cleanliness  of  their  teeth,  or  who  are  in  feeble  health.  According  to  Salter,  the 
disease  consists  essentially  in  vascular  dilatation  of  the  papillary  and  other 
capillaries,  with  a  general  thickening  of  the  gum  itself.  The  treatment  con- 
sists in  improving  the  general  health,  and  in  using  the  tooth-brush  vigorously 
with  some  astringent  mouth-wash.  '  The  spongy  gum  due  to  the  adminis- 
tration of  mercury,  differs  from  the  preceding" in  presenting  a  well-defined 
red  line  along  the  margin  of  the  gum,  before  the  sponginess  comes  on,  com- 
bined with  fetor  of  breath,  and  a  metallic  taste  in  the  mouth.  The  blue  line 
of  plumbism  is  due  to  a  formation  of  sulphide  of  lead,  and  the  green  line  of 
copper-poisoning  to  the  oxidation  of  copper  in  the  superficial  tissues  of  the 
gum. 

In  true  scurvy^  due  to  deprivation  of  vegetable  diet,  the  gums  are  swollen 
and  livid  from  submucous  extravasations  of  blood,  and  they  bleed  on  the 
slightest  touch.  In  advanced  cases  the  gums  become  black  and  sloughy, 
protrude  between  the  lips,  and  are  horribly  ofiensive.  Such  cases  are  seldom 
seen  except  in  seamen  who  have  been  improperly  fed  and  deprived  of  lime- 
juice  during  a  long  voyage ;  but  mild  cases  of  scurvy,  characterized  by  sub- 
cutaneous ecchymoses  in  other  parts  of  the  body,  may  be  met  with,  and  like  the 
more  severe  ones  yield  promptly  to  the  administration  of  fresh  fruit  and 
vegetables.  Bleeding  from  gums  apparently  healthy,  is  a  common  symptom 
in  the  hemorrhagic  diathesis,  and  may  be  best  checked  by  pressure  and  by 
the  administration  of  hsemostatics  in  the  form  of  iron  and  the  mineral  acids. 

Transparent  Hypertrophy  of  the  Gums. — Under  the  name  of  transparent 
hypertrophy^  Mr.  Salter^  has  described  a  very  rare  affection  of  the  gums,  first 
noticed  by  the  late  Mr.  Thomas  Bell,  F.  E.  S.  "  It  consists  in  the  slow  and 
gradual  hypertrophy  of  the  extreme  edge  of  the  gum,  at  first  like  a  cord, 
and  very  sharply  marked  from  the  immediately  contiguous  healthy-looking 
structure ;  but  the  most  remarkable  circumstance  is  the  singular  color  of  the 
hypertrophied  part :  it  is  pale  pink  and  semi-transparent.  It  is  very  callous 
and  insensitive,  and  scarcely  bleeds  when  cut.   As  the  disease  progresses,  the 


1  Deatal  Pathology  and  Surgery  1874. 


DISEASES  OF  THE  GUMS. 


917 


hypertrophy  of  the  gum-edge  increases,  but  it  does  not  alter  its  character  or 
lose  its  sharply  defined  limit.  The  teeth,  when  the  attection  exists,  become 
slowly  dislocated  and  pushed  into  irregular  positions  ;  they  ultimately  beconie 
very  loose ;  when  extracted,  scarcely  any  blood  Hows.  When  the  tooth  is 
removed,  the  gum  heals  very  slowly  indeed,  and  the  edge  of  the  wound  long 
continues  of  the  same  pale  transparent  aspect." 

Epulis  is  a  term  often  used  to  include  any  form  of  tumor  involving  the. 
gum,  but  may  be  conveniently  restricted  to  the  fibrous  form  which  alone  is 
strictly  connected  with  the  gum  and  alveolus.  It  is  a  slowly  growing  tumor, 
arising  most  commonly  between  two  teeth  which  may  or  may  not  be  decayed. 
By  pressure  it  tends  to  separate  the  teeth  if  they  are  healthy,  or  it  may 
completely  cover  in  the  stumps  of  decayed  teeth.  As  ei)ulis  is  closely 
■connected  with  the  periosteum  of  the  alveolus,  mere  cutting  away  of  the 
growth  is  insufficient  for  its  eradication,  and  nothing  less  than  cutting  away 
the  portion  of  alveolus  from  which  it  springs,  or  inducing  its  exfoliation  by 
the  application  of  the  actual  cautery,  can  be  relied  on.  In  order  to  do  this,  it 
is  generally  necessary  to  sacrifice  the  tooth  on  each  side  of  the  growtli,  and 
occasionally  in  removing  the  tooth  the  whole  growth  comes  away,  being 
in  these  cases  attached  to  the  peri-odontal  membrane,  instead  of  to  the  alve- 
olar periosteum.  An  epulis,  on  section,  is  found  to  consist  of  dense  fibrous 
tissue,  closely  resembling  the  normal  gum,  and  it  frequently  contains  masses 
of  bone,  which  may  or  may  not  be  directly  continuous  with  the  alveolus. 
According  to  Cornil  and  Ranvier,  the  common  epulis  is  an  ossifying  sarcoma, 
the  bone  transformation  being  of  an  imperfect  description. 

Myeloid  tumors  are  not  uncommon  about  the  alveoli  (hence  "myeloid 
epulis"),  but  are  only  the  superficial  portions  of  deeper  growths.  The 
remarkable  feature  about  these  grow^ths  is  the  dark  color  which  is  often  to 
be  seen  on  the  surface  of  the  gum-tumor  previous  to,  or,  more  frequently, 
after  removal.  A  very  thorough  and  complete  removal  of  these  growths  is 
necessary  to  insure  a  cure,  and  hence  they  are  more  properly  classed  among 
tumors  of  the  jaw,  which  they  commonly  involve. 

Papilloma  occasionally  affects  the  gums  and  requires  free  removal. 
Salter  describes  a  case  of  the  kind  which  occurred  in  Sir  W.  Fergusson's 
practice,  and  in  which  recurrence  after  removal  had  frequently  taken  place. 

Ulceration  of  the  gum  occurs  in  children  as  the  result  of  stomatitis,^  but 
in  the  adult  may  be  due  to  struma,  syphilis,  or  epithelioma.  Salter^  narrates 
a  case  of  strumous  ulceration  aftecting  the  gums  and  palate  in  a  youth  of 
nineteen,  of  highly  strumous  diathesis,  and  thinks  that  the  disease  may  be  more 
common  than  is  supposed.  Syphilitic  ulceration  may  affect  the  gums  as  well 
as  other  portions  of  the  buccal  mucous  membrane,  and  occurs  as  a  rule  before 
middle  age.  Epithelioma  affects  the  gums  in  patients  over  forty,  and  is  often 
apparently  connected  with  irritation  caused  by  ill-fitting  tooth-plates.  Any 
ulceration  in  the  mouth  of  an  elderly  patient  which  does  not  heal  readily, 
should  arouse  a  suspicion  of  epithelioma,  and  I  insist  upon  this  strongly, 
because,  in  the  early  stage,  cases  of  this  description  are  generally  seen  by 
dentists,  who  do  not  always  appreciate  the  full  gravity  of  the  case  and  the 
necessity  for  prompt  interference.  When  fully  developed,  the  ulceration  is 
ragged  and  irregular,  and  tends  to  spread  from  the  gum  to  the  cheek  exter- 
nally, or  to  the  side  of  the  tongue  internally.    The  teeth  in  the  neighborhood 


1  See  p.  887. 


2  Op.  cit. 


918  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

are  loosened,  and  possibly  the  submaxillary  lymphatic  glands  may  be  enlarged^ 
as  they  always  are  in  the  later  stages  of  the  disease. 

Having  treated  several  cases  of  epithelioma  of  the  gum,  I  am  convinced 
that  nothing  but  very  free  removal  offers  the  patient  a  chance  of  permanent 
relief.  It  is  impossible  to  say  how  deeply  in  the  jaw  the  epitheliomatous 
growth  may  have  penetrated,  and  therefore  it  is  better  not  to  be  content  with 
simply  cutting  away  the  alveolus  with  bone-forceps,  but  to  remove  a  piece  of 
the  whole  thickness  of  the  jaw,  well  beyond  the  disease.  It  is  true  that  this 
leads  to  a  permanent  deformity,  which  one  would  gladly  avoid;  but  to  omit  it 
is  to  almost  court  failure,  with  probable  infiltration  of  the  lymphatics,  and  a 
rapid  termination.  I  have  elsewhere^  reported  the  case  of  a  man,  aged  sixty- 
eight,  from  whom  I  removed  the  horizontal  ramus  of  one  side  of  the  jaw, 
together  with  part  of  the  floor  of  the  mouth,  for  extensive  epithelioma,  who 
notwithstanding  his  age  made  a  good  recovery,  and  who  presented  himself  tw^o 
years  afterw^ards  in  perfect  health.  Whereas  in  cases  in  which  I  have  been  con- 
tent to  remove  the  alveolus  only,  I  have  been  often  disappointed  in  the  results. 
Any  enlarged  lymphatic  glands  beneath  the  jaw,  may  readily  be  removed  at 
the  same  time,  and  thus  an  additional  chance  of  immunity  will  be  afforded. 
A  remarkable  example  of  extensive  and  successful  removal  of  epithelioma  of 
the  lower  jaw,  was  lately  seen  by  me  in  a  military  man  aged  fifty-three,  from 
whom  Dr.  Partridge,  of  Calcutta,  had,  in  December,  1879,  removed  the  left 
horizontal  ramus  with  the  submaxillary  glands.  Recurrence  taking  place 
at  the  chin,  the  right  horizontal  ramus  and  the  glands  were  removed  in 
March,  1880,  by  Dr.  McCleod,  also  of  Calcutta,  and  the  patient  returned  to 
England,  where  I  saw  him  in  July,  1881,  in  perfect  health ;  the  parts  w^ere 
quite  sound,  there  being  one  and  one-half  inches  of  space  between  the  tw^o 
halves  of  the  jaw,  and  his  only  complaint  being  of  a  sense  of  tightness  and 
want  of  saliva.    He  was  alive  and.  well  in  June,  1883. 


Diseases  of  the  Jaws. 

Inflammatory  deposit  may  take  place  in  the  lower  jaw  as  a  consequence  of 
tooth  irritation,  and  may  rapidly  lead  to  great  swelling  and  deformity. 
When  the  tooth  w^hich  has  excited  the  inflammation  is  extracted,  the  swell- 
ing slow^ly  subsides,  but  often  some  deformity  exists  for  months  ;  and  it  seems 
probable  that  some  at  least  of  the  cases  of  fibroma  found  in  the  interior  of  the 
lower  jaw,  have  originated  in  inflammatory  deposit  kept  up  and  irritated 
by  the  presence  of  the  fangs  of  carious  teeth. 

Alveolar  abscess  occurs  in  both  jaws  as  the  result  of  inflammation  con- 
nected with  the  teeth,  and  originating  in  the  socket.  The  earliest  symptom 
is  pain,  w^ith  slight  protrusion  of  the  tooth,  due  to  the  inflamed  condition  of 
the  membranes  covering  the  tooth  and  lining  the  alveolus.  If  not  relieved 
by  judicious  leeching  or  incision,  matter  forms  in  the  socket,  and  either  finds 
its  way  out  by  the  side  of  the  tooth,  which  is  necessarily  loosened,  or,  after 
causing  great  pain  for  a  day  or  two,  perforates  the  alveolus,  and  finds  its  way 
beneath  the  gum.  This  is  the  ordinary  form  of  "  gum-boil,"  which  breaks 
spontaneously,  after  causing  much  suftering,  unless  previously  relieved  by  a 
timely  incision.  The  propriety  of  an  early,  free  incision  through  the  gum, 
down  to  the  alveolus,  is  strongly  to  be  insisted  on,  since  necrosis  and  consequent 
exfoliation  of  large  portions  of  the  jaw  not  unfrequently  follow  neglect  or 
postponement  of  the  operation.    Extraction  of  the  tooth  alone  is  not  sufficient. 


'  Lancet,  voL  ii.,  I88O0 


DISEASES  OF  THE  JAWS. 


010 


where  the  alveolus  has  heen  perforated,  and  in  many  eases  the  incision  will 
serve  to  preserve  a  useful  though  dead  tooth  for  many  years.  Tlie  only  acci- 
dent which  I  have  known  to  occur  in  connection  with  this  operation,  was  the 
awkward  one  of  a  wound  of  the  facial  artery,  from  the  edge  of  the  knife 
heing  turned  towards  the  soft  tissues  instead  of  against  the  alveolus.^ 

But  alveolar  ahscess  does  not  always  point  within  the  mouth.  ^  The  per- 
foration of  the  alveolus  may  take  place  heyond  the  line  of  reflection  of  the 
buccal  mucous  membrane,  and  then  the  matter  has  to  find  its  way  to  the 
nearest  skin.  In  this  way  abscesses,  with  their  resulting  fistulas,  niay  be  seen 
on  any  part  of  the  face  or  neck;  and  occasionally  grave  errors  of  diagnosis  are 
made  from  non-recognition  of  the  fact  that  alveolar  abscesses  may  burrow  for 
long  distances.  I  have  known  one  instance  of  fatal  suppuration  between  the 
muscles  of  the  neck,  leading  eventually  to  suffocation,  due  entirely  to  mischief 
about  a  molar  tooth  in  a  i)atient  whose  health  was  undermined  by  drink;  and 
it  is  common  to  see  cases  of  fistulous  opening,  with  serious  scarring  of  the 
face  and  neck,  due  solely  to  the  presence  of  a  decayed  tooth.  In  tho  case  of 
the  upper  jaw,  abscess  connected  with  the  incisor  teeth  not  unfrequently 
finds  its  way  backwards  along  the  hard  palate,  and  occasionally,  but  rnore 
rarely,  into  the  nostril,  being  "thus  liable  to  be  mistaken  for  discharge  from 
the  nose  itself,  or  from  the  antrum. 

Chronic  abscesses  have  been  met  with  in  the  substance  of  the  lower  jaw, 
depending  no  doubt  upon  osteitis,  and  presumably  connected  originally  with 
tooth  mischief.  Since  the  swelling  is  the  only  evidence  of  the  abscess,  for  it 
must  be  very  rare  for  the  bone  to  be  sufficiently  thinned  to  yield  the  crackling 
feel  which  is  characteristic  of  contained  fluid,  it  is  not  surprising  that  eminent 
surgeons  should  have  removed  large  portions  of  the  jaw  in  error,  mistakhig 
the  tumor  for  a  solid  growth.  Hence  the  rule,  which  should  be  invariably 
followed,  to  perforate  tumors  of  the  lower  jaw  before  cutting  the  bone,  since 
both  abscesses  and  cysts  closely  simulate  solid  growths.  In  the  case  of  a 
chronic  abscess,  the  perforation  alone,  with  efficient  drainage,  would  be  suffi- 
cient treatment. 

Suppuration  or  empyema  of  the  antrum  is  another  form  of  chronic  abscess, 
but  with  the  peculiarity  that  the  pus  is  seldom  so  completely  shut  in  as  to 
produce  distension.  In  the  great  majority  of  cases,  the  matter  constantly 
escapes  by  the  anterior  or  posterior  nares,  and  it  is  this  discharge  which  first 
attracts  the  patient's  attention.  When  escaping  from  the  anterior  nares  upon 
the  handkerchief,  the  disdiarge  is  apt  to  be  attributed  erroneously  to  ozeena, 
but  the  absence  of  the  characteristic  crusts  and  fetor  sufficiently  mark  the 
distinction.  In  ozaena,  the  patient,  as  a  rule,  has  lost  the  sense  of  smell,  and 
is  unconscious  of  his  ofiensiveness ;  whereas,  in  cases  of  pus  in  the  antrum, 
the  patient  is  conscious  of  an  occasional  unpleasant  odor,  but  is  not  dis- 
agreeable to  his  neigh]>ors,  though  the  discharge  when  blown  on  the  hand- 
kerchief may  be  offensive.  Often  a  patient  suffering  from  pus  in  the  antrum 
complains  only  of  a  disagreeable  taste  in  the  throat  and  mouth,  on  awaking 
in  the  morning,  particularly  if  he  sleep  habitually  on  the  side  opposite  to  that 
of  the  affected  antrum,  the  purulent  fluid  then  slowly  flowing  backwards 
into  the  pharynx  and  being  partially  swallowed,  with  great  detriment  to  the 
digestion. 

In  the  exceptional  cases  where  the  opening  into  the  nose  is  closed,  the  pus 
tends  to  accumulate  and  produce  distension  of  the  antrum,  with  absorption 
of  the  bony  walls,  by  which  the  characteristic  crackling  is  produced.  It  may 
be  doubted,  however,  whether  some  at  least  of  these  cases  are  not  instances 
of  cyst  of  the  wall  of  the  antrum,  the  contents  of  which  have  become  purulent. 


^20  IXJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 


In  cases  of  distension  the  pain  is  severe,  and  of  a  neuralgic  and  intermittent 
character ;  but  in  the  ordinary  form  of  the  disease,  there  is  little  more  than 
an  occasional  sense  of  uneasiness  and  weight  about  the  jaws,  so  indistinct  as 
often  to  be  no  guide  to  the  side  on  which  the  mischief  exists. 

In  the  great  majority  of  cases,  empyema  of  the  antrum  depends  upon  inflam- 
mation of  the  lining  membrane  of  the  cavity,  caused  by  the  fangs  of  decayed 
teeth,  which,  if  not  actually  perforating  the  membrane,  are  in  close  proximity 
to  it,  either  from  unusual  depth  of  tlie  sockets  or  from  absorption  of  the 
intervening,  thin  portion  of  bone.  It  is  possible,  however,  that  the  mischief 
may  be  set  up  by  extension  of  catarrhal  inflammation  from  the  nose,  b}^ 
blows  on  the  face,  or  even  by  the  pressure  during  birth,  in  the  case  of  an 
infant.  A  careful  examination  of  the  teeth  will,  in  most  cases,  show  which 
of  them  is  in  fault,  and,  though  the  flrst  and  second  molars  are  those  of  which 
the  fangs  most  frequently  cause  mischief  of  this  kind,  it  must  be  remem- 
bered that  the  canine  frequently,  and  the  incisors  more  rarety,  are  connected 
with  an  unusually  extensive  antrum.  The  extraction  of  a  decayed  tooth  or 
fang  may  be  followed  by  an  immediate  discharge  of  j^us,  in  which  case  an 
enlargement  of  the  opening  will  probably  be  required ;  but  frequently  the 
tooth  which  has  set  up  the  mischief  has  been  long  extracted,  and  it  then  be- 
comes necessary  to  perforate  the  antrum  above  the  alveolus.  For  this  pur- 
pose a  drill,  a  gimlet,  or  an  ordinary  trocar  of  medium  size  may  be  employed. 
If  the  bone  happens  to  be  thin,  any  instrument  passes  through  readily,  and 
the  operator  is  aware  that  he  has  entered  a  cavity,  and  may,  if  he  does  not 
hold  the  perforator  judiciously  short,  transfix  it  and  come  in  contact  with 
the  orbital  plate.  But  in  many  cases  the  bone  is  extremely  dense,  and  the 
instrument  is  gripped  so  tightlj'  that  it  is  impossible,  until  it  is  withdrawn, 
to  be  sure  that  the  cavity  of  the  antrum  has  been  reached. 

Whether  the  perforation  be  made  through  or  above  the  alveolus,  an  ordi- 
nary Eustachian  catheter  of  silver  or  vulcanite  will  be  found  very  convenient 
for  washing  out  the  antrum,  and  a  simple  India-rubber  ear-syringe  with  a 
bullet-joint  will  be  sufficiently  powerful  for  the  purpose.  Ordinarily,  fluid 
injected  through  the  perforation  flows  readily  from  the  nose,  bringing  awa}^ 
a  quantity  of  more  or  less  inspissated  pus  of  oflfensive  character;  but  occa- 
sionally the  cavity  of  the  abscess  does  not  communicate  with  the  nose,  and 
the  fluid  must  then  be  allowed  to  flow  back  by  the  perforation. 

The  after-treatment  of  these  cases  consists  in  maintaining  the  aperture 
patent,  which  is  often  difficult,  until  all  purulent  secretion  has  ceased ;  in 
washing  out  the  cavity  at  least  thrice  daily  with  warm  Condy's  fluid  and 
water;  and  in  throwing  in  a  small  quantity  of  stimulating  lotion,  such  as  two 
grains  of  sulphate  of  zinc  in  a  fluidounce  of  rose-water.  When  the  opening 
is  above  the  alveolus,  there  is  little  danger  of  particles  of  food  entering  the 
cavity,  but  when  the  opening  is  through  the  alveolus,  food  will  readily  pene- 
trate, unless  an  artificial  denture  be  applied  so  as  to  cover  the  opening  during 
mastication.  When  a  dental  plate  is  employed,  a  silver  tube  should  be  fitted 
to  the  perforation  so  as  to  maintain  its  calibre,  and  thus  the  occasional  intro- 
duction of  a  trocar,  which  would  otherwise  be  necessary',  may  be  dispensed 
with.  Still,  it  must  be  allowed  that  the  cure  of  empyema  of  the  antrum 
is  often  very  tedious,  and  that  many  months  ma}'  elapse  before  a  patient  can 
dispense  with  daily  washing  out  of  the  cavity. 

Since,  as  has  already  been  said,  distension  of  the  antrum  with  facial  deformity 
occurs  only  when  the  accumulating  matter  does  not  discharge  into  the  nostril, 
it  is  easy  to  mistake  a  case  of  this  kind  for  a  solid  fumor  of  the  upper 
jaw,  should  the  amount  of  distension  not  be  sufficient  to  produce  much  thin- 
ning and  crackling  of  the  bone.  Again,  it  appears  possible  that  the  fluid 
portion  of  the  matter  contained  in  the  antrum  may  drain  away,  leaving  be- 


DISEASES  OF  THE  JAWS.  921 


hind  it  a  solid  mass  of  inspissated  pus  and  cliolesterine,  which,  as  m  a  case  of 
my  own,  may,  by  its  presence,  induce  partial  absorption  of  the  floor  of  the 
antrum,  with  a  protrusion  of  the  palate  and  all  the  symptoms  ot  maxillary 
tumor.  '  In  order  then  to  avoid  an  error  which  has  overtaken  very  excellent 
suro-eons,  it  is  advisable,  in  all  cases  of  tumor  of  the  upper  jaw  in  which  the 
nature  of  the  swelling  is  not  obvious,  to  perforate  the  antrum  beneath  the 
cheek,  before  incising  the  skin  of  the  face  and  taking  the  necessary  steps  lor 
removal  of  the  jaw. 

The  secondary  effects  produced  by  distension  of  the  antrum  are  sometimes  se- 
rious. Thus,  protrusion  of  the  eyeball  from  elevation  of  the  floor  of  the  orbit 
is  not  infrequent,  and  cases  of  permanent  amaurosis  have  been  recorded  by 
Salter  and  Gaine,  while  occasionally  death  has  been  known  to  follow  suppu- 
ration within  the  antrum. 

Periostitis,  both  acute  and  chronic,  affects  the  jaws,  but  the  former  is  so 
prone  to  run  into  suppuration  with  consequent  necrosis,  that  it  is  only  in  the 
early  stao-es  that  it  can  be  recognized.  The  more  chronic  form  is  commonly 
connected  with  syphilis,  and  leads  to  the  formation  of  nodes  about  the  palate, 
and  to  enlargement  of  portions  of  the  lower  jaw.  In  these  latter  cases,  the  ad- 
ministration of  the  iodides  in  full  doses  gives  most  satisfactory  results.  Many 
cases  of  persistent  facial  neuralgia  which  are  unrelieved  by  qumine,  etc.,  yield 
to  the  administration  of  iodide  of  potassium,  and  may  be  concluded  to 
depend  upon  chronic  periostitis  or  osteitis,  with  probably  pressure  upon  the 
dental  nerves. 

Necrosis  aftects  the  lower  much  more  frequently  than  the  upper  jaw, 
probably  in  consequence  of  its  being  less  abundantly  supplied  with  blood. 
Beo-iunino;  as  periostitis  from  tooth  irritation,  injury,  or  the  action  ot  some 
specific  poison,  the  o;eneral  symptoms  are  pain,  with  pyrexia,  and  the  part 
affected  will  be  found  to  be  swollen,  injected,  and  hot,  the  teeth  being  raised 
from  their  sockets,  and  unable  to  bear  the  slightest  pressure.  It  relieved  by 
timely  depletion  by  leeches  or,  better,  a  free  incision,  and  the  assiduous  use 
of  hot  o-aro-les  and  poultices,  the  symptoms  may  subside  without  further 
mischief;  but  usually  matter  has  already  formed  beneath  the  periosteum 
before  the  patient  is  seen,  and  then,  although  promptly  evacuated,  necrosis  is 
very  apt  to  follow.  Fortunately,  necrosis  sometimes  afiects  the  outer  plate  of 
the  alveolus  only,  so  that  the  teeth  are  supported  by  the  inner  plate  and  can 
be  kept  in  situ;" hi\t  when  the  entire  socket  is  involved,  the  teeth  are  rendered 
loose  and  useless,  and  are  better  away,  since  they  only  plug  the  openings 
throucrh  wdiich  the  discharo;e  would  find  its  way  out.  It  is  very  undesirable 
to  attempt  removal  of  sequestra  until  they  are  completely  loosened,  since  by 
doing  so  damao;e  may  be  inflicted  on  the  surrounding  parts,  and  the  process 
of  repair  be  interfered  w^ith;  and  this  is  especially  the  case  witji  children  in 
whom  the  second  teeth  are  still  undeveloped.  It  is  impossible  to  lay  down 
any  rules  for  the  period  of  separation,  which  must  depend  upon  the  extent 
and  position  of  the  sequestrum,  and  the  strength  of  the  patient;  but  ordinarily, 
from  six  weeks  to  three  months  must  elapse  before  lai^ge  sequestra  can  be 
safely  extracted. 

By  exanthematous  necrosis  (Salter),  is  meant  the  necrosis  occurring  m  young 
children,  for  the  most  part  after  attacks  of  the  specific  fevers,  especially 
scarlet  fever  and  smallpox.  iTecrosis  of  portions  of  the  alveolus  ot  either 
jaw,  and  usually  on  both  sides  symmetrically,  or  even  of  the  whole  thickness 
of  the  lower  jaw,  is  fully  recognized  now^  as  one  of  the  sequelae  ot  these  dis- 
orders ;  and  doubtless  many  of  the  cases  which  were  attributed  to  the  admin- 
istration of  calomel,  in  former  days,  were  really  due  solely  to  the  action  ot 


922 


INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAAVS,  ETC. 


the  specific  poison.  The  course  and  treatment  of  these  cases  ditfer  in  no 
respect  from  those  of  ordinary  necrosis. 

The  action  of  the  fumes  of  phosphorus  in  producing  necrosis  of  the  jaws  in 
persons  employed  in  lucifer-match  making,  has  now  been  recognized  'for  up- 
wards of  forty  years,  Lorinser  being  the  earliest  writer  upon  the  subject  in 
Germany.  The  work  of  Yon  Bibra  and  Geist,  of  Erlan2:en  (1847),  and  the 
Eeport  to  the  Privy  Council,  by  Dr.  Bristowe  (1863),  give  the  best  accounts  of 
the  disease,  which  is  now^  becoming  rare,  owing  to  the  precautions  taken  in 
the  manufacture  of  lucifers. 

It  was  found  that,  as  long  as  workers  among  phosphorus  had  perfectly 
sound  teeth,  their  health  remained  unaffected  ;  but  that  as  soon  as  the  teeth 
became  carious,  or  were  from  any  cause  extracted,  the  fumes  of  phosphorus 
found  their  way  to  the  periosteum  of  the  jaws,  and  excited  periostitis  with 
rapid  necrosis.  The  symptoms  were  severe,  the  swelling  of  the  jaws  and  tissues 
of  the  face  being  extreme,  and  the  discharge  of  purulent  fluid  from  the  mouth 
being  constant  and  in  large  quantities.  The  general  health  became  second- 
arily affected,  the  patient  being  worn  out  with  pain  and  inability  to  take  solid 
food,  and  in  very  severe  cases  being  liable  to  gangrene  of  the  gums  and 
cheeks.  All  these  discomforts  have  been  put  an  end  to  by  insisting  upon 
cleanliness  in  the  use  of  the  phosphorus,  by  the  careful  examination  of  the 
mouths  of  the  workers,  but  most  especially  by  the  employment  of  the  amoi;- 
phous  phosphorus  in  the  manufacture  of  lucifer-match es. "  ' 

The  remarkable  point  about  phosphorus  necrosis  is  the  peculiar  deposit  of 
pumice-like  bone  which  takes  place  upon  the  sequestra.  This  is  doubtless 
derived  from  the  periosteum,  although  so  closely  adherent  to  the  sequestrum 
as  to  be  invariably  brought  away  wdth  it ;  and  though' resembling  true  bone 
in  some  particulars,  it  is  of  a  decidedly  lower  development.  A  form  of  bone 
closely  resembling  this  pumice-like  deposit  has,  however,  been  noticed  in 
cases  in  which  no  phosphorus  was  involved,  and  it  would  appear  that  in  some 
instances,  possibly  of  rheumatic  origin,  the  deposit  of  new  bone  partakes  of 
this  character.  Whenever  it  does,  it  can  in  no  w^ay  tend  to  the  repair  of  the 
necrosis,  for  the  deposit  is  always  firmly  adherent  to  the  sequestrum,  and 
must  be  removed  with  it. 

Besides  phosphorus  necrosis,  mercurial  necrosis  was  once  common,  not  only 
as  a  consequence  of  the  excessive  administration  of  mercury  for  antisyphilitic 
purposes,  but  as  a  result  of  the  destructive  ptyalism  produced  by  the  fumes  of 
liquid  mercury,  as  formerly  employed  in  the  manufacture  of  looking-glasses. 
"When  glass  plates  were  converted  into  mirrors  by  sliding  and  compressing 
them  on  to  sheets  of  tinfoil  covered  with  pure  quicksilver,  the  men  em- 
ployed ^yere  liable  to  have  their  teeth  drop  out,  and  frequently  lost  portions^ 
of  their  jaws,  their  lives  being  notoriously  shortened.  Since  the  introduction  ' 
of  a  chemical  process  by  which  the  mercury  is  deposited  on  the  glass,  these 
cases  of  induced  necrosis  have  become  almost  unknown. 

In  ordinary  cases  of  necrosis  of  the  upper  jaw,  no  reproduction  of  bone 
takes  place,  the  gap  left  in  adults  being  permanent,  though  in  children,  the 
subjects^  of  exanthematous  necrosis,  the  granulation-tissue  is  slowly  con- 
verted into  fibrous  tissue,  which  does  not,  as  a  rule,  ossify.  In  the  lower 
jaw,  abundant  new  bone  is  produced  by  the  periosteum,  and,  for  a  time  at  least, 
most  extensive  losses  are  repaired.  The  museum  of  the  Bellevue  Hospital, 
Xew  York,  contains  a  remarl^ble  illustration  of  this  in  a  large  phosphorus 
sequestrum,  extracted  by  the  late  Dr.  J.  R.  Wood  from  a  girl  who  survived 
three  years,  and  in  whom  reproduction  of  a  semicircle  of  new  bone,  about 
five-eighths  of  an  inch  broad,  with  all  the  epiphyses,  took  place  (Erichsen). 
It  is  certain,  however,  that,  in  the  course  of  years,  a  great,  if  not  complete,  reab- 
sorption  of  the  new  bone  thus  formed  takes  place,lhe  patient  being  left  ulti- 


DISEASES  OF  THE  JAWS. 


923 


matelv  with  very  little,  if  any,  support  for  artificial  teeth.  Salter  lias  sug~ 
o-ested  that  the  early  application  of  artificial  teeth  would  tend  by  use  to 
strengthen  and  maintain  the  permanence  of  the  new  bone ;  but  there  are  no 
facts  to  support  this  view. 

Hyperostosis  of  Jaws. — Under  the  name  hyperostosis,  may  be  conveniently 
2;rouped  together  a  number  of  cases  in  which  general  enlargement  ot  the 
maxillary  bones  occurs,  without  any  distinct  tumor  w^hich  could  be  properly 
placed  among  the  osteomata.  Enlargement  of  the  angles  of  the  lower  jaw, 
quite  unconnected  with  tlie  development  of  the  teeth,  and  giving  a  peculiarly 
broad  appearance  to  the  face,  occurs  in  otherw^ise  healthy  subjects  of  about 
twenty,  and  these  enlargements  appear  to  remain  stationary.  In  true  hyperos- 
tosis, however,  there  are  large  bosses  of  bone,  often  symmetrical,  thrown  out  by 
the  bones  of  the  face  and  cranium,  w^hich  slowly  but  steadily  increase  in  size, 
producing  hideous  deformity,  and  ultimately  causing  the  death  of  the  patient. 
Howship,  Cooper,  and  Bickersteth  have  recorded  remarkable  instances  of  this 
affection,  which  appears  to  be  unconnected  with  syphilis,  and  to  be  unaffected 
by  medicines.  Cases  in  which  the  disease  is  unilateral,  may  fairly  be  sub- 
mitted to  operative  proceeding,  and  I  have  twice  relieved  patients  from 
considerable  deformity  by  sawing  or  gouging  away  a  portion  of  the  pro- 
jecting bone  without  any  external  incision.  In  one  case,  that  of  a  lady  aged 
thirty-nine,  the  enlargement  of  the  right  upper  jaw  was  attributed  to  a  blow 
on  the  cheek;  in  the  other,  that  of  a  man  aged  forty-six,  the  enlargement  in 
the  same  situation  came  on  apparently  without  cause.  Sir  James  Paget  has 
recorded^  some  cases  of  osteitis  deformans^  affecting  many  of  the  bones  of  the 
body,  including  the  skull,  which  closely  resembled  in  some  particulars  the  cases 
recorded  by  other  surgeons  as  hyperostosis;  but  in  these,  as  also  in  cases  recorded 
by  Dr.  Cayley  and  Dr.  Goodhart,^  cancer  of  some  sort  was  present  in  addition. 
This  would  appear  to  place  these  cases  of  general  osteitis  deformans  in  a  dif- 
ferent catea;ory  from  those  in  which  the  disease  is  confined  to  the  bones  of  the 
skull  or  face,  and  in  which,  as  far  as  is  known,  no  cancer  has  been  found. 

OdontOxMA,  or  tooth-tumor,  is  the  name  given  by  Broca  to  the  group  of  cases 
in  which  the  tumor  consists  of  tooth-elements  more  or  less  hypertrophied. 
The  majority  of  these  are  outgrowths  from  the  pulp  of  well-formed  teeth,  or 
at  least  have  their  connection  with  the  teeth  well  marked,  and  may  therefore 
be  more  properly  considered  in  the  pages  devoted  to  dental  surgery There 
is  one  form  of  odontoma,  however,  which  is  strictly  surgical,  since  it  is  apt  to 
give  rise  to  serious  mistakes  in  the  diagnosis  and  treatment  of  one  form  of 
tumor  of  the  jaw.  This  depends  upon  some  modification  of  the  germs  of  one 
or  more  of  the  molar  teeth  of  the  lower  jaw,  before  the  development  of  the 
cap  of  dentine,  leading  to  the  formation  of  an  irregular  mass  of  dental  tissues 
in  no  way  resembling  a  tooth  in  shape.  These  cases  are  very  rare,  and  occur 
only  in  the  lower  jaw.  The  symptoms  are  those  of  a  dense  tumor  expanding 
the  bone,  in  which  there  is  no  paiuy  unless  the  mass  should  mterfere  with  the 
development  of  the  w^isdom-tooth,  or  be  mistaken  for  a  misplaced  tooth  or  a 
sequestrum,  wdien  acute  inflammation  may  be  excited  in  the  jaw  itself  by  inef- 
fectual attempts  at  removal.  Very  eminent  surgeons  have  been  misled  by 
these  cases,  and  have  unnecessarily  sacrificed  portions  of  the  lower  jaw%  when, 
as  experience  has  showm,  enucleation  of  the  growth  could  invariably  have 
been  undertaken  Avith  success.  I  have  recently  had  under  my  care  a  case  of 
this  kind,  in  which  persistent  efforts  to  remove  what  w^as  supposed  to  be  an  im- 


•  Medico-Chirurgical  Transactions,  vol.  Ix. 

2  Pathological  Society's  Transactions,  vol.  xxix. 


INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 


pacted  tooth  had  given  rise  to  so  much  inflammation  about  the  jaw  and  gums, 
that,  when  1  was  tirst  consulted,  I  believed  the  patient  to  be  suffering  from  a 
rapidly  growing  tumor  of  the  interior  of  the  jaw,  and  recommended  removal 
of  a  portion  of  the  bone.  Fortunately,  on  the  subsidence  of  the  inflammation 
the  case  more  resembled  one  of  necrosis,  and,  on  attempting  to  search  for  and 
remove  a  sequestrum,  I  was  enabled  to  enucleate  an  odontoma  measuring  one 
and  one-half  inches  by  one  and  one-quarter,  and  weighing  three  hundred  and 
tifteen  grains.^  The  tumor  consisted  of  dental  tissues  irregularly  arranged ,  and 
represented  one  or  two  molar  teeth. 

Displacement  of  otherwise  healthy  and  well-formed  teeth  may  give  rise  to 
enlargementof  either  jaw,  and  even  supernumerary  teeth  have  been  known  to 
form  distinct  tumors  connected  with  the  maxillary  bones.  Such  cases  must 
necessarily  be  very  difficult  of  diagnosis,  and  are  best  treated  by  exploration 
before  any  serious  mutilation  is  undertaken. 

Cysts  op  the  Jaws.— The  developments  of  cysts  in  connection  with  uncut 
teeth  is  a  subject  of  great  practical  importance  for  the  surgeon,  since  mistakes 
m  the  diagnosis  and  treatment  of  these  cases  are  far  from  rare.  Bentigerous 
cysts  may  occur  in  either  jaw,  a  tumor  heing  gradually  formed,  the  growth 
of  which  is  slow  and  for  the  most  part  painless.  A  careful  examination  of 
the  neighboring  teeth  will  be  the  best  guide  to  a  correct  diagnosis,  for,  if  a 
tooth  be  absent,  or,  as  sometimes  happens,  if  a  temporary  tooth  occupy  the 
position  of  a  permanent  one,  the  tumor  in  all  probability  is  a  dentigerous 
cyst,  and  no  mutilating  operation  should  be  undertaken  without  first  opening 
up  the  tumor  to  discover  its  nature. 

Dentigerous  cysts  arise  in  connection  with  teeth  which  from  some  cause  have 
remained  within  the  jaw,  and  have  undergone  a  certain  amount  of  irritation. 
They  are  most  commonly  connected  with  the  permanent  teeth,  though  I  have 
met  with  a  cyst  in  a  boy  of  four,  in  whom  a  temporary  canine  tooth  was 
wanting,  and  on  cutting  into  the  cyst  I  extracted  seven  small,  irregular 
nodules  of  dentine  and  enamel.  Frequently  the  tooth  in  fault  is  inverted, 
but  often  there  is  nothing  to  explain  the  formation  of  the  cyst,  which  is 
apparently  due  to  the  increase  in  quantity  of  the  small  amount  of  fluid 
ordinarily  found  in  the  tooth-sac  after  the  completion  of  the  development  of 
the  enamel.  The  cyst-wall  is  usually  too  dense  to  give  rise  to  the  cracklino- 
so  characteristic  of  the  presence  of  fluid  within,  and  is  lined  by  a  thick, 
vascular  membrane.  Usually  the  tooth  projects  through  this  membrane,  but 
I  have  met  with  a  case  in  w^hich  a  large  cyst  of  the  lower  jaw^  was  carefully 
searched  in  vain  for  a  tooth,  which  however  made  its  appearance  some  weeks 
after,  when  the  m^embrane  had  been  to  a  great  extent  destroyed  by  suppuration. 

Dentigerous  cysts  have  been  mistaken  for  solid  growths  on  many  occasions, 
one  of  the  most  remarkable  specimens  of  the  kind  being  one  side  of  the  lower 
jaw,  removed  in  error  from  a  girl  of  thirteen  by  the  late  Mr.  Fearn,  and  now 
in  the  Museum  of  the  Royal  College  of  Surgeons  of  England.  Here  the  two 
plates  of  the^  lower  jaw  are  expanded  from  the  angle  on  the  left  to  beyond 
the  symphysis  on  the  right  side,  forming  a  bony  cyst,  the  cavity  of  which  is 
lined  with  a  thick,  vascular  membrane  through  which  a  well-formed,  perma- 
nent canine  tooth  projects. 

The  treatment  of  these  cases  of  dentigerous  cyst  is  sufficiently  simple 
when  once  a  diagnosis  has  been  made  by  an  exploratory  puncture.  The 
removal  of  a  portion  of  the  cyst-wall,  so  as  to  allow  of  a  search  for  and  the 
removal  of  the  hidden  tooth,  is  all  that  is  necessary,  the  cyst  shrinking  down 
as  soon  as  a  free  vent  for  the  contained  fluid  is  secured.    Occasionally  the 


Transactions  of  Clinical  Society,  1882. 


DISEASES  OF  THE  JAWS. 


925 


contents  of  these  cysts  have  suppurated  before  being  opened,  and  m  all  cases 
care  should  be  taken  to  use  antiseptic  lotions,  and  to  insure  cleanhness  by 
syriiii^ing.  Cysts  in  connection  with  fully  developed  teeth  undoubtedly 
occurt  although  possibly  some  of  the  so-called  cysts  are  nothing  more  than 
abscess-sacs,  which  follow  the  fangs  to  which  they  are  attached  when  these  are 
extracted.  The  only  post-mortem  examination  of  such  a  case  is  one  recorded 
by  Fischer,  of  Ulm,  who,  after  removing  the  facial  wall  of  the  antrum,  found 
a  cyst  connected  with  the  apex  of  the  last  molar  tooth,  which  tilled  the  whole 

cavity.  . 

But  cysts  of  the  upper  jaw  are  by  no  means  uncommon  in  wliicii  no 
counection  with  the  teeth  can  be  made  out,  and  wdiich  certainly  do  not  fill 
or  in  any  way  occupy  the  antrum.  In  fact,  it  may  be  doubted  whether  the 
old  term  hydrops  antri  is  not  altogether  a  misnomer,  the  cases  which 
have  hitherto  been  grouped  together  under  that  name  being  either  cysts  of 
the  wall  of  the  antrum,  or  cysts  altogether  outside  the  antrum,  which  push  in  its 
wall  as  they  develop.  The  history  of  these  cases  is  one  of  gradual,  painless 
dilatation  of  some  part  of  the  upper  jaw,  usually  close  above  the  alveolus, 
the  bony  wall  becoming  so  thin  as  to  crackle  like  parchment,  or  eventually 
becoming  simply  membranous,  in  which  case  a  characteristic,  bluish  ap})ear- 
ance  is  seen  on  lifting  the  lip,  and  fluctuation  can  be  readily  perceived.  On 
incising  such  a  cyst,"a  quantity  of  dark-colored  fluid  of  varying  consistency 
escapes,  and  the  linger  passes  into  a  smooth  cavity  not  perforated  by  the  tangs 
of  teeth,  and  quite  outside  the  antrum.  By  cutting  away  a  portion  of  the 
cyst-wall,  so  as  to  insure  free  drainage,  the  cure  of  the  cyst  is  gradually 
brought  about,  but  very  slowly.  The  same  form  of  cyst  occurs,  but  less 
frequ^entlv,  I  think,  in  the  lower  jaw. 

In  the  earlier  stage  of  the  complaint,  when  the  jaw  is  distended,  but  when 
absorption  is  not  so  far  advanced  as  to  make  the  nature  of  the  case  clear,  a 
puncture  with  a  trocar  will  probably  evacuate  cystic  fluid,  often  containing 
cholesterine,  and  diftering  entirely  from  the  mucous  secretion  of  the  lining 
membrane  of  the  antrum.  A  remarkable  specimen  in  the  King's  College 
Museum,  figured  in  Fergusson's  Practical  Surgery,  shows  complete  absorption 
of  the  front  wall  of  the  antrum,  with  great  distension  of  the  cavity,  which  does 
not  communicate  with  the  nose ;  but  "it  is  impossible  to  tell  whether  this  was 
originally  a  case  of  empyema,  or  one  of  so-called  hydrops  antri. 

Adams,  Giraldes,  and  Luschka  have  shown  that  both  single  and  multiple 
cysts  develop  occasionally  from  the  wall  of  the  antrum  and  project  into  the 
cavity,  and  that  polypoid  growths  form  in  the  same  situation.  A  recent 
case  recorded  by  Sir  James  Paget,^  supplies  a  symptom  of  such  polypoid 
growths  hitherto  unnoticed,  viz.,  the  constant  flow,  from  the  nostril  of  the 
aftected  side,  of  clear  watery  fluid  in  considerable  quantity.  The  patient,  a 
lady,  aged  forty-nine,  suftered  for  nearly  two  years  from  this  inconvenience, 
and  wal  then  relieved,  and  ultimately  cured,  by  the  use  of  ^  sulphate  of  zinc, 
locally  and  internally,  as  recommended  by  Brodie  in  a  similar  case.  The 
patient  dying  from  causes  unconnected  with  the  antrum,  its  "floor  was  found 
to  be  covered  with  two  broad-based,  convex,  polypoid  growths,  deep,  clear, 
yellow,  with  the  fluid  inflltrated  in  their  tender  tissue.  They  looked  like 
very  thin- walled  cysts,  but  were  formed  of  very  fine  membranous  or  filamentous 
tissue  infiltrated  with  serum." 

Cysts  occur  in  the  lower  as  in  the  upper  jaw,  and  may  be  single  or  mul- 
tiple. These  cysts  probably  originate  in  the  cancelli  of  the  bone,  and  are 
in  many  cases  due  to  the  irritation  caused  by  neighboring  teeth  ;  a  cancel- 
lus,  being  filled  with  fluid,  expands,  and  produces  gradual  absorption  and 

I  Clinical  Society's  Transactions.    1879.  ' 


926 


INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 


.  obliteration  of  neighboring  cancelli,  until  a  cyst  of  considerable  size  is  pro- 
duced. One  of  the  largest  known  is  in  the  Museum  of  St.  George's  Hospital ; 
it  is  figured  in  Holmes's  System  of  Surgery.  It  extends  from  the  symphysis 
to  the  condyle  on  the  right  side,  and  had  existed  for  eighteen  years.  The 
multilocular  cysts  of  the  lower  jaw  appear  to  be  more  closely  connected  with 
the  teeth  than  the  single  cysts,  since  in  many  cases  the  extraction  of  teeth  or 
stumps  gives  exit  to  a  quantity  of  glairy  discharge.  Distension  and  absorp- 
tion of  the  alveoli  go  on  as  the  cysts  increase  in  size,  so  that  the  walls  at 
length  become  membranous,  and  the  macerated  bone  shows  great  gaps  in  its 
outline.  One  remarkable  clinical  feature  in  these  cases  is  the  length  of  time 
over  which  they  extend  without  materially  affecting  thejiealth  of  the  patient, 
except  by  their  size  and  the  consequent  inconvenience  produced.  I  have 
recently  put  on  record^  the  history  of  a  cystic  tumor  of  the  low^er  jaw%  extend- 
ing over  thirty  years,  the  patient  having  had  a  portion  of  the  right  side  of  his 
jaw  removed  by  Sir  "Wm.  Fergusson  in  1847,  and  having  remained  in  good 
health  for  fifteen  years.  He  then  noticed  the  formation  of  a  cyst  in  the 
incisor  region,  w^hich  was  tapped  from  time  to  time  by  Sir  Wm.  Fergusson. 
The  patient  came  under  my  care  in  1877,  when  I  found  cystic  disease  of  the  sym- 
physis and  left  side  of  the  body  of  the  jaw,  extending  up  to  the  molar  teeth. 
I  then  extracted  all  the  remaining  teeth  and  opened  up  the  cysts  freely,  crushing 
in  the  walls  and  removing  some  solid  material  with  the  gouge.  Considerable 
consolidation  followed  this  proceeding,  but  a  year  afterwards  a  fresh  develop- 
ment of  cysts  had  taken  place,  and  required  a  repetition  of  the  operation, 
wdiich  was  on  this  occasion  followed  by  such  good  results  that  early  in  1879 
the  jaw  was  completely  consolidated,  and  the  patient  able  to  wear  artificial 
teeth.  Late  in  the  same  year,  a  rapidly  growing,  round-celled  sarcoma 
developed  in  the  jaw,  and  w^as  removed,  but  similar  tumors  developed  in 
the  humerus  and  pelvis,  and  the  patiently  gradually  sank  in  1880. 

The  liability  of  multilox^ular  cysts  of  the  lower  jaw  to  develop  eventually 
solid  tumors  of  an  epithelial  type,  has  been  recently  illustrated  in  my  own 
practice  in  another  case ;  and  also  in  a  case  of  so-called  cystic  sarcoma,  I 
have  seen,  eleven  years  after,  a  recurrence  in  the  skin  of  an  epithelial  cancer. 
These  facts  have  led  me  to  accept  the  views  founded  upon  a  microscopical 
examination,  by  Mr.  Frederick  Eve,  of  tumors  removed  by  myself  and  others, 
in  the  Museum  of  the  Royal  College  of  Surgeons,  w^hich  views  are  given  at 
length  in  a  lecture  delivered  at  the  College  in  1881.^  Mr.  Eve  maintains 
that  cases  of  multilocular  cyst  and  of  cystic  sarcoma  should  be  grouped 
together  as  examples  of  epithelioma ;  and  if  that  be  so,  there  can  be  no  ques- 
tion that  complete  removal  of  the  afiected  portion  of  jaw  should  be  promptly 
undertaken,  if  any  solid  growth  is  found  in  connection  with  the  cysts. 

Mason  Warren  and  Butcher  have  shown  that  by  evacuating  the  contents 
of  the  cysts  from  within  the  mouth,  and  crushing  in  the  thin  walls  wdth  the 
fingers,  a  great  amount  of  consolidation  can  be  brought  about,  and,  if  the 
thick  lower  border  of  the  jaw  be  unaffected,  as  it  usually  is,  a  very  firm  basis 
of  support  for  artificial  teeth  may  thus  be  obtained.  The  operation  may 
bear  repetition  more  than  once  in  the  early  stage  of  the  cystic  disease,  but 
is  certainly  unsafe  as  soon  as  the  development  of  an  epithelial  tumor  begins  to 
show  itself,  when  more  radical  measures  must  be  adopted. 

'  British  Medical  Journal,  May  22,  1880. 
«  Ibid.,  January,  1882. 


TUMORS  OF  THE  JAWS. 


927 


Tumors  of  the  Jaws. 

The  progress  of  pathological  investigation  has,  of  late  years,  considerably 
modified  the  views  held  by  surgeons  as  to  the  nature  of  many  of  the  tumors 
found  in  both  the  upper  and  lower  jaws.  Modern  methods  of  investigation  have 
thrown  doubt  upon  those  formerly  employed,  and  hence  but  little  confidence 
can  be  placed  in  many  of  the  earlier-recorded  microsco[)ic  appearances  of  maxil- 
lary tumors.  Fairly  reported  clinical  histories  nmst  always  be  of  value,  but 
in  the  lio;ht  of  modern  pathology  it  is  impossible  in  many  cases  to  reconcile  the 
clinical  history  with  the  pathological  interpretation.  In  the  following  pages, 
an  attempt  will  be  made  to  classify  tumors  of  the  jaw^s  in  accordance  with 
modern  histoloi^y  ;  and  for  assistance  in.  this  endeavor  I  am' indebted  to  Mr. 
Kushton  Parker,  of  Liverpool,  and  to  Mr.  Eve,  Curator  of  the  Museum  of 
the  Royal  College  of  Surgeons  of  England. 

Among  non-malignant  tumors^  or  tumors  composed  of  one  of  the  modifications 
of  fully-developed  connective  tissue  (Erichsen),  w^e  may  recognize  fibroma, 
enchondroma,  and  osteoma. 

Fibroma. — This  is  found  in  the  upper  and  lower  jaw^s  in  the  form  of  the 
hard  fibrous  and  the  softer  fibro-cellular  tumor.  According  to  Broca,  both 
the  fibrous  and  fibro-cellular  tumor  may  be  of  dental  origin,  forming  one 
variety  of  odontoma,  which  is  found  in  young  persons  only,  and  which  has 
the  peculiarity  of  being  encysted  and  therefore  easily  removed.  I  have  only 
met  with  one  case  which  seemed  to  support  this  view,  in  the  person  of  a  young 
lady  who  had  a  tumor  of  the  upper  jaw,  evidently  due  to  expansion  of  the 
antrum,  the  walls  of  which  crackled  under  pressure.  Believing  the  swelling 
to  be  due  to  fluid,  I  punctured  it,  giving  exit  to  a  small  quantity  of  liquid,  and 
discovered  a  tumor  within.  On  laying  open  the  antrum,  I  w^as  able  to  enu- 
cleate with  the  finger  a  tumor  which  had  very  slight  attachments,  presenting 
all  the  appearances  of  a  fibrous  tumor,  but  microscopically  found  to  be  very 
rich  in  cell  elements  and  therefore  likely  to  recur.  ^Nevertheless,  the  patient 
is  now  in  perfect  health  ten  years  after  the  operation. 

Fibroma  of  the  jaws  closely  resembles  fibroma  in  other  parts  of  the  body, 
and  especially  the  uterus.  It  is  dense  in  structure  and  frequently  lobulated, 
and  on  section  shows  interlacing  bundles  of  fibres.  Two  varieties  of  origin 
are  found  :  the  periosteal,  springing  generally  from  the  alveolus,  and  indistin- 
guishable except  by  its  size  from  epulis ;  and  the  endosteal,  which  springs 
from  the  interior  of  the  bone,  and  in  the  upper  jaw  generally  makes  its  vvay 
into  the  antrum  and  nasal  cavities,  or,  in  the  lower  jaw,  expands  the  inner 
and  outer  plates  of  compact  bone.  Fibroma  produces  absorption  by  pressure, 
and  may  thus  destroy  a  great  part  of  the  skull ;  it  stretches  the  skin  of  the 
face,  and  may  by  tension  produce  ulceration,  and  thus  cause  an  aperture,  but 
it  never  involves  the  skin,  which  is  always  loose  and  movable  over  the 
tumor.  The  enormous  size  to  which  fibromata  may  grow  without  destrojdng 
the  patient's  life,  is  well  seen  in  some  of  Liston's  and  Fergusson's  cases,  but 
such  tumors  are  rarely  met  with  now^adays.  The  disease  never  gives  rise  to 
secondary  deposits,  and  if  freely  removed,  so  that  all  prolongations  with  the 
Haversian  canals  of  the  neighboring  bone  are  got  rid  of,  does  not  recur. 
Fibroma  of  the  jaw  may  undergo  calcareous  transformation,  as  in  tlie  uterus, 
and  occasionally  the  calcareous  matter  may  become  necrosed  and  cause  sup- 
puration. Suppuration  is  also  found  occasionally  in  connection  w^ith  simple 
fibroma,  but  only  when  it  has  been  punctured  for  diagnostic  purposes,  or  other- 
wise irritated. 


928 


INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 


Fibroma  appears  to  owe  its  origin  in  many  cases  to  the  irritation  of  decayed 
teeth,  which  may  sometimes  be  found  imbedded  in  the  tumor,  or  displaced 
by  it.  No  treatment  less  radical  than  the  removal  of  the  portion  of  bone 
from  the  periosteum  of  which  the  tumor  springs,  can  be  of  avail  in  the 
periosteal  variety  of  fibroma,  but  in  the  form  in  which  the  bone,  and  particu- 
larly the  lower  jaw,  is  expanded  by  a  slow-growing  tumor  within  it,  less  heroic 
measures  may  be  successful.  I  have  already  referred  to  a  case  in  w^hich  I  re- 
moved a  fibroma  from  within  the  antrum  by  enucleation,  with  complete 
success,  and  numerous  museum  specimens  serve  to  show  that  the  low^er  jaw 
is  often  expanded  by  fibrous  tumors  which  are  amenable  to  this  treatment. 
Sir  James  Paget ^  has  strongly  recommended  the  adoption  of  the  practice  of 
enucleating  non-malignant  tumors  of  bone,  in  all  parts  of  the  body,  and  it  is 
one  decidedly  to  be  followed  in  suitable  cases. 

Enchondroma  is  of  less  frequent  occurrence  in  the  jaws  than  fibroma,  and 
like  it  may  be  either  periosteal  or  endosteal.  The  tumor  appears,  ordinarily, 
early  in  life,  springing  from  the  surface  of  either  jaw,  or  from  within  the 
antrum  or  the  interior  of  the  lower  jaw,  and  growls  steadily,  and  more 
rapidly  than  a  fibroma.  It  is  more  tuberous  and  harder  than  a  fibroma, 
and  in  the  case  of  the  upper  jaw  is  apt  to  send  processes  into  the  fissures 
and  cavities  of  the  skull,  thus  giving  rise  to  great  deformity  by  involving 
the  nose  and  orbit.  Many  remarkable  specimens  of  this  kind  are  to  be 
found  in  museums,  the  patient  in  some  cases  having  been  sufiTocated  by  the 
growth  involving  the  mouth  and  pharynx.  And  yet,  in  these  cases,  it  will  be 
seen  that  the  tumor  does  not  invade  the  surrounding  parts  except  by  its  pres- 
sure, and  could  have  been  enucleated.  Enchondroma  has  undoubtedly  a 
greater  tendency  to  recur  locally  than  has  fibroma,  and  it  is  essential  therefore 
in  its  treatment  that  free  removal  should  be  practised.  Mr.  George  Law- 
son^  has  recorded  a  case  of  enchondroma  of  the  lower  jaw  upon  which  Sir  W. 
Eergusson  operated  six  times,  recurrence  taking  place  on  each  occasion,  and 
eventually  leading  to  the  formation  of  a  large  mass  weighing  eighteen  ounces, 
which  Mr.  Lawson  successfully  removed.  I  have  also  recorded^  a  remarkable 
instance  of  repeated  recurrences  of  a  cartilaginous  tumor,  extending  over  five 
and  tw^enty  years ;  the  patient  died  of  erysipelas,  and  no  secondary  deposits 
were  found  in  the  internal  organs.  Cases  of  deposit  in  the  lungs,  which 
have  been  from  time  to  time  recorded  after  the  removal  of  enchondromata^ 
have  been  doubtless  examples  of  "  chondro-sarcoma,"  an  afiiection  which  will 
be  considered  hereafter,  and  which  has  but  recently  been  difl:erentiated  from 
simple  enchondroma. 

Enchondroma  of  the  jaws  may  have  fibrous  tissue  mixed  with  it,  or  may 
in  great  part  be  converted  into  bone;  and  no  doubt  many  of  the  remarkable 
osseous  tumors  of  the  jaws  to  be  found  in  museums,  were  originally  cartilagi- 
nous in  their  nature. 

Osteoma  is  found  in  the  jaws  as  a  cancellous  or  as  an  ivory  tumor.  The 
simplest  form  is  the  condensed  hypertrophy  due  to  the  presence  of  a  misplaced 
tooth,  and  the  fact  that  numerous  serious  operations  have  been  performed  in 
these  cases,  should  make  the  surgeon  especially  careful  as  to  his  diagnosis. 
The  cancellous  osteoma  has  a  covering  of  compact  bone  of  varying  thickness, 
but  sometimes  so  thin  as  to  crackle  ilnder  the  finger.  It  grows  slowly  to  a 
very  large  size,  as  may  be  seen  in  a  remarkable  specimen  in  the  Musee 

'  Medico-Chirurgical  Transactions,  vol.  liv. 

'  Lancet,  June  8,  1878.  3  Injuries  and  Diseases  of  the  Jaws,  p.  244. 


TUMORS  OF  THE  JAWS.  ^^29 

Dupuytren,  at  Paris,  but  when  removed  by  section  of  the  healthy  bone  beyond, 
shows  no  tendency  to  reproduction. 

The  ivory  osteoma  I  have  met  with  both  as  an  outgrowth  from  the  lower 
law  of  a  healthy  woman,  and  as  a  tumor  of  the  upper  jaw  of  which  the  ivory 
Vas  but  a  portion,  the  rest  being  composed  ot  dense  cancellous  bone,  borne 
very  remarkable  cases  of  osteoma  which  are  on  record,  are  doubtless  examples 
of  ossified  enchondroma.  In  these  cases  the  tumor  has  a  tendency  to  become 
loosened  from  its  attachment  to  the  surrounding  parts,  and  either  to  drop 
awav  as  in  Mr.  Hilton's  case,  or  to  be  readily  removed,  as  m  Dr.  Duka  s. 

In  the  treatment  of  these  tumors,  an  exploratory  puncture,  or  trephining 
may  enable  the  tooth  which  is  the  cause  of  the  malady  to  be  extracted,  and 
hence  this  should  never  be  neglected  except  m  the  case  ot  the  ivory  growth. 
This  again  may  be  sawed  otf,  showing  no  tendency  to^  recur,  or  it  may  be 
extracted  from  the  cavity  of  the  antrum,  or  from  the  interior  ot  the  lower 
law  As  a  last  resource  the  upper  jaw,  or  a  portion  of  the  lower  may  be 
removed  with  the  tumor,  but  extensive  mutilations  should  not  be  undertaken 
for  benign  and  slowly  increasing  tumors  if  they  can  be  avoided. 

Pulsating  tumors  of  the  upper  jaw  have  been  occasionally  met^with,  and 
are  mostly  examples  of  vascular  sarcoma.  In  the  Museum  of  University 
Colleo-e  London,  is  a  specimen  of  true  erectile  tumor  of  the  upper  jaw  and 
pterygo-maxillary  fossa,  removed  in  1841  by  Mr.  Liston  from  a  man  aged 
twenty-one,  who  had  suffered  from  frequent  hemorrhages  from  the  growth 
The  tumor  is  everywhere  bounded  by  a  dense  layer  of  fibrous  tissue,  but 

on  section  the  divided  surface  has  a  uniformly  open,  cavernous  structure, 
like  that  of  the  corpus  cavernosum  penis,  the  meshes  of  which  are  nowhere 
occupied  by  a  solid  substance,  and  probably  allowed  of  the  circulation  of 
blood  through  them." 

Cystic  SARCOMA.-Under  the  old  term  "cystic  sarcoma,"  were  included 
Drobably  more  than  one  variety  of  solid  growth  in  which  cysts  were  developed. 
The  presence  of  cysts  was  held  to  mark  the  non-malignant  character  of  the 
disease  and  the  clinical  histories  of  the  recorded  cases  appeared  to  support 
this  view.  The  naked-eye  appearance  of  the  solid  growth  was  that  of  a 
fibrous  or  fibro-cellular  tumor,  and  this  was  considered  to  be  its  nature  until 
within  a  few  years.  In  1871,  Mr.  Wagstaffe^  described  a  tumor  of  this  kind 
as  consistino-  of  a  peculiar  arrangement  of  what  appeared  to  be  acini  or 
cylinders  of'closely-packed  cells,  supported  by  a  fibro-nucleated  matrix  In 
the  same  year,  I  removed  a  large  cystic  sarcoma  involving  the  figlit^^^^e  of 
the  lower  law,  which  presented  many  of  the  appearances  described  by  .Ur. 
Wa-staffe,  and  led  Mr.  Beck  to  describe  the  tumor,  in  the  Catalogue  of  the 
Mu?eum  of  University  College,  as  a  peculiar,  "gland-like  tumor  of  bone 
afi-ectino-  only  the  lower  jaw.  One-half  of  this  tumor  having  been  presented 
to  the  Royal  College  of  Surgeons,  has  recently  undergone  fresh  examination 
bv  Mr  Eve,  the  cuJator,  who^from  his  investigations  upon  it  and  other  similar 
tumors,  has  come  to  the  conclusion  that  they  originate  m  an  ingrowth  from 
the  epithelium  of  the  gum,  and  should  be  classed  among  the  epitheliomata. 
He  would  attribute  the  development  of  cysts  to  degeneration  of  the  epithe- 
lial cells,  and  the  apparent  immunity  from  recurrence  to  the  fact  that^  these 
tumors  are  more  or  less  completely  encased  in  a  shell  of  bone.  I  was  hardly 
prepared  to  accept  this  view  in  its  clinical  aspects  when,  early  m  l»»'^..t^^^ 
patient  from  whom,  in  1871,  I  had  removed  nearly  the  whole  of  the  right 
side  of  the  lower  jaw  for  "  cystic  sarcoma,"  reappeared  with  a  large  ulcer  ot 

'  Pathological  Transactions,  vol.  xxii. 

VOL.  IV. — 59 


930  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

the  cheek,  presenting  all  the  appearance  of  epithelioma.  Upon  removing 
this,  hy  cutting  freely  around  it,  I  found  it  connected  strongly  and  deeply 
with  the  coronoid  process  and  condyle  of  the  lower  jaw,  which  I  had  not 
removed  at  my  former  operation,  thinking  it  unnecessary  to  do  more  than 
go  well  beyond  the  disease.  This  case  then  goes  far  to  confirm  the  view 
that  "cystic  sarcoma"  is  really  epitheliomatous  in  its  origin,  and  that  its 
removal  should  be  as  free  as  in  cases  of  more  fully  recognized  epithelioma. 

But  a  much  wider  question  is  thus  opened  up,  viz.,  whether,  as  Mr.  Eve 
believes,  cases  of  multilocular  cyst  in  the  lower  jaw,  accompanied,  as  thev 
usually  are,  by  more  or  less  solid  growth,  are  also  examples  of  epithelioma 
In  his  Erasmus  Wilson  Lectures  for  1882,  Mr.  Eve  has  fully  discussed  this 
question,  and  certainly  the  fact  recorded  by  myself  on  a  preceding  page,  of  a 
solid  tumor  forming  after  a  thirty  years'  existence  of  cystic  disease,  would  tend 
to  show  that  the  malady  in  question  is  not  as  harmless  in  its  course  as  has 
hitherto  been  supposed.  Still,  the  clinical  history  of  these  cases,  and  also  of 
the  cases  of  ordinary  "  cystic  sarcoma,"  difiers  so  completely  from  that  of  ordi- 
nary epithelioma  as  to  rapidity  of  progress  and  recurrence  after  removal,  that 
further  observation  is  necessary  before  a  decided  opinion  can  be  arrived  at 
on  the  whole  question. 

Sarcomata.— Under  the  term  sarcoma,  modern  pathologists  include  all 
tumors  composed  of  tissue  which  is  either  embryonic,  or  which  is  undero-oing 
one  of  the  primary  modifications  seen  in  the  development  of  adult  connective 
tissue  (Erichsen). 

In  connection  with  the  jaws,  various  forms  of  sarcoma  are  found,  many  of 
which  have  hitherto  been  known  by  other  names;  and  many  recurrent 
growths,  formerly  called  cancers,  come  properly  into  this  class. 

1.  Sjnndle-celled  sarcoyna  is  of  frequent  occurrence  about  the  jaws,  forming 
many  of  the  specimens  formerly  indiscriminately  named  "osteo-sarcoma." 
Under  this  heading  must  be  included  also  the  "recurrent  fibroid"  cases,  re- 
ported by  Mr.  Holt  and  Mr.  Lawson,  in  the  last  of  which  recurrence  took 
place  after  three  operations,  and  led — as  may  be  seen  in  the  specimen,  which 
is  preserved  in  the  museum  of  the  Eoyal  College  of  Surgeons  of  England— 
to  enormous  reproductions  of  the  disease  in  the  maxillary  and  temporal 
regions,* 

The  principal  clinical  features  of  spindle-celled  tumors  of  the  jaw  are 
rapidity  of  growth,  with  invasion  of  surrounding  parts,  but  no  glandular  in- 
filtration, at  least  in  the  earlier  stages.  Free  removal  is  essential,  because 
of  the  tendency  to  cj^eep  along  the  periosteum  beyond  the  defined  tumor, 
which  is  common  in  these  cases;  and  recurrence  is  frequent.  A  remarkable 
feature  in  the  recurrent  growths  is  their  tendency  to  become  softer  with  each 
recurrence,  until  the  patient  dies,  worn  out,  with,  rarely,  secondary  deposits  in 
mternal  organs.  In  1867 1  removed  a  very  large  tumor,  probably  of  this  kind, 
which  in  its  growth  had  destroyed  the  entire  body  of  the  lower  jaw  of  a  man 
aged  32.  The  tumor  is  in  the  Ilunterian  Museum,  and  a  wax  model,  made 
soon  after  its  removal,  is  in  University  College,  London.  It  is  of  an  irregularly 
oval  shape,  measuring  antero-posteriorly  eight  inches,  and  from  side  to  side 
about  five  inches.  A  tumor  had  been  present  ni  the  jaw  for  some  years,  but  had 
latterly  grown  rapidly  under  the  application  of  quack  remedies,  and,  when 
the  patient  came  under  my  notice,  he  was  nearly  starved  from  the  projection 
of  a  great  mass  of  the  growth  into  his  mouth.  The  jaw,  with  the  tumor,  was 
removed  by  disarticulating  on  one  side  and  sawing  through  the  ramus  on  the 
other,  without  any  great  loss  of  blood,  but  the  patient  died  on  the  sixth  day.^ 


Pathological  Transactions,  vol.  xi. 


2  Lancet,  Dec.  21,  1867. 


TUMORS  OF  THE  JAWS. 


This  tumor  has  recently  undergone  a  fresh  examination  by  Mr.  Eve  who 
believes  it  to  be  an  example  of  a  combination  of  sarcoma  with  epithelioma, 
of  which,  as  far  as  is  known,  it  is  a  unique  specimen.  . 

2  Round-celled  sarcoma  (the  encephaloid  sarcoma  ot  Cornil  and  Kanvier, 
and*  others)  is  a  more  vascular  and  softer  growth,  and  hence  has  more  ot  the 
characters  of  a  "malignant"  tumor.  It  grows  very  rapidly  invading  the 
skin  and  forming  fungous  protrusions,  and  leads  to  deposits  in  internal 
oro-ans.  Many  of  the  recorded  cases  of  -  medullary  cancer  of  the  jaw 
beTono;  to  this  class.  In  the  Museum  of  University  College,  London  is  the 
headSf  a  woman,  aged  twenty-four,  who  came  under  my  care  m  1868  with 
an  enormous  development  of  round-celled  sarcoma  in  the  bones  of  the  tace, 
invading  the  orbits  and  cranium.  This  originated  in  a  gro^^;th  on  the  mar- 
orin  of  the  orbit,  which  had  twice  been  removed  by  Sir  W.  Fergusson,  and 
had  again  recurred.  In  a  child  of  live,  who  was  also  under  my  care,  a  large 
tumor  of  the  lower  jaw  had  grown  in  seven  weeks  when  I  removed  it 
with  the  rirfit  side  of  the  lower  jaw.  Recurrence  took  place  in  six  weeks, 
when  I  again  operated,  removing  a  further  portion  ot  jaw,  with  a  fungous 
crrowth  on  the  skin.  Within  three  months  the  disease  again  recurred,  and 
destroyed  the  patient  in  less  than  six  months  after  its  first  appearance.  ^ 

3  Myeloid  sarcoma  has  long  been  recognized  m  relation  with  the  jaws,  in 
which  situation  it  was  originally  described  by  Paget  It  is  found  in  connec- 
tion with  the  alveolus,  forming  the  so-called  myeloid  epulis,  and  also  m  the 
interior  of  the  lower  jaw.  Occurring  in  children  or  young  adults,  tiie  mye- 
loid o-rowth  springs  from  the  interior  of  the  alveolus,  and  protrudes  between 
the  feeth,  which  may  be  displaced.  The  growth  is  softer  than  the  fibrous 
epulis  and  more  vascular,  and  occasionally  presents  characteristic  dark  spots 
beneath  the  mucous  membrane.  Or,  when  developed  deeply  m  the  interior 
of  the  lower  jaw,  it  expands  the  bone  without  forming  an  external  protrusion. 
The  development  of  cysts  is  not  infrequent  in  the  interior  of  the  growtli, 
which  may  pulsate.  A  section  of  the  tumor  shows  the  maroon  color  result- 
ino-  from  hemorrhage  within  the  tissue,  so  common  m  myeloid  growths. 

The  question  of  recurrence  in  connection  with  myeloid  growths  is  a  very 
important  one ;  and  it  may  be  considered  that  after  complete  removal,  recur- 
rence does  not  take  place.  In  1875, 1  removed  a  myeloid  tumor  from  the 
interior  of  the  lower  jaw  of  a  gentleman,  aged  nineteen,  by  free  gouging,  but 
without  dividing  the  jaw.  Recurrence  took  place,  when  I  again  operated 
very  freely,  leaving  nothing  but  the  thick  lower  border  of  the  bone,  and 
since  then  the  patient  has  remained  well.  A  remarkable  case  in  which 
myeloid  tumors  of  both  angles  of  the  lower  jaw  were  present  m  a  boy  ot 
seven,  was  successfully  operated  on  by  me  some  years  ago,  and  1  believe  that 
the  patient  has  remained  well  since.  -,  .  iv/r  ^ 

4  Alveolar  sarcoma  occasionally  affects  the  jaws,  and  in  the  Museum  ot 
the  Royal  College  of  Surgeons  of  England,  will  be  found  a  specimen  ot  the 
kind  "This  form  of  sarcoma  was  called  by  AVedl  a  fibrous  form  ot  cancer 
arisincrfrom  bone,"  and  should  midoubtedly  include  the  cases  hitherto  de- 
scribed as  examples  of  scirrhus  of  bone.  Mr.  Wilkes,  of  Salisbury,  has 
recorded  a  case  of  the  kind  in  a  man  of  fifty,  who  had  a  globular  mass  below 
the  middle  of  the  horizontal  ramus  of  the  jaw,  adherent  to  the  bone,  but 
movable,  and  after  removal  of  one-half  of  the  jaw  the  tumor  was  found  to  be 
inclosed  in  a  thick  fibrous  capsule  connected  with  the  periosteum.  A  simi- 
lar o-rowth  of  the  size  of  a  chestnut,  with  a  cavity  in  the  centre,  was  removed 
by  Mr.  Coates  from  a  man  of  sixty-seven,  and  both  specimens  are  now  m  the 

Hunterian  Museum.  ^,  .  i  a 

5.  Fibrosarcoma  closely  resembles  fibroma  in  external  appearance,  ana 
generally  grows  beneath  the  periosteum.    A  tumor  of  the  upper  jaw  in  the 


932  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

Museum  of  University  College,  London,  is  of  this  nature,  springing  from 
the  antrum  and  projecting  through  its  anterior  wall,  and  also  through  the 
hard  palate. 

6.  Chondrosarcoma,  in  which  spindle-celled  or  round-celled  sarcoma  is 
mixed  with  the  cartilage  which  forms  the  bulk  of  the  tumor,  occurs  in 
both  jaws,  and  frequently  leads  to  secondary  deposits  in  the  lungs.  I  have 
elsewhere^  recorded  the  case  of  a  woman,  aged  forty-four,  from  whom  I 
removed  a  large  piece  of  the  lower  jaw  with  an  enchondromatous  tumor  of 
large  size,  the  patient  being  discharged  from  hospital  twenty-one  days  after^ 
with  the  wound  quite  healed,  and  with  no  signs  of  recurrence.  Eleven  weeks 
after  being  discharged,  she  was  readmitted  with  a  recurrence  of  disease  on 
both  sides  of  the  gap  in  the  lower  jaw,  and  a  second  operation  was  per- 
formed ;  but  it  was  found  impossible  to  remove  the  whole  of  the  growth, 
which  had  spread  into  the  pterygoid  region.  A  large,  fungating  mass  formed 
and  protruded  externally,  and  the  patient  sank  on  the  forty-third  day  after 
the  second  operation.  At  the  autopsy,  the  mass  of  growth  extended  from 
the  zygoma  downwards  for  over  seven  inches,  and  was  from  five  to  six  inches 
in  thickness.  Another  tumor  sprang  from  the  right  segment  of  the  divided 
jaw,  and  the  left  side  of  the  tongue  and  floor  of  the  mouth  were  largely 
invaded.  The  upper  jaw  was  not  involved,  but  only  imbedded  in  the  growth, 
which  had  forced  itself  deeply  among  the  neighboring  parts,  where  the  veins 
were  filled  with  firm  white  clots,  though  no  growth  had  sprung  up  in  connec- 
tion with  their  walls.  The  tumor  on  section  varied  in  color,  being  yellowish- 
white  in  some  parts,  whilst  it  was  red  and  vascular  in  others,  and  mottled 
with  patches  of  extra vasated  blood.  It  weighed  two  pounds  and  three  ounces. 
There  were  two  nodules  of  secondary  growth  in  the  left  lung,  and  three 
larger  ones  in  the  right  lung.  One  of  these  was  distinctly  seen  to  be  lying 
in  the  course  of  a  good-sized  branch  of  the  pulmonary  artery,  whose  walls 
were  expanded  over  it.  It  did  not  completely  block  the  lumen  of  the  vessel, 
and  on  its  surface  was  a  white  fibrous  deposit. 

The  mass  removed  at  the  first  operation  consisted  chiefly  of  <gnchondroma 
with  dim  hyaline  and  fibrous  matrix,  but  interspersed  were  islets  of  round- 
celled  sarcoma.  The  recurrent  masses  were  made  up  chiefly  of  round-celled 
and  spindle-celled  sarcoma,  whilst  scattered  throughout  were  isolated  portions 
of  cartilaginous  tissue  with  fibrous  matrix. 

7.  The  names  osteosarcoma  and  osteoid  chondrosarcoma  imply  the  occur- 
rence of  ossification  in  tumors  containing  sarcomatous  elements,  and  include 
the  cases  hitherto  described  as  "  osteoid  cancer."  A  good  specimen  of  the 
kind  is  preserved  in  the  Hunterian  Museum,  and  is  figured  in  Howship's 
*'  Surgical  Observations."  The  preparation  has  been  macerated,  and  the  part 
which  remains  consists  of  an  oval  mass  of  light,  cancellous  bone,  about  five 
inches  in  its  chief  diameter,  and  very  slightly  connected  with  the  remaining 
bones  of  the  face.  At  its  lowest  part,  it  preserves  somewhat  of  the  form  of 
the  alveolar  border  of  the  upper  jaw ;  and  the  incisor,  canine,  and  bicuspid 
teeth  are  implanted  in  it.  The  frontal  bone  shows  evidence  of  a  secondary 
growth  from  within  it.  The  patient  was  a  woman  of  thirty,  and  had  had 
the  tumor,  which  is  described  as  "  fleshy,"  for  five  years,  dying  from  hemor- 
rhage consequent  upon  extraction  of  a  tooth. 

A  good  example  of  ossifying  sarcoma  in  the  lower  jaw,  has  recently  been 
under  my  care,  in  a  man  of  fifty,  from  whom,  in  May,  1881,  I  removed  a 
portion  of  the  horizontal  ramus  of  the  lower  jaw,  cutting  well  beyond  a 
fleshy  tumor  which  involved  it,  and  which  had  been  growing  some  months. 
A  recurrence  took  place,  and  I  disarticulated  the  jaw  on  the  aflected  side 


'  Lancet,  November  24,  1877. 


TUMORS  OF  THE  JAWS. 


983 


ill  October  of  the  same  year.  Shortly  after,  the  disease  reappeared  on  the 
central  portion  of  the  jaw,  and  I  removed  a  further  portion,  going  beyond 
the  median  line,  in  January,  1882,  but  was  unable  to  remove  the  whole 
of  the  disease,  which  had  by  this  time  extensively  involved  the  soft  tissues 
of  the  cheek.  The  patient  died  exhausted  in  April,  1882.  In  this  case  the 
specimens  showed  ossihcation  taking  place  in  the  sarcomatous  tissue,  and  the 
funo-atino-  mass  which  formed  before  death  would  doubtless  have  developed 
&  complete  skeleton  similar  to  that  in  Ilowship's  case,  had  the  patient's 
strength  held  out  sufficiently  long. 

Carcinoma.— The  only  form  of  carcinoma  aifecting  the  jaws  is  epithelionia, 
which  is  found  in  at  least  two  varieties,  the  squamous  and  the  tubular.  The 
position  of  these  depends  upon  the  nature  of  the  normal  epithelium  of  the 
part :  thus  the  squamous  epithelioma  is  developed  primarily  in  the  mucous 
membrane  of  the  palate  and  gums,  the  normal  epithelium  of  which  is  squa- 
mous ;  whilst  the  tubular  fonn,  Avith  cylindrical  epithelium,  begins  in  the 
antrum  or  nose,  the  epithelium  of  both  of  which  is  columnar.  Both  lornis  of 
epithelioma  have  a  great  tendency  to  invade  surrounding  parts,  especially 
the  bones,  and  hence  the  difficulty  of  completely  extirpating  the  disease, 
except  by  proceedings  of  a  magnitude  which  may  not  be  justifiable  in  the 
weak  condition  of  the  patient.  •    .  v 

Squamous  epithelioma  of  the  palate  and  gums  begins  very  insidiously,  and 
its  nature  is  therefore  often  mistaken  at  first.  Commencing  as  a  small,  rag- 
ged ulcer  on  the  mucous  membrane  of  the  gum,  it  is  often,  and  probably 
correctly,  attributed  to  the  irritation  of  decayed  teeth  or  fangs,  or  to  second- 
ary syphilis,  but  is  regarded  as  of  little  importance,  or  is,  perhaps,  as^gravated 
by  the  application  of  nitrate  of  silver  or  other  irritants.  Ulceration  ot  the 
palate  of  an  epitheliomatous  character  is  more  frequently  attributed  to  ter- 
tiary syphilis,  and  even  large  gaps  in  the  hard  palate,  caused  by  epithelioma, 
are  supposed  to  be  the  result  of  a  broken-down  gumma.  But  epithelioma  of 
the  gums  or  palate  never,  T  believe,  occurs  before  the  age  of  forty,  and  more 
often  nearer  sixty  than  fifty,  whereas  the  secondary  manifestations  of  syphilis 
take  place,  as  a  rule,  earlier  in  life,  and  the  tertiary  symptoms  are  much  less 
urj^ent  than  those  of  epithelioma. 

By  involving  the  subjacent  bone,  necrosis  is  induced  in  the  course  of  an 
epithelioma,  and  here  again  error  may  arise  if  the  presence  of  bare  bone  be 
regarded  as  pathognomonic  of  necrosis,  without  considering  the  cause. 
Loosening  of  the  teeth  is  a  natural  consequence  of  the  invasion  of  the  alveolus, 
and  afibrds  a  fair  criterion  as  to  the  extent  of  the  mischief  in  the  deeper 
parts.  Creeping  up  the  sockets  of  the  teeth  of  the  upper  jaw,  squamous' epi- 
thelioma tends  to  invade  the  antrum  secondarily,  and  without  givino;  rise  to 
any  marked  symptoms  of  antral  disease.  This  form  has  been  described  by 
Reclus^  under  the  title  of  epitheliome  tercbraM  (boring  or  burrowing  epithe- 
lioma), and  Mr.  Butlin^  has  described  a  case  of  the  kind  in  a  man,  aged  sixty- 
two.  I  do  not  agre6  with  that  gentleman,  however,  in  regarding  the  disease 
as  extremely  rare,  tor  I  have  had  at  least  three  cases  recently  under  my  care, 
in  which  the  gums  and  palate  were  primarily  affected,  but  in  which  the 
antrum  was  found  to  be  extensively  involved  when  it  was  opened  up. 

The  treatment  of  squamous  epithelionia  of  the  jaws,  as  of  that  in  other 
parts  of  the  body,  consists  in  prompt  and  free  removal  of  the  affected  part. 
AVhen  the  disease  is  confined  to  the  gum  and  margin  of  the  alveolus,  com- 
paratively mxild  proceedings  may  be  justifiable  in  the  first  instance ;  but  if 
the  disease  has  gone  at  alf  deeply,  removal  of  the  upper,  or  of  a  large  por- 


•  Progres  Medical.  1876. 


8  Pathological  Transactions.  1881. 


934  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

tion  of  the  lower  jaw,  should  be  undertaken  without  hesitation.  Even  then 
it  may  be  impossible  to  clear  away  the  whole  of  the  disease,  which,  as  in 
Mr.  Butlin's  case,  may  "  extend  through  the  lower  wall  of  the  orbit  to  the 
eyes,  into  the  spheno-maxillary  fossa,  and  up  between  the  temporal  and  mas- 
seter  muscles  and  beneath  the  temporal  aponeurosis."  Mr.  Lawson^  has- 
advocated,  after  removal  of  the  jaw,  the  use  of  caustic  paste,  and  the  destruc- 
tion of  the  skin  covering  epitheliomatous  growths  of  the  antrum,  as  being  the 
most  efficient  mode  of  treatment,  and  I  believe  with  good  ground  ;  but  the 
drawback  is  of  course  the  terrible  deformity  resulting,  which  to  many  per- 
sons would  be  worse  than  the  disease. 

The  tubular  form  of  epithelioma  may  originate  in  the  antrum,  or,  commenc- 
ing in  the  nose,  may  secondarily  invade  the  anti^um.  The  growth  is  charac- 
terized by  great  rapidity  of  development,  and  softness,  and  the  surrounding 
structures  are  apt  to  be  rapidly  involved.  Hence  tumors  of  this  class  were 
formerly  considered  as  examples  of  soft  cancer.  When  beginning  on  the 
nasal  mucous  membrane,  the  stoppage  of  the  nostril  is  generally  the  first 
symptom  noticed,  and  possibly  temporary  relief  may  be  obtained  by  the 
removal  of  the  so-called  polypi.  When  the  disease  begins  in  the  antrum,  it 
leads  to  a  rapid  expansion  of  the  cheek,  with  stretching  and  thinning  of  the 
skin,  which  eventually  becomes  involved,  and  ulcerates,  giving  exit  to  a  fetid^ 
watery  discharge,  and  permitting  the  formation  of  a  yellow,  fungous  growth. 
The  nose  and  tlie  orbit  become  secondarily  involved,  and  the  growth  is  apt  to 
•  find  its  way  into  the  several  fossae  of  the  outside  of  the  skull. 

In  the  treatment  of  this  form  of  disease,  the  remarks  already  made  on  the 
treatment  of  squamous  epithelioma  apply  with  double  force.  But  the  ques- 
tion often  arises,  when  it  is  obviously  impossible  to  hope  for  such  a  complete 
removal  as  shall  insure  future  immunity  from  relapse,  whether  any  operation 
may  be  undertaken  with  the  view  of  giving  relief  and  prolonging  life.  I 
have  no^  hesitation  in  recommending  an  operation  undertaken  with  these 
objects,  in  suitable  cases,  because  I  have  found  that  I  have  been  able  to  give 
enormous  relief,  both  bodily  and  mental,  to  patients  with  incurable  tumors  of 
the  jaw,  by  getting  rid  of  the  mass  of  the  disease,  which,  by  its  size  and  un- 
sightly appearance,  was  a  daily  burden ;  and  have  prolonged  life  for  some 
months,  in  comparative  comfort,  by  giving  space  in  which  the  fresh  formation 
could  lodge  itself  without  interfering  with  deglutition  or  respiration,  and 
without  causing  the  sufferer  to  be  an  eyesore  to  himself  as  well  as  to  others. 


Operations  on  the  Jaws. 

In  all  operations  upon  the  jaws,  the  greatest  care  should  be  taken  to  avoid 
extensive  scarring  of  the  face,  and  the  infliction  of  unnecessary  deformity, 
particularly  by  breaking  the  line  of  the  lower  jaw.  Incisions  for  the  relief 
of  inflammation  or  the  evacuation  of  matter,  and  punctures  for  emptying 
cysts  or  the  antrum,  should  invariably  be  made  within  the  mouth.  Extrac- 
tion of  sequestra  may  be  performed  in  most  cases  more  conveniently  through 
the  mouth  than  by  external  incision,  though  the  surgeon  may  occasionally 
avail  himself  of  existing  sinuses.  The  removal  of  epulis  in  all  its  varieties 
can  be  readily  accomplished  through  the  mouth,  if  the  operator  is  provided 
with  proper  bone-forceps  of  various  kinds,  and  even  large  portions  of  the  jaws 
may  thus  be  removed  with  success.  The  late  Mr.  Maunder ,2  on  two  occasions,, 
removed  large  portions  of  the  right  side  of  the  lower  jaw  with  the  surround- 

'  Clinical  Society's  Transactions.  1873. 
2  Med.  Times  and  Gazette,  July,  1874. 


I 


OPERATIONS  ON  THE  JAWS.  935 


ino-  tumor,  without  any  external  incision,  geparatnig  the  soft  parts  with  a 
raspatory,  and  sawing  the  bone  in  front  of  and  behnid  the  tnmor.  The 
principal  difficulty  in  these  operations  was  not  so  much  the  separation  ot  the 
tumor,  as  its  ''delivery"  through  the  mouth,  which  was  slightly  split  in  one 
instance.  Fortunately  the  hemorrhage  in  both  cases  was  slight,  and  the 
patients  did  well,  but  another  surgeon  was  less  fortunate,  and  lost  his  patient 
by  secondary  hemorrhage ;  and  considering  the  close  proximity  ot  the  facial 
artery  and  the  necessary  division  of  the  inferior  dental  artery,  this  is  not  to 
be  wondered  at.  For  my  own  part,  I  do  not  think  that  the  extra  trouble  and 
risk  of  the  proceeding  are  balanced  by  the  absence  of  a  scar,  which  m  the  major- 
ity of  cases  need  not  involve  the  lip,  and,  if  properly  placed,  will  be  nearly  invisi- 
ble afterwards.  The  same  may  be  said  of  the  so-called  "  sub-periosteal  resec- 
tions" of  the  upper  and  lower  jaws.  In  cases  of  necrosis,  it  is  of  course 
advisable  to  preserve  all  the  periosteum,  and  in  extracting  a  sequestrum,  it 
may  be  occasionally  necessary  to  turn  aside  the  soft  parts  with  a  raspat(ny ; 
but  any  systematic  stripping  of  periosteum  from  a  jaw  involved  in  a  tumor, 
is  not  only  impossible  in  most  instances,  but,  if  undertaken,  will  only  leave 
shreds  of  periosteum  with  possibly  some  portions  of  diseased  tissue  attached. 
In  one  case  in  which  I  took  considerable  trouble  to  preserve  the  muco-perios- 
teum  of  the  palate,  when  removing  the  upper  jaw,  the  flap  proved  a  great 
annoyance  to  the  patient  during  convalescence. 

Removal  of  the  Upper  JA^v.— Partial  or  complete  removal  of  the  upper  jaw 
may  be  most  conveniently  performed  as  follows,  the  incisions  being  extended 
as  the  gravity  of  the  case  may  indicate.  A  straight  incision  through  the 
medianline  of  the  upper  lip,  and  prolonged  on  one  side  of  the  columna  nasi 
into  the  nostril  of  the  affected  side,  will  allow  the  tissues  of  the  face  to  be 
readily  dissected  up  from  the  jaw,  so  as  to  expose  completely  the  Iront  wall  ot 
the  antrum.  This  may  then  be  perforated  and  removed  with  bone-forceps, 
so  as  to  permit  of  the  extraction  of  a  tumor  from  within,  or  room  may  thus 
be  found  for  the  removal  of  large  portions  of  the  palate.  _ 

In  a  case  of  more  extensive  disease,  in  addition  to  the  incision  already 
made,  one  should  be  begun  near  the  inner  angle  of  the  orbit,  and  be  earned 
down  by  the  side  of  the  nose  and  around  the  ala  into  the  nostril.  I  his  will 
allow  of  further  reflection  of  the  soft  tissues,  and  more  complete  exposure  of 
the  bone,  so  that  it  would  be  easy  to  cut  away  large  portions  ot  the  jaw  with 
suitable  bone-forceps ;  or  a  small  saw  could  be  readily  earned  transversely 
from  the  nostril  at  any  desirable  level,  so  as  to  preserve  either  the  palatine 

or  orbital  plate.  ,  -,  .   1 1  ^       i  ij- 

For  removal  of  the  entire  upper  jaw,  it  will  be  advisable  to  make  an  addi- 
tional incision  below  the  orbit  from  the  inner  angle  to  the  malar  bone, 
following  the  natural  curve  of  the  skin-markmgs  of  the  part.  J  his  incision 
may  be  prolonged  on  to  the  malar  bone  as  far  as  may  be  necessary,  and  may 
be  met  at  its  extremity  by  another  at  right  angles  to  it  in  very  extensive 
disease  of  that  bone.  The  flap  of  skin  is  now  to  be  reflected  outwards,  and 
this  method  has  the  great  advantage  of  preserving  the  facial  nerve,  and  ot 
dividing  only  small  branches  of  the  facial  artery. 

Division  of  the  bone  will  be  required  at  three  pomts:  (1)  the  palate,  (:^)  the 
nasal  process  of  the  maxilla,  and  (3)  the  malar  bone;  and  these  sections 
may  be  made  with  the  saw  or  bone-forceps,  or  more  conveniently  with  both. 
A  narrow  saw^  with  movable  back,  is  to  be  passed  into  the  nostril,  and  the 
hard  palate  divided  with  the  alveolus,  from  which  a  central  mcisor  tooth 
should  have  been  previously  extracted.  The  saw  should  be  kept  parallel  to  the 
floor  of  the  nostril,  and  there  need  be  no  fear  of  damaging  the  pharynx  with  its 
extremity.    The  movable  back  allows  the  blade  of  the  saw  to  pass  through 


936 


INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 


the  bone  into  the  mouth,  thus  dividing  the  whole  of  the  hard  palate  without 
the  splintering  which  usually  follows  division  with  bone-forceps.  The  soft 
palate  escapes  injury  from  the  saw,  and  any  attempt  to  dissect  off  and  pre- 
serve the  soft  covering  of  the  hard  palate  is  tutile.  The  nasal  process  of  the 
maxilla  may  be  conveniently  notched  or  completely  divided  with  a  small  saw, 
and  the  saw  is  next  to  be  applied  to  the  malar  bone,  parallel  to  and  imme- 
diately in  front  of  the  masseter  muscle.  This  cut  will  then  run  into  the 
spheno-maxillary  fissure,  and  the  prominence  of  the  cheek  will  be  preserved  ; 
but  in  cases  of  very  extensive  involvement  of  the  malar  bone,  it  will  be  neces- 
sary to  remove  the  whole  of  it  by  dividing  the  zygomatic  process,  and  the 
frontal  process  at  its  junction  with  the  frontal  bone. 

Before  dislocating  the  bone,  it  is  well  to  divide  the  soft  palate  transversely, 
close  to  its  attachment  to.  the  hard  palate,  w^hich  can  be  readily  done  from 
the  mouth.  With  a  pair  of  angular  bone-forceps,  the  three  cuts  made  with 
the  saw  should  then  be  thoroughly  cleared,  and  it  is  convenient  to  take  them 
in  the  reverse  order,  viz.,  malar  bone,  nasal  process,  palate.  The  bone-forceps, 
when  dividing  the  palatine  attachments,  may  be  conveniently  used  to  tilt  the 
whole  jaw  forward,  and  the  lion-forceps  should  then  be  employed  to  grasp  it, 
and  forcibly  depress  the  mass,  while  the  scalpel  is  used  to  divide  the  infra- 
orbital nerve  behind  the  bone  so  as  to  prevent  its  being  stretched,  and  also 
any  soft  tissues  which  may  remain  attached  to  the  jaw.  The  hemorrhage, 
which  is  often  sharp  for  the  moment,  is  best  checked  temporarily  by  thrusting 
a  sponge  into  the  opening,  and  this  after  a  few  minutes'  pause  may  be  with- 
drawn, in  order  to  allow  of  the  application  of  the  actual  cautery  at  a  black 
heat,  so  as  to  sear  any  bleeding  vessel.  A  careful  examination  should  be 
made  to  see  that  all  the  diseased  tissue  is  removed,  when  caustic  paste  may 
be  advantageously  applied  to  any  doubtful  parts;  after  which  the  flap  of 
skin  is  to  be  replaced  and  fixed  with  fine  wire  sutures,  and  with  harelip  pins 
for  the  lip,  the  red  margins  of  which  are  best  approximated  by  a  fine  silk 
stitch.  Unless  the  oozing  of  blood  is  so  considerable  as  to  necessitate  plug- 
ging the  wound,  it  is,  I  am  sure,  better  not  to  introduce  any  lint  beneath 
the  cheek,  since  it  only  collects  discharge  and  becomes  very  offensive  in  a 
few  hours,  when  its  withdrawal  is  both  difficult  and  painful.  Thorough 
sponging  with  a  strong  solution  of  chloride  of  zinc  (forty  grains  to  the  ounce), 
and  subsequent  dusting  with  iodoform,  will  keep  the  parts  sweet  for  some 
days,  after  which  free  syringing  with  antiseptic  lotions  is  useful,  and  for  this 
purpose  nothing  answers  better  than  the  continuous  stream  of  the  siphon 
nasal  douche. 

Removal  of^  both  upper  Jaws  has  been  performed  a  few  times,  and  in  very 
severe  operations  of  the  kind  recourse  may  be  had  to  Trendelenburg's  method 
of  performing  tracheotomy  and  plugging  the  trachea  by  an  India-rubber 
tampon  around  the  tracheal  tube.  This  instrument  is  somewhat  unsatis- 
factory, however,  for  if  blown  up  sufficiently  to  really  plug  the  trachea,  it  is 
apt  to  produce  urgent  dyspnoea  by  pressure  "on  the  rings  of  that  tube  ;  and  a 
more  satisfactory  method  will  be  found  to  consist  in  performing  tracheotomy, 
and  then  plugging  the  upper  part  of  the  pharynx  with  a  sponge,  to  which 
a  string  is  attached  for  safety's  sake. 

Dr.  Goodwillie,  of  ^^ew  York,  and  other  surgeons,  have  employed  the 
"  dental  engine"  in  operating  upon  the  upper  jaw,  and  profess  to  have  found 
their  operations  greatly  facilitated  by  the  use  of  this  machine.  There  can  be 
no  question  that  great  rapidity  may  be  gained  in  the  use  of  various  drills 
and  saws  ingeniously  adapted  to  the  engine,  but  experience  is  wanting,  in 
England,  at  least,  in  its  use,  and  the  great  rapidity  of  its  action  would  appear 
to  be  not  unaccompanied  by  danger. 


OPERATIONS  ON  THE  JAWS. 


987 


Removal  of  the  Lower  Jaw.— In  removing  portions  of  the  lower  jaw,  the 
incision  slionkl  as  far  as  possible  be  placed  below  its  border,  so  that  the  cica- 
trix may  be  hidden.    An  incision  from  the  median  line  to  the  angle,  thus 
placed,  will  divide  the  facial  artery  immediately  in  front  of  the  masseter 
muscle,  and  both  ends  should  be  at  once  secured  with  a  ligature.    1  he  tissue 
of  the  face  can  now  be  dissected  up,  and  the  cavity  of  the  mouth  o\mMid  by 
dividino-  the  mucous  membrane  close  to  the  gums,  when  any  part  ot  the  body 
of  the  law  can  be  removed  by  makina;  a  section  with  the  saw  on  each  side 
of  it.    In  making  these  sections,  it  is  better  not  to  complete  one  before  the 
other  is  beonin,  because  of  the  loss  of  resistance  consequent  upon  breaking 
the  contiimity  of  the  bone ;  but  each  cut,  being  carried  nearly  through  the 
bone  with  the  saw,  may  be  conveniently  finished  with  the  bone  forceps 
Should  it  be  necessary  to  prolong  the  incision  beyond  the  median  line,  and 
to  remove  the  symphysis,  care  must  be  taken  to  guard  against  tlie  falling 
back  of  the  ton2:ue  by  having  a  stout  thread  passed  through  it,  upon  whicli 
traction  may  he  made.    The  mylo-hyoid  muscle  and  mucous  membrane 
inside  the  bone  can  then  be  divided,  and  the  piece  removed  but  whenever 
i^ossible  the  alveolus  alone  should  be  divided  and  the  border  of  the  jaw 
preserved.    In  removal  of  one-half  of  the  lower  jaw,  it  will  be  advisable  to 
divide  the  lower  lip  in  the  median  line ;  for  though  it  is  possible  to  perform 
the  operation  without  this,  yet  if  th^  disease  is  at  all  serious,  it  unnecessarily 
complicates  the  operation  to  save  the  lip,  which  reunites  readily  enough. 
The  incision  should  then  be  carried  at  right  angles  to  that  in  the  hp,  along 
the  lower  border  of  the  bone  as  far  as  the  angle,  and  then  upwards  to  near 
the  lobule  of  the  ear.    This  will  necessarily  divide  the  facial  artery,  but  no 
important  branches  of  the  facial  nerve,  unless  prolonged  into  the  parotid 
o-land.   The' tissues  of  the  face  and  the  masseter  being  dissected  up  from  the 
bone  or  tumor,  the  jaw  is  to  be  divided  at  a  convenient  point,  a  tooth  hav- 
ino-  been  previouslv  extracted.  The  scalpel  is  then  to  be  carried  closely  along 
the  inner  surface  of  the  jaw,  to  divide  the  tissues  forming  the  floor  of  the 
mouth,  and  care  must  be  taken  not  to  detach  or  damage  the  sub-lingual 
gland.    The  cut  end  of  the  jaw,  being  grasped  with  the  lion -forceps,  can  now 
be  everted  so  as  to  bring  the  internal  pterygoid  muscle  into  view,  and  this 
must  be  dissected  from  the  bone.    Should  the  disease  be  of  a  non-malignant 
character,  and  not  involve  the  articulation,  the  ramus  of  the  jaw  should  be 
sawn  across  in  preference  to  disarticulating,  and  even  when  the  tumor 
encroaches  very  closely  upon  the  joint,  it  may  be  possible  to  divide  the  neck 
of  the  condyle  and  the  coronoid  process  separately,  with  bone  forceps. 

In  order  to  disarticulate  the  condyle,  the  soft  tissues  should  be  held  out  of 
the  way  with  spatulas,  when  the  jaw,  behig  firmly  grasped  with  the  lion-for- 
ceps,  is  to  be  depressed  so  as  to  bring  the  coronoid  process  forward,  and  to  allow 
division  of  the  insertion  of  the  temporal  muscle.  This  is  sometimes  rendered 
difficult  by  an  unusual  length  of  the  process,  or  by  its  being  jammed  against 
the  malar  bone  by  the  bulk  of  the  tumor.  In  this  case  it  may  be  necessary 
to  cut  off  the  coronoid  process  with  bone  forceps,  or  to  break  it  by  force.  The 
coronoid  process  having  been  cleared,  the  depression  of  the  jaw  from  before 
backw^ards  is  to  be  continued,  in  order  -to  throw  the  condyle  forward ;  but 
o-reat  care  must  be  taken  not  to  rotate  the  jaw  outwards,  lest  the  internal 
maxillary  artery  should  be  stretched  around  the  neck  of  the  bone,  and  be 
either  torn  or  divided,  when  the  hemorrhage  would  be  severe  and  difficult 
to  arrest.  The  condyle  being  made  prominent,  the  knife  is  to  be  carefully 
applied  over  it,  when  the  bone  will  start  forward,  tearing  through  and 
bringing  away  wath  it  a  portion  of  the  external  pterygoid  muscle.  The 
knife  must  not  be  used  to  divide  the  muscular  fibres,  which  bleed  less  it 


938 


INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 


torn,  but  may  be  employed  to  divide  the  inferior  dental  nerve  so  as  to 
save  it  from  bemg  pulled  out  of  the  bony  canal. 

When  from  the  nature  of  the  tumor  the  leverage  of  the  jaw  is  lost  and 
consequently  disarticulation  of  the  condyle  becomes  difficult,  recourse  may 
be  had  with  great  advantage  to  the  broad  spatula  recommended  by  Professor 
(xross  tor  disarticulating  the  condyle  from  the  glenoid  cavity.  In  this  way 
the  bone  may  be  forced  from  its  socket,  and  the  risk  of  hemorrha2:e  from  the 
internal  maxillary  artery  be  completely  avoided. 

Any  bleeding  vessels  should  be  secured  with- ligatures,  when  the  lip  should 
be  united  with  hai-elip  pins  and  the  wound  with  sutures,  care  beins;  taken 
to  leave  a  dependent  opening  for  the  discharges. 


Closure  of  the  Jaws. 

Inability  to  separate  the  jaws  may  be  temporary  or  permanent  In  the 
former  case,  setting  aside  cases  of  trismus  from  nervous  affections,  the  cause 
is  contraction  of  the  muscles  of  mastication,  especially  the  masseter  due  to 
the  irritation  from  an  uncut  wisdom-tooth.  Owing  to  want  of  room  between 
the  second  molar  and  the  ramus  of  the  jaw,  or  owing  to  some  malposition  of 
the  tooth  Itself,  the  wisdom-tooth  is  unable  to  assume  its  normal  position 
and  by  the  pressure  which  it  exerts  on  the  neighboring  structures  sets  up 
irritation,  which  induces  a  state  of  tonic  spasm  of  the  masseter  and  internal 
pterygoid  muscles. 

The  majority  of  these  cases  occur,  as  might  be  anticipated,  about  the  age- 
ot  twenty,  and  the  diagnosis  is  easy,  unless  very  great  swelling,  and  possibly 
abscess,  should  have  supervened  and  obscured  the  nature  of  ^the  case.  The 
treatment  consists  in  administering  chloroform  thoroughly,  so  as  to  relieve 
the  spasm  somewhat,  and  allow  of  the  introduction  of  a  screw-gag  between 
the  teeth,  in  order  to  separate  the  jaws.  This  must  be  done  slowly  and 
steadily,  so  as  not  to  inflict  injury  upon  the  front  teeth,  and  the  back  of  the 
jaw  may  then  be  reached.  If  the  wisdom-tooth  is  presenting  in  its  normal 
position,  a  free  division  of  the  gum  over  it,  and  removal  of  the  flaps  thus  made 
with  scissors,  will  be  sufficient  treatment,  if  the  patient  will  patiently  bear  a 
little  inconvenience  for  a  time.  But  when  there  is  obviously  not  space  for  the 
wisdom-tooth  to  be  erupted,  room  must  be  made  by  extracting  the  second 
molar,  unless  the  wisdom-tooth  itself  can  be  reached  and  extracted,  which  is 
seldom  the  case.  Occasionally  the  extraction  of  the  upper  wisdom-tooth, 
against  which  the  lower  wisdom-tooth  is  pressing  injuriously,  may  completely 
relieve  the  trouble.  In  whatever  way  room  is  given,  relief  is  sure  to  follow, 
and  m  the  course  of  a  few  hours  the  spasm  of  the  muscle  passes  off'. 

Permanent  closure  of  the  jaws  may  depend  upon  destruction  of  the  temporo* 
maxillary  articulation,  or  more  frequently  upon  the  contraction  of  cicatrices 
in  the  cheek,  following  ulceration  or  sloughins^.  This  latter  condition  is 
frequently  the  result  of  gangrenous  stomatitis^occurring  in  childhood,  in 
which  case  destruction  of  the  whole  thickness  of  the  cheek  not  unfrequently 
takes  place  ;  but  the  same  result  may  follow  an  attack  of  fever,  etc.,  at  any  age. 
When  the  mischief  is  confined  to  the  lining  membrane  of  the  cheek,  the 
soft  parts  become  firmly  adherent  to  the  alveoli  of  both  jaws,  and  a  rigid 
cicatrix  of  fibrous  tissue,  in  which  bone  not  unfrequently  develops,  binds 
the  jaws  firmly  together.  Under  these  circumstances  the  patient  is  often 
nearly  starved,  for  he  can  only  rub  soft  food  between  the  teeth,  or  push  it 
with  the  finger  behind  the  teeth,  on  the  unaftected  side.  In  the  cases  where 
destruction  of  the  cheek  has  taken  place,  although  the  deformity  is  more 


CLOSURE  OF  THE  JAWS. 


939 


unsightly,  the  patient  is  generally  able  to  feed  better,  particularly  if  one  of 
the  molar  teeth  is  wanting.  ,        .  .       .  i  •  .-u  •  ^ 

The  treatment  of  cicatrices  by  simple  division  within  the  mouth,  is  pertectly 
futile  for  although  wedges  may  be  employed  for  a  time  to  keep  the  jaws 
apart'  they  will  certainly  bo  drawn  together  by  the  rigid  contraction  of  heal- 
ing In  order  to  secure  improvement  in  the  patient's  condition,  it  is  necessary 
to  prevent  the  adhesion  of  the  cheek  to  the  alveoli,  and  to  restore  as  far  as 
possible  the  pouch  of  mucous  membrane  between  them.  This  can  only  be 
done  by  adapting  to  the  teeth  metal  plates  or  shie  ds  which  can  be  constantly 
worn  after  free  division  of  the  cicatrices,  and  which,  reaching  well  beyond  the 
sums  can  prevent  adhesion  taking  place  between  the  cheek  and  the  alveoh. 
After  a  lono-  time,  a  formation  of  mucous  membrane  takes  place  m  the  sulcus 
thus  formed,  and  the  plates  may  then  be  dispensed  with  m  the  daytime,  but 
must  be  worn  for  many  months  at  night.  It  is  obvious  tbat  treatment  ot  sucli 
a  protracted  nature  cannot  be  carried  out  in  children,  and  that  the  cooperation 
ot' an  able  mechanical  dentist  is  essential  for  success.  The  method  is  appli- 
cable only  to  cases  in  which  the  whole  thickness  of  the  cheek  is  not  involved  ; 
but  the  extent  of  the  adhesions  is  comparatively  unimportant,  since  the  plates 
can  be  adapted  to  both  sides  of  the  mouth,  as  m  a  case  of  my  own.^ 

In  the  case  of  unilateral  adhesions,  division  ot  the  lower  jaw  m  front  ot 
the  cicatrices,  and  the  formation  of  a  false  joint,  give  very  good  results.  Jis- 
march  removed  a  wedo:e-shaped  piece  of  bone,  so  as  to  secure  fibrous  union 
with  free  mobility,  while  Rizzoli  contented  himself  with  dividing  the  jaw 
from  the  mouth,  and  trusted  to  the  subsequent  movements  to  establish  a 
false  ioint.  I  have  no  experience  of  Rizzoli's  method,  but,  having  t^vlce  per- 
formed Esmarch's  operation,  have  every  reason  to  be  satisfied  with  it  ihe 
operation  is.  a  very  simple  one,  an  incision  along  the  lower  border  ot  the  jaw 
ea^lv  admittinp;  of  the  use  of  a  narrow  saw  for  the  removal  of  a  wedge  ot 
bone,  the  base  of  which  should  be  below.  The  only  point  of  importance  is 
that  the  section  should  be  made  thoroughly  in  front  of  the  cicatrix  in  the 
cheek  for  if  this  is  not  attended  to,  the  operation  will  fail.  The  operation  is 
applicable  mostly  to  cases  in  which  one  side  of  the  mouth  is  aflected,  and 
in  two  or  three  weeks  restores  to  the  patient  a  very  useful,  though  one-sided, 
amount  of  masticatory  power,  with  very  little  suftering  or  annoyance.  One 
side  of  the  iaw  remains  of  course  permanently  useless,  and  there  is  necessarily 
some  deformity  left,  but  the  relief  is  permanent.  A  patient  upon  whom  i 
operated  in  1864,  called  on  me  in  1880,  to  show  how^  satisfactory  the  move- 
ment of  her  jaw  continued.  .    -,    .  1 

Inflammation  of  the  temporo-maxillary  articulation  may  lead  to  coniplete 
anchylosis  of  the  joint,  and  consequent  immobility  of  the  jaws.  Anhritis 
occurs  as  the  result  of  injury,  or  of  constitutional  affection.  In  children  it 
follows  the  exanthemata,  and  is  often  connected  with  suppuration  m-  the 
tympanum.  In  adults,  it  is  of  a  rheumatic  or  gouty,  and  therefore  more 
chronic,  character.  Rheumatoid  arthritis  also  aftects  the  temporo-maxillary 
articulation,  and  leads  to  great  suffering  from  the  painful  movement  of  the 
iaw  In  two  patients  I  have  noticed  the  characteristic  enlargement  ot  the 
condyle  and  neck  of  the  bone,  with  protrusion  of  the  chin  to  the  opposite 
side,  described  by  Robert  Adams  in  his  great  work  on  the  subject.  Ihis 
disease  does  not,  however,  lead  to  the  osseous  anchylosis,  or  synostosis,  which 
is  met  with  in  cases  of  common  arthritis  wnth  suppuration.  ^         .  ,    •  i 

In  acute  inflammation  of  the  joint,  leeching  and  fomentations,  with  timely 
evacuation  of  pus,  would  be  the  appropriate  treatment.  In  the  more  chronic 
forms,  attention  to  the  constitutional  diathesis,  and  the  frequent  application 


1  Injuries  and  Diseases  of  the  Jaws. 


940  INJURIES  AND  DISEASES  OF  THE  MOUTH,  TONGUE,  JAWS,  ETC. 

of  blisters  over  the  joint,  offer  the  best  chance  of  relieving  the  patient,  but 
the  treatment  is  eminently  unsatisfactory.  Dr.  Goodwillie,^  of  New  York, 
has  ingeniously  proposed  to  produce  extension  between  the  two  surfaces  of 
the  temporo-maxillary  articulation  by  fitting  blocks  upon  the  molar  teeth, 
and  by  then  drawing  up  and  fixing  the  chin;  and  he  gives  several  cases  in  which 
a  cure  was  thus  brought  about.  The  anchylosis  resulting  from  articular 
inflammation  may  be  fibrous  or  osseous,  and  the  diagnosis  can  only  be  made 
when  the  patient  is  thoroughly  under  the  effect  of  an  anaesthetic.  Fibrous 
adhesions  may  be  broken  by  forcibly  opening  the  jaws,  but  very  great  sub- 
sequent care  will  be  necessary  to  prevent  reunion,  and  it  may  be  better  to 
perform  Esmarch's  operation  of  division  of  the  bone  in  front  of  the  angle. 
Dr.  Goodwillie^  has  recorded  two  cases  in  which  he  succeeded  in  thus 
breaking  adhesions  with  the  best  results. 

In  ^  cases  of  anchylosis  of  the  temporo-maxillary  joint,  the  operation  of 
excising  the  condyle  of  the  jaw  has  been  performed  in  a  few  instances.  The 
first  removal  of  the  condyle  was  by  Professor  Humphry ,3  of  Cambridge, 
and  was  undertaken  for  chronic  rheumatic  arthritis.  He  exposed  the  con- 
dyle by  a  curved  incision  from  the  side  of  the  orbit,  across  the  zygoma  to  the 
ear,  passing  a  little  above  the  temporo-maxillary  articulation  ;  and  by  a  second 
incision  from  the  termination  of  the  first,  directly  upward  in  front  of  the  ear 
and  across  the  zygoma  again,  avoiding  the  temporal  artery.  The  flap  thus 
made  was  reflected,  and  the  neck  of  the  condyle  cut  through  with  a  narrow 
saw.  Dr.  Bottini,''  in  1872,  communicated  to  the  Royal  Academy  of  Medicine 
at  Turin,  the  case  of  a  lad  of  seventeen,  who  had  fallen  on  his  chin  when  seven 
years  old ;  inability  to  open  the  mouth  gradually  set  in,  so  that  in  a  few 
months  he  was  quite  unable  to  separate  the  jaws.  Bottini  opened  the  mouth 
forcibly  during  ansesthesia,  and  inserted  a  wedge.  This  however  was  so 
troublesome  to  the  patient  that  it  was  removed,  and  resection  was  deter- 
mined on.  An  incision  was  made  on  one  side,  and  the  head  of  the  jaw-bone, 
after  the  periosteum  had  been  separated,  was  removed  with  the  chisel  and 
hammer.  This  had  no  appreciable  effect,  and  it  was  only  after  the  operation 
had  been  repeated  on  the  other  side  that  the  jaw  could  be  freely  moved. 
In  neither  of  these  cases  was  there  true  synostosis,  such  as  may  be  seen  in  a 
specimen  of  a  negro's  head  in  Guy's  Hospital  Museum,  and  such  as  existed  in 
a  case  successfully  treated  by  Dr.  James  Little,^  of  IsTew  York,  in  1873.  The 
patient  was  nineteen  years  of  age,  and  had  some  years  before  suffered  from 
suppuration  of  the  temporo-maxillary  articulation,  leading  to  anchylosis.  Dr. 
Little  made  an  incision  along  the  lower  border  of  the  jaw,  and  turned  up  the 
masseter,  when  the  neck  of  the  condyle  was  seen  to  be  very  much  enlarged, 
and  continuous  with  the  temporal  bone.  A  trephine  half  an  inch  in  dia- 
meter was  then  applied,  and  a  button  of  bone  three-eighths  of  an  inch  in  thick- 
ness was  removed.  The  portion  of  bone  on  each  side  of  this  opening  was 
next  cut  through  with  a  chisel,  and  the  neck  of  the  condyle  cut  away  piece 
by  piece,  so  as  to  leave  no  portion  projecting  from  the  temporal  bone.  The 
result  was  quite  satisfactory. 

A  similar  operation,  but  performed  by  a  different  method,  was  successfully 
undertaken  by  Dr.  Eobert  Abbe,^  of  J^ew  York,  on  a  boy  of  ten  who  had 
suffered  from  otitis  media  and  suppuration  of  the  joint  seven  years  before. 
A  longitudinal  incision  was  made  in  front  of  the  ear,  and  a  transverse  one,  meet- 

1  Archives  of  Medicine,  vol.  v.  June  3,  1881. 

3  Monthly  Review  of  Dental  Surgery,  October,  1875. 

8  Association  Medical  Journal,  1856. 

*  British  Medical  Journal,  August  31,  1872. 

6  Transactions  of  New  York  State  Medical  Society.  1874. 

«  New  York  Medical  Journal,  April,  1880. 


CLOSURE  OF  THE  JAWS. 


941 


ins:  the  upper  end  of  the  first,  was  carried  along  the  lower  border  of  the  zygoma. 
The  parotid  and  the  facial  nerve  were  drawn  down,  and  with  a  periosteal  ele- 
vator the  posterior  fibres  of  the  masseter  were  cleared  away,  and  the  articu- 
lation  exposed.  A  narrow  osteotomy  chisel  was  now  applied  to  the  neck  ot 
the  condyle,  and  carefully  driven  half  through  the  bone,  vyhen  by  torcibly 
openincr  the  mouth  the  bone  was  broken  through.  Ihe  neck  ot  the  condyle 
was  then  carefully  removed  piecemeal,  but  the  condyle  itselt  was  lett  in  situ. 
The  result  was  satisfactory.  Sedillot^  mentions  that,  in  a  case  of  true  anchy- 
losis of  the  temporo-maxillary  articulation,  M.  Grube,  in  1863  carried  a^straight 
chisel  throuo'h  the  mouth  to  the  neck  of  the  jaw,  which  he  broke  by  hammer- 
ino-  Some  months  later  he  divided  the  masseter  subcutaneously,  and  the  cure, 
b>%e  formation  of  a  false  joint,  was  permanent.  In  1879 1  performed  the  same 
operation  in  a  child  of  six,  but  the  results  were  unsatisfactory.  Su^yiiration 
was  set  up,  and  required  an  external  opening,  and  the  movement,  which  was 
free  at  first,  became  as  limited  as  before  the  operation.  It  would  appear, 
therefore,  that  mere  division  of  the  neck  of  the  bone  does  not  offer  such  good 
prospect  of  a  permanent  false  joint  as  removal  of  the  neck  or  the  condyle, 
thoudi  these  operations  are  necessarily  more  severe.  ^ 

Esmarch's  operation,  performed  in  front  of  the  masseter,  is  of  course  as 
applicable  to  cases  of  anchylosis  from  disease  of  the  joint  as  to  cases  ot  cica- 
trix, and  Fischei^  appears  to  have  performed  the  operation  on  both  sides  ot 
the  iaw,  in  a  case  of  bilateral  anchylosis  of  the  temporo-maxillary  aTticulation 
with  very  good  result,  the  patient  obtaining  complete  and  useful  control 
over  the  central,  movable  portion  of  the  jaw. 

I  M6decine  operatoire,  tome  ii.  p.  30. 
a  British  Medical  Journal,  June  1,  1872. 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


BY 

NORMAN  W.  KINGSLEY,  M.D.S.,  D.D.S., 

LATE  PROFESSOK  OF  DENTAL  ART  AND  MECHANISM  IN  THE  NEW  YORK  COLLEGE  OF  DENTISTRY. 


Dentistry,  although  a  specialty  of  surgery,  has  become  almost  a  distinct 
science — distinct  in  the  fact  that  it  may  be  taught  independently,  and  also 
in  the  fact  that  heretofore  many  of  its  most  skilful  practitioners  have  reached 
the  highest  excellence  without  any  knowledge  of  general^  surgery.  Never- 
theless, it  is  a  department  of  the  great  science  and  art  of  medicine,  and  its 
highest  possible  attainments  must  have  the  more  comprehensive  science  for 
their  foundation. 

Its  best  results  have  been  due  so  much  to  the  dexterous  manipulative 
ability  of  its  practitioners,  that  the  general  surgeon  has  regarded  it  as  a 
mechanical  trade,  and  has  ignored  it  in  the  acquirement  of  his  education. 

The  science  of  dentistry  is  medical,  surgical,  and  prothetic.  Dental  thera- 
peutics includes  a  class  of  operations  which  are  not  taught  in  the  medical 
schools,  and  are  not  practised  in  the  offices  of  physicians  and  surgeons,  but 
the  successful  performance  of  which  requires  special  appliances,  special  sur- 
roundings, and  mechanical  and  aesthetic  qualities  of  a  high  order;  hence, 
by  universal  consent,  these  operations  have  been  assigned  to  a  special  class  of 
practitioners,  who,  by  limiting  their  range  of  action,  have  perfected  tnem- 
selves  in  their  chosen  sphere  of  work.  Every  operation  of  oral  surgery 
requires  a  delicacy  and  precision  of  touch  which  is  rarely  found  in  the  prac- 
tice of  general  surgery.  There  is  no  preparatory  training  which  the  general 
surgeon  could  add'to  his  other  necessary  acquirements,  to  perfect  himself  in 
the  dexterous  use  of  instruments,  at  all  comparable  to  a  mastery  of  the 
operations  in  dentistry. 

Surgery  of  the  Deciduous  Teeth. 

Lancing  the  Gums. — Surgical  interference  is  frequently  demanded  even 
before  a  tooth  is  erupted  in  infancy.  Localized  stomatitis  may  be  relieved 
in  many  cases  by  lancing  the  gums,  an  operation,  however,  which  is  not  always 
indicated,  and  which  has  undoubtedly  been  many  times  resorted  to  injudi- 
ciously. If  the  tooth  or  teeth  suspected  to  be  the  cause  of  local  irritation,  as 
well  as  of  constitutional  disturbance,  are  not  far  advanced  and  ready  to  erupt, 
lancing  the  gums  may  do  more  harm  than  good,  the  incision  perhaps  closing 
with  cicatricial  tissue,  w^hich  may  cause  subsequently  greater  disturbance 
than  if  no  incision  had  been  made.  "When  tumefaction  of  the  gum  is 
dependent  on  tooth  eruption,  and  the  child  is  of  healthy  condition,  a  certain 
evidence  is  found  in  the  glistening  character  of  the  swelling,  the  part  imme- 
diately over  the  tooth  or  teeth  looking  stretched  and  feverish.  This  tense 
look  is  nearly  always  present,  and  may,  under  all  circumstances,  be  esteemed 

(943) 


944 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


an  indication  demanding  the  lancet."  Lancing  in  such  cases,  if  properly  per- 
formed, yields  almost  instantaneous  and  complete  relief. 

The  incision  should  be  njade  with  reference  to  the  shape  of  the  tooth  ;  thus, 
for  any  of  the  anterior  teeth,  either  above  or  below,  the  cut  should  be  made 
on  a  line  with  the  cutting  edge  of  the  tooth,  and  deep  enough  to  strike  the 
enamel.  For  the  canine  teeth  and  those  posterior  to  them,  the  crucial  incision 
is  better,  making  the  lines  diagonal  to  the  jaw  rather  than  parallel  or  at 
right  angles  with  it.  Undue  hemorrhage  need  not  be  apprehended.  The  loss 
of  a  little  blood  is  ordinarily  rather  to  be  desired  than  otherwise. 

Extraction  of  Deciduous  Teeth.— The  mere  removal  of  a  temporary  tooth 
when  dentition  is  proceeding  regularly,  and  the  period  has  arrired  for  it  to 
be  shed,  is  an  operation  of  minor  character.  In  normal  dentition,  the  waste  of 
roots  and  surrounding  processes  goes  on  relatively  and  simultaneously  with 
the  advance  of  permanent  successors,  and,  without  interference,  the  temporary 
crown  will  literally  be  shed  from  the  gum  ;  but  abnormal  second  dentition 
is  of  such  frequent  occurrence,  together  with  diseases  which  attack  the  crowns 
and  roots,  that  extraction  in  advance  of  shedding  is  often  demanded. 

If  there  be  no  disease,  such  as  a  painful  pulp  exposed  by  caries,  or  an 
ulceration  or  abscess  following  such  exposure,  it  is  unwise  to  remove  a  tem- 
porary tooth,  unless  its  permanent  successor  is  emerging  from  the  gum  beyond 
the  boundary  line  of  the  dental  arch.  The  normal  order  is  to  follow  and 
succeed  to  the  exact  position  occupied  by  the  temporary  tooth.  The  abnor- 
mal is  an  emergence  from  the  gum,  either  within  or  without  the  arch,  while 
the  temporary  tooth  is  still  in  place.  As  soon  as  such  abnormality  is  dis- 
covered, extraction  of  the  deciduous  tooth  should  be  immediate.  The 
extraction  of  deciduous  teeth  that  have  remained  firm  in  the  jaw  after  the 
period^of  shedding  has  been  reached  without  any  evidence  of  the  emergence 
of  their  successors,  is  not  indicated.  Sometimes  a  permanent  tooth  never 
erupts,  and  the  sacrifice  of  a  deciduous  tooth  which  has  occupied  its  position 
is  an  irrecoverable  loss. 

^  It  is  very  common  for  there  to  be  a  want  of  development  or  increase  in  the 
size  of  the  jaw,  commensurate  with  the  demand  for  more  room  which  the 
growth  of  large  permanent  teeth,  to  occupy  the  place  of  their  small  predeces- 
sors, demands.  The  result  is  an  apparent  necessity  for  removing  tw^o  tempo- 
rary teeth  to  make  room  for  one  permanent  tooth.  This  is  frequently  the 
case  as  the  six  front  teeth  in  either  jaw  are  erupting,  and  whenever  the  difift- 
culty  has  been  met  by  extracting  two  teeth  to  make  room  for  one,  it  has  almost 
inevitably  created  a  crowding  out  of  line,  and  an  irregularity  in  the  perma- 
nent dental  arch.  Only  in  very  rare  and  exceptional  cases  should  such  a 
procedure  be  adopted,  and  it  is  especially  desirable  that  each  of  the  canine 
teeth  should  be  retained  unti  the  certainty  of  the  eruption  of  its  successor 
has  been  assured. 

When  it  becomes  necessary  to  extract  the  deciduous  molars  long  in  ad- 
vance of  their  period  of  shedding,  care  should  be  taken  that  the  alveolar  pro- 
cess be  not  grasped  in  the  forceps,  lest  the  germ  or  partly-developed  crown  of 
the  pernianent  tooth  should  be  included  and  removed,  which  would  be  an  irre- 
parable injury.  The  premature  extraction  of  temporary  teeth  has  been  strenu- 
ously opposed  by  some,  because  it  has  been  believed  that  contraction  or  shrink- 
age of  the  jaw  would  follow ;  but  this  view  has  been  found  to  be  fallacious, 
because  the  maxillae  develop  quite  independently  of  the  teeth.  The  teeth, 
It  will  be  remembered,  grow  upon,  not  out  of,  the  jawbone,  and  the  alveolar 
processes  form  and  increase  about  the  roots  of  the  advancing  teeth.  Alveolar 
processes  grow  up  with  the  teeth,  and  are  absorbed  and  waste  away  when 


SURGERY  OF  THE  PERMANENT  TEETH. 


945 


the  teeth  are  gone.  The  maxillae,  during  the  process,  develop  up  to  the  type 
of  their  inheritance,  irrespective  of  the  changes  in  the  alveolar  processes. 


Surgery  of  the  Permanent  Teeth. 

Extraction  of  Permanent  Teeth.— The  removal  of  a  tooth  is  rarely  a 
difficult  operation,  when  its  anatomy  and  that  of  its  surroundings  are  appre- 
hended;  but  there  is  no  operation  in  dentistry  which  requires  more  tirmness, 
self-control,  and  confidence  in  one's  own  ability.  A  timid,  nervous,  unstable 
hand  will  be  almost  certain  to  do  damage,  sometimes  almost  irreparable. 

The  roots  seldom  penetrate  the  true  maxilla  to  any  extent,  and  the  sur- 
rounding walls  of  alveolar  process  are  so  vascular,  elastic,  or  frail,  that  they 
give  way  more  rapidly  than  might  be  supposed.  Nevertheless,  there  are 
exceptional  cases  which  tax  the  utmost  ingenuity  and  strength  ot  the  operator 
to  manao-e.  The  most  difficult  teeth  to  extract  are  ordinarily  the  cuspidati  of 
either  iaw,  and  the  first  two  molars  of  the  upper  jaw.  The  difficulty  with 
the  canines  is  owins;  to  their  extremely  long  roots,  and  with  the  molars  to 
their  having  three^ roots  each,  which  generally  diverge  from  the  crown  so 
that  the  diameter  of  the  socket  at  the  neck  of  the  tooth  is  less  than  the  ex- 
treme breadth  at  the  apices  of  the  roots.  It  is  indeed  a  wonder,  sometimes 
that  they  ever  come  away  without  tearing  the  alveolar  process  along  with 
them.  The  teeth  which  are  removed  most  readily  are  the  lower  mcisors,  and 
after  them  but  little  difference  is  seen  in  the  extraction  of  the  upper  mcisors 
and  the  bicuspids  of  both  upper  and  lower  jaws.  All  of  these  last  named 
have,  substantially,  but  one  nearly  straight  root,  and  all  are  of  about  the  same 
leno-th.  The  first  two  molars  of  the  lower  jaw,  each  with  two  roots,  are  more 
readily  removed  than  the  corresponding  teeth  of  the  upper  jaw,  while  the 
third  molars  above  and  below  are  taken  out  with  comparatively  little  strength. 

The  propriety  of  the  removal  of  teeth  must  be  determined  entirely  by  the 
judgment  of  the  operator.  In  the  present  advanced  state  of  dental  skill,  the 
absolute  necessity  for  the  extraction  of  a  tooth  ought  to  be  very  rare.  As 
patients  avail  themselves  of  the  benefits  of  dental  science,  so  will  the  extrac- 
tion of  teeth  which  are  firm  in  the  jaw  become  more  and  more  infrequent. 

Experience  has  shown  that  the  simplest  and  best  instrument  for  extraction 
is  the  forceps.  Formerly  the  turnkey  was  the  sole  instrument  employed,  but 
the  principle  of  its  application  is  so  ill-adapted  to  the  end  required,  that  any 
directions  for  its  use  are  unnecessary.  It  is  a  dangerous  instrument  to  use 
in  almost  all  cases,  and  has  been  superseded  by  such  as  are  admirably  adapted 
to  their  purpose.  The  specialist  may  have,  with  some  slight  advantage,  a 
peculiar  forceps  adapted  to  each  tooth  in  the  mouth,  and  the  variety  of  these 
forms  is  now  such  that  each  different  kind  of  tooth  may  have  its  special 
forceps ;  but  for  the  general  surgeon  such  an  army  of  instruments  is  quite 
unnecessar  v . 

Dr.  Ilasbrouck,  of  ^ew  York,  who  has  for  sixteen  years  made  a  specialty 
of  extracting  teeth  with  the  aid  of  ansesthesia  induced  by  the  administration 
of  nitrous-oxide  gas,  finds  that  he  can  extract  all  the  teeth  of  both  upper  and 
under  jaws  with  but  two  pair^?  of  forceps.  With  a  forceps  of  bayonet-shape, 
with  straight  handles,  and  with  beaks  alike  of  medium  width,  every  tooth  of 
the  upper  jaw  can  be  removed  ;  and  what  is  called  the universal  lower-molar 
forceps"  may  be  used  for  all  the  teeth  of  the  lower  jaw,  provided  that  the 
blades  or  beaks  are  not  too  wide.  An  additional  set  of  two  pairs  may  be 
added  with  advantage,  viz.,  one  nearly  straight,  and  one  curved  almost  to  a 
right  angle,  both  with  quite  narrow  beaks  ;  these  are  more  appropriate  to  the 
small  teeth  above  and  below  than  the  instruments  first  described.  Any  number 
VOL.  IV. — 60 


946 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


more  than  these  will  be  absolutely  required  only  to  suit  the  fancy  of  the 
operator,  or  to  meet  some  extraordinay  occasion. 

In  extracting  any  of  the  upper  teeth,  the  best  position  is  with  the  head  of 
the  patient  against  the  left  breast  of  the  operator,  who  places  his  left  arm 
around  the  head,  and  clasps  it  by  putting  his  fingers  in  the  mouth  and  a2:ainst 
the  upper  jaw.  For  the  lower  jaw  the  operator  should  stand  behind,  with  the 
patient's  head  against  his  stomach;  thus,  with  his  left  hand  holding  the  chin 
and  his  thumb  in  the  mouth,  the  jaw  is  held  firm  while  extracting.  Many 
authors  lay  much  stress 'upon  lancing  the  gum  previous  to  the  appUcation  of 
the  forceps,  but  in  the  experience  of  those  who  have  the  largest  practice  in 
this  specialty,  lancing  is  rarely  required.  Forceps  as  now  made  have  thin 
edges,  and  m  using  them  should  always  be  firmly  forced  up  the  surface  of  the 
tooth  until  they  reach  the  alveolar  process  ;  this  act  will  drive  away  the  gum 
and  render  lancing  unnecessary.  No  special  directions  can  be  given  for  the 
manner  in  which  a  tooth  should  be  drawn,  except  that  luxation  or  rotation 
may  be  of  a  little  advantage  with  teeth  that  have  single  roots ;  but  rotation 
with  the  molars  is  impossible.  The  strength  required  and  the  direction  of 
movement  must  be  left  to  the  judgment  of  the  operator,  as  he  feels  the  neces- 
sity at  the  moment. 

Sometimes  it  is  impossible  to  extract  an  upper  molar  without  resorting  to 
an  intentional  removal  of  the  buccal  wall  of  the  alveolar  process,  but  this 
should  only  be  a  last  resort.  If,  in  the  effort  to  extract  any  tooth  that  has  a 
living  pulp  (particularly  a  molar),  it  should  be  broken  off,  the  immediate 
results  may  be  serious.  An  upper  molar  with  strong  surrounding  walls, 
broken  in  this  way,  may  be  almost  impossible  of  removal,  and  the  fractured 
and  exposed  pulp  will  cause  violent  pain.  The  best  immediate  treatment 
will  be  the  use  of  the  actual  cautery,  if  it  can  be  applied ;  otherwise,  a 
minute  quantity  of  arsenious  acid  upon  a  small  pledget  of  cotton,  dipped  in 
oil  of  cloves,  will  give  relief. 

The  removal  of  small  portions  of  the  process  accidentally,  is  not  uncommon, 
and  serious  results  need  not  be  apprehended.  .  That  which  has  come  away 
would  be  absorbed  within  a  short  time  if  it  had  been  left.  Neither  is  there 
to  be  any  danger  anticipated  from  prolonged  hemorrhage. 

Hemorrhage  for  a  few  minutes  is  to  be  expected,  but  if  profuse  and  pro- 
longed, a  plug  of  lint  with  tannin  placed  in  the  socket,  and  a  compress  to 
hold  it,  will  soon  stop  the  bleeding. 

Sound  teeth  should  never  be  extracted  to  make  way  for  artificial  ones. 
One,  two,  or  three  sound  teeth  which  are  firm  in  the  jaw,  will  be  worth 
more  for  mastication  than  all  the  artificial  substitutes  that  can  be  employed. 

Irregularities  of  the  Teeth. — With  advancing  civilization  there  is  an 
apparent  increase  of  deformities  of  the  dental  arch.  In  the  higher  social 
scale,  it  is  exceptional  to  find  a  young  person  with  a  perfectly  developed  and 
regular  row  of  teeth  set  in  a  well-formed  and  rounded  arch.  More  commonly, 
departures  from  this  type  will  be  found  of  every  grade,  more  or  less  pro- 
nounced, exhibiting  some  of  the  phases  of  narrowed  jaws,  with  teeth  pro- 
truding, overlapping,  and  crowded  in  every  conceivable  state  of  disorder. 
In  many  instances,  the  cause  has  some  direct  connection  with  other  evils 
that  seem  inseparable  from  a  state  of  high  civilization. 

A  close  observer  for  a  generation  has  seen  a  multitude  of  cases  which  had 
no  apparent  local  cause,  were  not  of  hereditary  origin,  and  could  only  be 
attributed  to  constitutional  conditions  developed  in  the  individual.    As  a 

feneral  statement,  the  finer  the  nervous  organization— the  more  precocious,  or 
rilliant,  the  intellect — the  greater  will  be  the  tendency  to  dental  deformity. 


SURGERY  OF  THE  PERMANENT  TEETH. 


947 


The  converse  is  true  of  feeble-minded  people  who,  having  a  fair  physique, 
show  well-rounded  jaws  and  regular  dental  arches. 

Many  peculiarities  are  of  inherited  ori<jin  as  far  as  the  individual  is  con- 
<}ern«d,  but  what  may  have  caused  the  initial  departure  from  a  normal  type 
in  preceding  generations,  it  is  impossible  to  determine.  More  readily, 
perhaps,  than  any  other  deformities  of  the  human  organization,  are  dental 
irregularities  transmissible,  and  departures  from  a  normal  type  in  the 
parents  reappear  in  the  children  in  an  exaggerated  form. 

Irregularities  that  requ-ire  treatment  are  never  seen  in  tlie  deciduous  teeth. 
The  deciduous  dental  arch  is  always  well  formed  and  symmetrical.  It  is 
only  in  the  second  set  that  deformities  make  their  appearance ;  and  it  is 
exceptional  that  such  peculiarities  can  be  foreseen  and  prevented.  It  can- 
not be  determined  with  any  certainty,  before  eruption,  that  a  dental  arch  is 
going  to  be  abnormal,  the  causes  being  generally  hidden  and  remote. 

The  normal  type  of  the  dental  arch  describes  a  regular  line ;  the  arch  may 
be  wider  or  narrower,  varying  somewhat  in  individuals  or  races,  but  the  line 
will  be  an  easy,  graceful  curve,  without  break  or  tendency  to  form  an  angle. 
Within  certain  limits,  a  narrow  dental  arch,  as  associated  with  certain  fea- 
tures, may  become  the  perfection  ot  beauty;  while  with  another  form  of  head 
and  face,  the  widest  development  may  be  equally  pleasing.  That  which  is 
recognized  now*as  the  standard  or  full  measure  of  beauty,  as  well  as  ot  utility, 
is  not  unlike  that  which  existed  in  the  remotest  historic  ages,  nor  different 
from  that  which  is  now  exhibited  among  all  communities  not  degenerated 
by  luxury  or  vice. 

Abnormalities  include  such  a  shape  of  the  arch  as  is  not  in  harmony  with 
the  surrounding  features,  all  crowding  and  twisting  of  the  teeth,  and  all 
departures  from  a  regular  line  in  their  positions.  One  form  of  irregularity 
seems  to  be  due  to  unwise  or  premature  extraction  of  the  deciduous  canines 
of  the  upper  jaw.  In  the  ordinary  course  of  nature,  these  teeth  should  be  the 
last  to  drop  out.  If  extracted  long  anterior  to  their  period  of  shedding,  the 
permanent  bicuspids  arc  liable  to  encroach  upon  the  domain  of  the  canines, 
and  thus  deprive  them  of  their  place  in  the  arch.  Such  a  malposition  can 
be  foreseen  and  prevented.  Another  abnormality  of  the  superior  dental  arch 
which  can  be  prevented  is  the  result  of  thumb-sucking,  or  its  equivalent,  in 
the  earlier  years  of  childhood.  The  effect  of  this  habit  is  to  protrude  all 
the  teeth  in  the  front  part  of  the  mouth.  This  deformity  will  not  show^ 
itself  until  the  eruption  of  the  permanent  teeth,  sometimes  even  after  the 
practice  which  caused  it  may  have  ceased.^  But  a  large  proportion  of  dental 
irregularities  cannot  be  predetermined  with  certainty,  even  where  there  is  an 
hereditary  tendency,  and  can  be  corrected  only  when  they  develop.  An 
observer  with  limited  experience  may  often  be  misled  by  the  appearance  of 
teeth  as  they  first  erupt.  The^^  may  seem  to  be  growing  out  of  the  line  of 
the  arch,  and  it  may  be  thought  that  a  permanent  irregularity  is  inevitable. 
But  many  such  cases  need  no  interference  ;  if  left  to  themselves  the  teeth  will 
acquire  regularity,  and  wnll  often  assume  their  true  places  unless  the  occlusion 
of  the  antagonizing  teeth  prevents  them. 

But  interference  is  demanded  as  soon  after  eruption  as  it  becomes  certain 
that  a  deformity  is  inevitable.  There  is  then  no  longer  justification  for 
delay,  for  r<t'ter  that  period  every  year  increases  the  difficulties,  both  patho- 
logical and  mechanical,  and  prejudices  the  stability  of  the  dental  apparatus. 
But  all  irregularities  in  the  position  of  the  teeth  are  not  deformities  which 


^  In  one  instance  which  came  under  the  author's  observation,  a  mother  of  good  social  position 
had  nursed  from  her  breast  a  daughter  until  the  latter  was  nine  years  old,  the  result  being  that 
the  girl's  six  upper  front  teeth  were  protruding  so  that  her  lips  could  not  be  closed. 


948 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


demand  treatment ;  there  are  many  departures  from  a  normal  type  where 
neither  the  utility  nor  the  beauty  of  these  organs,  nor  the  symmetry  of  sur- 
rounding "features,  is  seriously  affected  by  the  malposition.  "  The  regulation 
of  teeth,  moreover,  often  involves  the  wearing  of  fixtures  which  cannot  be 
removed  and  cleansed  as  frequently  as  the  health  of  the  mouth  demands ; 
their  continued  presence  may  provoke  caries  of  the  teeth ;  and  prolonged 
treatment  may  seriously  injure  the  nervous  system  ;  wherefore  the  regulation 
of  teeth  should  not  be  undertaken  without  due  consideration. 

Regulation  of  teeth  may  be  undertaken,  under  favorable  circumstances,  at 
any  age  short  of  full  maturity;  but,  all  things  considered,  the  most  desirable 
period  to  begin  the  correction  of  an  extensive  irregularity,  is  when  the  cus- 
pidati  and  second  molars  are  fully  erupted.  The  occlusion  of  the  teeth 
is  an  important  factor  in  determining  the  permanency  of  the  change.  All 
attemps  at  correction,  at  any  age,  will  be  futile,  unless  the  antagonizing  teeth^ 
upon  occlusion,  will  serve  to  hold  the  displaced  teeth  in  their'new  positions. 
Success  in  treatment  is  based  upon  the  fact  that  the  teeth  are  placed  upon  the 
maxillse,  surrounded  by  vascular,  elastic,  bony  processes,  which  are  easily 
moved  or  absorbed  under  pressure,  and  that  reproduction  of  bone  will  follow, 
and  will  make  the  teeth  solid  in  their  new  locations.  The  possibilities 
under  favorable  conditions,  within  certain  limits,  are  almost  unbounded, 
is'arrow  jaws  may  be  widened,  protruding  jaws  made  to  recede,  individual 
teeth  moved  considerable  distances,  and  teeth  elongated  or  shortened,  or 
twisted  in  their  sockets.  The  success  of  skilful  efforts  in  this  direction  has 
been  triumphant. 

Some  of  the  most  marked  cases  are  where  the  face  is  deformed  by  a  pro- 
truding or  receding  jaw,  either  upper  or  low^er.  Strictly  speaking,  when  this 
occurs  with  the  upper  jaw,  it  is  not  the  maxilla  which  is  at  fault,  but  rather 
the  whole  dental  arch.  Such  a  condition  in  the  lower  jaw  is  more  likely  to 
arise  from  a  defective  articulation  at  the  joint,  but  in  either  case,  when  taken 
at  the  proper  age,  it  is  quite  amenable  to  treatment.  It  is  not  always  advis- 
able to  attempt  to  alter  the  form  and  expression  of  a  mouth  where  the 
condition  is  an  inherited  peculiarity — a  part  of  the  family  type — and  W'here 
the  change  would  involve  prolonged  effort,  with  possible  breaking  up  of  a. 
good  articulation  of  masticating  organs,  and  with  the  knowledge  that  nature 
will  be  constantly  making  an  effort  to  return  to  the  hereditary  type.  In 
hereditary  cases  of  extensive  deformity,  in  which  interference  has  been  de- 
layed until  at  or  near  maturity,  we  can  never  feel  certain  but  that  the 
original  tendency  to  malposition,  so  long  unbroken,  may  reassert  itself  at  any 
time  that  we  abandon  the  use  of  retaining  fixtures. 

Upon  general  principles  it  is  desirable  to  retain  every  sound  tooth  in  the 
mouth,  yet  there  are  many  cases  of  crowded  dentition  where  the  removal  of 
a  tooth  upon  each  side  of  the  jaw  is  justifiable.  The  retention  of  every  tooth 
in  the  mouth  is  not  necessary  to  the  efficiency  of  the  masticating  apparatus, 
and  is  not  required  to  maintain  the  contour  of  the  jaw,  while  the  loss  of  cer- 
tain teeth  produces  no  visible  external  effect. 

The  articulation  of  masticating  organs  is  of  more  importance  than  their 
number,  and  a  limited  number  of  grinding  teeth,  fitting  closely  upon  occlu- 
sion, will  be  of  greater  benefit  to  the  individual  than  a  mouth  full  of  teeth 
with  their  articulation  disturbed. 

The  treatment  of  irregularities  is  almost  entirely  mechanical.  To  the  ana- 
tomical, physiological,  and  pathological  knowledge  required  of  the  operator^ 
there  must  be  added  a  knowledge  of  mechanical  science,  and  the  ingenuity  to 
appl}^  it.  Levers,  pulleys,  inclined  planes,  wedges,  and  elastics,  singly  and  in 
combination,  are  required  for  this  purpose.    It  is  quite  impossible  for  any 


SURGERY  OF  THE  PERMANENT  TEETH. 


949 


one  to  overcome  a  complicated  dental  irregularity,  who  has  not  a  compre- 
hension of  each  and  all  of  these  instrumentalities. 

As  far  as  pressure  itself  is  concerned,  it  is  immaterial  from  whence  it  is 
derived.  The  same  weight,  force,  or  power  will  produce  the  same  result. 
It  is  only  a  matter  of  convenience  what  source  shall  be  employed.  For 
widenino'  a  narrowed  arch,  a  jackscrew  is  the  most  effective  means,  and  can 
be  used  to  spread  one  tooth  only,  or  all  the  teeth  upon  both  sides  according 
as  it  is  applied.  Wedges  driven  between  the  teeth  will  enlarge  the  arch. 
Levers,  with  elastics,  are  used  to  twist  teeth  in  their  sockets,  and  an  inclined 
plane  can  be  made  to  move  teeth  laterally.  The  application  of  such  appa- 
ratus to  effect  the  movement  of  teeth,  is  one  of  the  most  responsible  duties  the 
dentist  is  called  upon  to  perform.  Each  and  every  one  of  these  mechanical 
powers  can  be  made  to  do  his  bidding,  and  equally  each  one  of  them  may 
become  a  formidable  engine  of  disaster.  When  applied  to  the  mouth,  they 
should  have  constant  watchfulness  and  care.  Not  one  of  them  but,  in  the 
hands  of  an  empiric,  may  cause  the  destruction  of  those  valuable  organs  which, 
when  skilfully  used,  they  can  be  made  to  conserve. 

Dental  Caries. —Caries  of  the  teeth  depends  on  a  constitutional  condition 
wliich  originates  in  an  impairment  of  function,  either  in  the  individual  or  in 
his  ancestors ;  consequently,  on  a  condition  which  is  common  among  highly 
civilized,  and  correspondingly  rare  among  savage  races.  Civilization  bears 
the  same  relation  to  caries  of  the  teeth,  that  it  does  to  other  diseases  which 
are  incidental  to,  and  the  outgrowth  .of,  a  violation  of  hygienic  laws.  In  a 
strono;  and  healthy  organization,  where  there  is  no  inherited  predisposition 
to  caries  shown  in  a  defective  organic  structure,  teeth  will  not  decay  except- 
ino-  from  want  of  nutrition  arising  from  functional  disturbance. 

Like  any  other  tissue  of  the  body,  the  teeth  require  constant  nutrition,  or 
they  will  yield  to  external  agents;  but  unlike  other  tissues,  repair  will  not 
follow  the  return  of  nutrition.  Excepting  for  defective  nutrition,  teetli  of 
good  organization,  in  a  healthy  body,  will  remain  sound  for  a  lifetime  with- 
out care^;  while  teeth  with  an  inherited  frail  organization,  and  easily  liable 
to  decay,  may  resist  for  a  lifetime  adverse  influences,  by  the  aid  of  constant 
supervision  and  attention  to  bodily  health. 

Microscopic  investio;ation  shows  that  the  organic  matter  of  a  tooth  forms 
a  reticular  network,  which  traverses  the  entire  structure,  dentine,  cementuni, 
and  enamel  inclusive.  It  forms  the  matrix  of  the  lime  salts,  and  is  the  vehi- 
cle for  the  nourishment  of  the  organism.  Caries  is  lu  solution  of  the  lime 
salts,  oria:iiiating  always  from  outside  influences  favored  by  a  congenitally 
frail  organization,  or  by  an  acquired  state  of  diverted  or  impaired  nutrition. 

External  agents  of  an  acid  character  are  the  sole  local  cause  of  decay,  aiid 
by  far  the  greater  part  of  this  decalcification  is  caused  by  acids  produced  iii 
the  mouth  by  fermentation— lactic,  acetic,  butyric,  etc.  All  electrical  con- 
ditions found  associated  with  decay,  as  well  as  the  presence  of  bacteria,  micro- 
cocci, or  leptothrix,  do  not  constitute  causes,  but  are  incidental  results. 

Micro-organisms  are  always  present  in  carious  dentine,  but  it  is  very 
doubtful  if  they  have  the  ability  to  penetrate  beyond  the  layer  of  tissue 
softened  by  acids.  In  healthy  conditions  the  saliva  is  alkaline,  while  the 
secretions  of  the  mucous  membrane  are  acid ;  but  the  teeth  do  not  suffer 
from  this  acidity,  because  it  is  neutralized  by  the  saliva,  whereas  in  an 
unhealthy  condition  the  mucous  secretions  may  be  m  excess,  or  the  saliva 
may  become  acid.  Food  in  its  fermentative  stages,  between  the  teeth,  may 
contribute  to  this  state.  Starchy  foods  are  found  to  give  decided  acidity, 
^vhile  animal  food  gives  an  alkaline  or  neutral  reaction.  The  vulnerable 
points  are  found  in  fissures  of  the  enamel  in  defectively  formed  teeth,  which 


950 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


permit  the  entrance  of  decomposing  agents.  In  well-formed  teeth,  caries  is. 
most  likely  to  begin  upon  the  adjoining  surfaces,  where  food  has  lodged  and 
fermentation  ensued.  Caries  in  the  beginning  is  almost  always  circumscribed 
and  local,  its  progress  being  along  the  line  of  the  dentinal  tubuli,  in  the 
direction  of  the  pulp,  and  more  rapid  in  the  dentine  than  in  the  enamel, 
because  of  its  higher  organization. 

The  teeth  most  liable  to  decay  are  the  bicuspids  and  molars,  upon  their 
adjoining  surfaces ;  and  those  least  liable  are  the  six  front  teeth  upon  the 
lower  jaw,  with  the  canines  of  the  upper  jaw. 

There  is  another  manifestation  of  caries,  differing  from  that  already  de- 
scribed, which  fortunately  is  not  very  common,  but  which  is  equally  disas- 
trous in  its  results  and  more  difficult  to  combat.  It  shows  itself  in  a  general 
wasting  of  the  buccal  or  labial  surfaces  of  the  teeth,  sometimes  forming  great 
horizontal  grooves  near  the  gum,  with  clean  polished  surfaces,  and  with  no- 
trace  of  decomposed  dentine. 

The  usual  treatment  of  circumscribed  caries  is  here  seldom  applicable. 
The  cause  appears  to  be  systemic,  and  the  w^asting  can  only  be  arrested  by  a 
change  in  the  general  tone  of  the  system ;  local  and  topical  remedies  are  of 
little  avail. 

Treatrnent  of  Caries. — This  is  almost  exclusively  surgical  and  mechanical ; 
medical  remedies,  independent  of  other  treatment,  are  of  little  value.  In 
some  exceptional  cases  of  shallow,  superficial  decay,  if  the  affected  part  be 
removed  with  proper  instruments,  until  sound  dentine  is  reached,  and  if  the 
new  surface  be  polished,  decay  will  not  again  set  in.  But  probably  in  not  one 
case  in  a  thousand  treated  in  this  way,  can  caries  be  prevented  from  reap- 
pearing. As  a  general  statement,  there  is  only  one  course  now  known  which 
can  be  regarded  as  effectual,  viz.,  to  cut  out  the  aflected  part  and  replace  it 
with  some  indestructible  material  which  will  close  the  orifice  of  the  cavity 
absolutely. 

The  choice  of  the  material  to  be  used  is  of  secondary  importance.  An}'- 
thing  which  will  be  permanent  and  fluid-tight  will  meet  the  conditions,  but 
some  substances  which  have  been  used  are  much  better  suited  to  the  purjiose 
than  others. 

Gold,  tin,  amalgam,  gutta-percha,  and  plastic  materials,  such  as  the  oxy- 
chloride  and  oxyphosphate  of  zinc,  are  in  common  use.  iN'one  of  these  sub- 
stances, unless  possibly  the  above-named  plastic  articles,  possess  any  medicinal 
power  upon  tooth  structure :  the  benefits  derived  from  their  use  are  purely 
mechanical — their  office  is  solely  to  make  a  tight  plug. 

Gold  in  the  form  of  foil  or  crystals  has  proven  to  be,  in  accessible  cavities 
with  strong  walls,  the  best  material.  It  will  make  a  filling  against  which  no 
objection  can  be  urged,  except  its  color,  and  even  in  that  respect  it  harmonizes 
better  with  tooth-structure  than  any  of  the  other  materials  named.  Some  of 
the  efforts  of  operators  in  gold  have  been  marvels  of  skill ;  by  the  aggregation 
of  small  particles,  welded  together  as  the  work  proceeds,  whole  crowns  of  teeth 
have  been  built  up  of  pure  gold.  The  discovery  of  the  cohesive  property  of 
gold  is  due  to  dentistry.  But  for  a  large  class  of  cases  gold  is  not  applicable, 
and  if  used  may  prove  to  be  the  worst  material.  For  large  cavities,  its  intro- 
duction involves  great  expenditure  of  time  and  force,  to  condense  the  filling 
properly,  and  consequently  great  danger  of  injuring  frail  walls.  In  the  hands 
of  injudicious  though  skilful  manipulators,  gold  has  frequently  been  pro- 
ductive of  more  harm  than  good.  Frail  walls  have  been  weakened  and 
shattered,  and  sooner  or  later  disintegration  of  tooth-structure  has  ensued  and 
the  tooth  been  sacrificed.  To  some  of  the  methods  of  using  gold  is  attribu- 
table much  of  the  damage  that  has  occurred.  After  the  discovery  that  gold 
could  be  welded  under  pressure,  the  mallet  came  into  general  use  for  condens- 


SURGERY  OF  THE  PERMANENT  TEETH.  ^^1 


inff  the  mass,  and  each  particle  of  gold  was  hammered  into  solidity  as  it  was 
introduced  ;  automatic  mallets,  electric  mallets,  and  mallets  run  by  machinery 
were  introduced,  but  by  whatever  force  the  mallet  was  propelled,  there  is 
no  doubt  of  the  injury  which  it  caused,  unless  used  with  exceeding  caution. 
A  mallet  is  really  umiecessary  to  the  perfection  of  any  filling.  ' 

The  only  advantage  that  tin  has  over  gold,  is  that  it  is  cheaper  and  can  be 
introduced  with  less  skill,  but  it  is  not  as  durable  as  gold,  because  in  time  it 
becomes  completely  oxidized.  .     ,    x-      v  ^ 

Amalgam  is  now  used  under  various  names  to  disguise  the  tact  that  mercury 
forms  one  of  its  principal  ingredients.  Its  composition  is  of  silver  and  tin, 
about  eijual  parts,  alloyed  and^iade  into  tilings.  Tliese  tilings  are  softened  and 
amalcramated  with  mercury,  which  gives  the  mass  the  property  of  setting  or 
crystallizing  in  a  short  time,  and  becoming  a  piece  of  dense,  solid  metal. 

A  very  small  percentage  of  gold  or  platinum,  or  of  botli,  is  sometimes  added, 
and  the  mixture  is  called gold  and  platinum  alloy;"  but  the  addition  of  these 
metals  does  not  give  the  composition  any  appreciable  quality,  and  by  whatever 
name  it  may  be  Called,  it  is  simply  an  amalgam.  Very  exhaustive  experiments 
have  been  made  within  a  few  years,  and  all  the  resources  ot  science  have  been 
brouo-ht  to  bear,  to  improve  this  tilling  material,  until,  as  now  made,  it  has  all 
the  <?ood  qualities  that  are  ever  likely  to  be  obtained.  The  best  article  will 
not  tarnish  in  the  mouth,  and  will  not  shrink,  and,  excepting  its  color,  seems 
to  be  as  near  a  perfect  metallic  tilling  as  is  likely  to  be  found.  Although  the 
color  is  a  steel-gray,  which  it  will  retain,  it  is  not  a  color  that  harmonizes  as 
well  with  tooth-substance  as  that  of  gold,  and  is  not  as  well  adapted  for  fillings 
wdiich  are  exposed  to  sight.  The  great  advantage  of  amalgam  is  the  readiness 
and  certainty  with  which  it  can  be  used,  and  its  indestructibility.  ^  :N'o  tooth 
has  ever  been  made  weaker  by  its  introduction.  At  certain  }»eriods  much 
prejudice  has  existed  against  the  use  of  amalgam  for  a  filling,  because  it  con- 
tains mercury,  but  the  observations  of  all  unbiased  practitioners,  together 
with  the  most  critical  tests  which  can  be  made,  show  that  this  prejudice  is 
groundless. 

Gutta-percha  is  one  of  the  best  substances  for  filling  teeth  that  has  ever 
been  discovered.  The  preparation  employed  is  made  by  bleaching  the  gum, 
and  adding  a  small  percentage  of  mineral  substance,  thoroughly  incorporated. 
For  very  large  cavities  upon  the  adjoining  surfaces  of  the  teeth,  which  reach 
under  the  gum,  it  has  no  equal.  It  is  tolerated  by  the  gum  in  contact  with 
it  as  no  other  material  is.  It  is  not  difficult  of  introduction,  will  not  weaken 
a  tooth  in  its  application,  and  is  insoluble.  The  objection  to  it  is  that  it  will 
not  bear  the  abrasion  to  which  a  filling  upon  the  grinding  surfaces  is  subjected. 
Nevertheless,  it  is  probable  that  if  every  filling  which  has  heretofore  been 
made  of  gold  had  been  made  of  gutta-percha  instead,  more  teeth  would  hav-e 
been  permanently  saved. 

Two  other  preparations  in  common  use  are  worthy  of  mention  :  the  so-called 

oxychloride  of  zinc"  and  "  oxyphosphate  of  zinc."  They  are  prepared  by 
first  roasting  the  oxide  of  zinc  of  commerce,  grinding,  and  then  mixing, 
for  one  with  muriate  of  zinc,  and  for  the  other  w4th  phosphoric  acid.  The 
zinc,  being  in  a  fine  powder,  when  mixed  forms  a  paste  which  sets  almost 
instantly,'and  which  makes  a  very  hard  substance,  only  soluble  in  the  fluids 
of  the  mouth  to  a  moderate  extent.  These  are  valuable  preparations,  particu- 
larly the  "  oxyphosphate"  which  seems  to  exert  a  medicinal  influence  upon  the 
pulp  of  a  tooth  and  upon  supersensitive  dentine.  For  fillings  in  children's 
teeth,  it  seems  to  be  w^ell  adapted.  It  is  also  of  especial  value  in  large  cavi- 
ties near  exposed  pulp,  wdiere  it  may  nearly  fill  the  cavity  and  be  finished 
out  with  o-old.  •    1  • 

The  preparation  of  a  cavity  for  filling  requires  delicate  manipulation,  in 


952 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


removing  the  decay,  and  in  shaping  the  cavity  so  as  to  assist  in  the  retention 
of  the  filling.  All  that  portion  about  the  orifice  which  is  decayed  must  be 
removed  until  sound  structure  is  reached. 

It  is  prudent  to  remove  all  softened  dentine  from  the  cavity,  if  it  can  be 
done  without  exposing  the  pulp,  but  it  is  very  imprudent  and  unnecessary  to 
remove  all  the  softened  dentine  from  the  bottom  of  the  cavity,  if  in  so  'doing 
pulp-exposure  is  liable  to  occur.  If  any  decay  be  permitted  to  remain,  it 
should  be  treated  antiseptically  before  the  filling  is  introduced,  and  recalcifi- 
cation  of  that  portion  may  be  expected.  When  caries  has  advanced  to  the 
stage  in  which  the  pulp  is  irritated  or  inflamed,  grave  difiiculties  may  be  en- 
countered. It  is  not  yet  settled  what  is  the  best  treatment  to  pursue  in  all 
cases. 

The  earlier  practitioners  made  no  attempt  to  save  a  tooth  after  the  pulp  had 
become  exposed.  It  was  sacrificed  to  the  forceps.  This  plan  has  been  followed 
for  a  generation  by  that  of  destroying  the  pulp,  removing  it,  and  filling  the 
vacancy  even  to  the  apex  of  the  roots.  The  destruction  of  the  pulp  is  bro\ight 
about;  in  almost  all  cases,  "by  the  application  of  arsenious  acid.  The  usual 
course  is  to  make  a  paste  of  the  arsenic  with  sulphate  of  morphia  and  a  little 
creasote;  a  minute  quantity,  less  in  bulk  than  a  small  pin's  head,  is  sufii- 
cient  to  devitalize  a  pulp;  if,  however,  after  two  or  three  days,  sensation  still 
remain,  the  application  may  be  repeated.  At  as  early  a  date  as  possible 
after  sensation  ceases,  the  pulp  should  be  removed.  Small  Swiss  broaches 
which  have  been  barbed,  will  enable  the  operator  to  do  this  in  most  cases  of 
single-root  teeth,  but  with  the  molars  it  is  doubtful  if  every  shred  from  each 
root  is  always  removed.  After  as  thorough  a  removal  as  possible,  the 
remains,  if  any,  should  be  treated  with  creasote,  and  the  cavities  immediately 
filled.  Occasionally  an  operator  may  be  found  who  will  extirpate  a  pulp 
without,  the  previous  application  of  arsenic,  but  the  treatment,  while  sanc- 
tioned by  sound  philosophy,  is  too  heroic  to  be  put  into  general  practice. 
Within  a  few  years,  an  outcry  has  been  made  against  the  devitalization  of 
pulps,  even  after  exposure  ;  or,  if  pulpitis  has  occurred,  the  practice  of  attempt- 
ing to  restore  them  to  health  and  usefulness  is  advocated.  The  method  is  to 
remove  with  much  care  all  extraneous  matter  from  contact  with  the  pulp, 
and  cap  it  in  such  a  way  that  the  superincumbent  filling  will  not  impinge 
upon  it.  A  favorite  plan  is  to  make  a  thin  paste  of  oxy phosphate  of  zinc, 
gently  bring  it  in  contact,  and  allow  it  to  set,  before  the  filling  of  the  main 
cavity  is  undertaken.  But  the  results  have  been  far  from  generally  success- 
ful, and  it  is  still  doubtful  if  it  be  the  better  practice  in  most  cases  to  attempt 
to  retain  the  pulp  alive. 

Before  the  introduction  of  any  filling,  the  cavity  should  be  made  perfectly 
dry,  and  kept  so  during  the  entire  operation.  This  can  be  done  by  taking  a 
piece  of  bandage-rubber,  punching  a  small  hole  in  it,  and  slipping  it  over  the 
tooth.  Another  important  result  is  obtained  by  using  this  sheet-rubber 
even  before  the  excavation  of  the  cavity  is  begun.  Softened  dentine  is  hyper- 
sensitive ;  in  sound  dentine  there  is  rarely  any  painful  sensation  from  cutting, 
but  decalcified  dentine  seems  to  be  in  a  state  of  inflammation,  and  is  easily 
irritated ;  by  using  the  rubber-dam,  as  before  intimated,  the  cavity  of  decay 
can  be  made  dry  by  absorbents  and  by  a  jet  of  warm  air;  the  complete  drying 
of  the  irritkble  dentine  destroys  its  sensibility.  This  is  found  to  be  the  most 
successful  method  of  obtunding  the  sensitiveness  of  dentine,  as  almost  every 
other  means  fails.  Occasionally,  an  application  of  some  escharotic  appears 
to  act  beneficially,  but  long  experience  has  shown  these  to  be  so  unreliable 
that  there  is  little  use  in  resorting  to  them.  Dentine  is  usually  most  sensi- 
tive when  it  borders  upon  the  enamel,  and  least  so  in  larger  cavities  as  decay 
approaches  the  pulp.    Free  access  to  cavities  is  necessary  to  insure  success 


SURGERY  OF  THE  PERMANENT  TEETH.  9o3 


.  £11-  +v.^r..  onrl  ViPnoo  if  cavities  occur  upon  adjoining  surfaces  of  teeth 
"^SlM^^^i^  ".-t  be  .nad^.  Fi/ing  teeth  fo-uch  a  pur- 
pose is  almost  always  unjustitiable.  Space  ca.i  be  luade  by  wedguig.  \V  ood, 
cotton  or  rubber  nxay  U  used  for  wedges,  and  in  a  few  days  suthcien  space 
wUl  gained  for  opirating.  The  teeth  will  resume  their  positions  after  the 
wedge  is  removed. 

Tooth ACHE.-This  arises  more  frequently  from  an  exposed  pulp  than  from 
anv  other  cause.  The  next  most  frequent  source  of  toothache  is  m  the  invest- 
in^  membrane  of  the  root.  This  second  form  rarely  it  ever,  occurs  while  the 
pulp  is  Uving  and  healthy;  in  fact,  inflammation  ot  this  membrane  seems 
never  to  occu?  until  after  the  pulp,  for  some  cause  or  other,  has  died. 

Too  hache  may  arise  also  from  other  more  hidden  and  less  tangible  causes 
Os5£  ion  of  the  pulp,  exostosis  of  the  root,  and  the  formation  ot  so-called 
mlD  stoics  are  not  uncommon  sources  of  pain.  Pain  may  be  localized  in  a 
rootMvhicht  quite  sound,  and  the  cause  may  be  discovered  to  exist  m  soine 
diseased  tooth  far  removed  from  the  aching  member.  Teniporary  i^.j  .nay 
follow  the  eating  <.f  certain  fruits  or  sweets,  which  come  into  contact  with  sen- 
sit  ve  dentine  through  some  minute  crevice  in  the  enamel ;  this  is  a  common 
occurrence  in  apparent!  v  sound  teeth,  and  such  pam  does  not  alvvays  indi- 
cate that  the  atticted  tooth  is  decayed  or  requires  filling.  Aching  teeth 
are  sometimes  only  a  symptom  of  systemic  disturbance,  and  the  cause  must 
Ten Tlooked  for  elsewhere.  Pulpitis  and  pericementitis  are,  however,  the 
chief  causes  of  this  disease.  Exposed  pulps  that  have  not  taken  on  an  ac  ive 
state  of  inflammation  may  be  relieved  of  pain  by  the  application  of  oil  of 
c  oves  creasote,  oil  of  peppermint,  laudanum,  chloroform,  tincture  of  aconite, 
nblsrfioric  acid  anu  possibly  many  other  remedies,  any  ot  which  may  be 
£pltd  to  the  exposed  pulp  by  saturating  a  small  bit  of  lint,  and  gently 

^'S^f  tht  ^e-rtLSy  to  immediately  destroy  the  pulp.  If  devi 
taliz  ition  is  desired,  a  minute  quantity  of  arsenious  acid  may  be  used  wi  h 
ei  r;  of  the  foregoing  as  a  menstruum.  Toothache  may  sometimes  be 
?e  eved  by  the  external  use  of  a  lotion  composed  of  equal  parts  ot.  chloro- 
form laudanum,  and  tincture  of  aconite,  applied  on  the  cheek  against  the 
tooth  but  particularly  using  it  immediately  behind  the  ear  ot  the  same  side 
of  the  head  A  last  resource  is  extraction,  which,  except  in  very;  rare  cases, 
h  not  iust  fiable.  In  many  cases,  neuralgia  of  the  head  and  face  is  owm^  to 
de  taUnton.  Cavities  of  the  teeth  which  do  not  reach  the  pulp  receding 
tTms  whfch  expose  roots  too  near  their  apices,  and  the  encroachment  of 
tartar  under  the  gums,  are  among  its  fruitful  causes. 

"  Anv  portion  of  the  head,  th?oat,  or  associate  parts  supplied  by  the  fifth 
nerv^  o^r  hideed  by  its  related  nerves,  may  be  the  seat  of  reflex  trouble  from 
a  dead  pu  p-thus  we  have  odonto-gastralgia,  odonto-cephalalgia,  odonto- 
ca  dTaUa  etc.;  even  sciatica  has  beeii  cured  by  the  extraction  ot  a  diW 
tooth Pain  arising  from  exostosis  cannot  be  diagnosed  with  certainty,  but 
when  it  become^  evi°lent  that  that  is  its  cause,  extraction  is  the  only  remedy 
taown  iSmentitis,  as  before  stated,  only  follows  death  ot  t l>u  |.  In 
theTarlier  sta-es  of  inflammation,  an  application  to  the  gum  ot  a.mixtuie 
of  tiroture  rf  iodine  and  tincture  of  aconite,  over  the  seat  of  pain,  may 
Sbrdt  ef ;  or  the  gum  mav  be  stippled  with  saturate.l  t  ncture  ot  iodine, 
Zs  estabHshing  mfnute  blisters.  Tins  failing,  resort  shoiild  be  had  to 
leechino-  which,  if  done  before  suppuration  has  set  m,  will  produce  the  desired 
•result  bul,  if  sJippuration  has  begun,  will  be  likely  to  aggravate  the  evil. 
If  the'  suppurative  stage  has  been  reached,  and  the  pain  continues,  poulticing 
or  lancina;  is  indicated. 


954 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


Alveolar  Abscess.— In  many  cases  of  abscess  at  the  roots  of  the  sinde 
1  '  wl^""'  may  be  reached  without  lancing,  bypassing  a  line  broach 
through  the  nerve  canal.  This  is  not  difficult  with  the  six  front  teeth,  and  is 
preferable  to  making  an  opening  through  the  gum,  unless  the  pus  have  alreadv 
made  its  way  through  the  alveolus.  Alveolar  abscesses  are  often  difficult  to 
cure,  particularly  when  there  are  no  fistulous  openings,  and  when  thev  have 
been  ot  long  standing.  Opening  into  them  through  the  canals  of  the  roots 
and  treating  them  with  antiseptics,  is  the  usual  course,  but  it  is  a  common 
experience  that  this  cure  is  but  temporary.  Latterly  iodoform  has  been 
used  in  these  cases,  and  it  is  claimed  with  perfect  success.  Oftentimes  a 
chronic  alveolar  abscess  can  only  be  cured  by  heroic  treatment,  viz.,  making 
an  openmg  through  the  gum  and  alveolus,  cutting  away  the  ulcerating  sac  at 
the  root,  and  cutting  and  scraping  away  the  devitalized  bone  in  the  imme- 
diate vicinity.  Then  cleansing  the  cavity  with  tepid  water,  to  which  a  little 
salt  has  been  added,  a  complete  cure  will  be  pretty  certain  to  follow. 

Cystic  tumors  of  the  jaw  are  of  two  kinds,  simple  and  compound  The 
lirst  show  only  expansion  of  the  bone  with  varying  fluid  or  gaseous  contents, 
beginning  as  slighfly  flattened  enlargements  on  the  side  of  either  upper  or 
lower  jaw,  and  slowly  increasing  until  they  reach  the  size  of  half  a  hickorv- 
nut,  but  seldom^  larger.  They  are  tardy  in  growth,  unaccompanied  by  pain 
and  local  m  their  origin,  their  occurrence  being  evidently  attributable  to  den- 
tal irritation.  The  gum  covering  them  always  appears  normal,  without  con- 
gestion, inflammation,  or  anything  to  indicate  its  implication  in  the  disease. 
Iheir  course  is  chronic  and  benign  in  character. 

In  some  cases,  pressure  upon  such  a  tumor  will  produce  a  parchment-like 
crackling  sound,  but  this  is  by  no  means  general,  as  the  outer  wall,  in  many 
instances,  will  be  found  upon  examination  to  be  supported  by  a  spongy  growth 
or  septa  of  bone,  too  firm  to  yield  under  any  ordinary  external  pressure  The 
term  "  spina  ventosa"  has  been  applied  to  these  cases.  Treatment  of  such  a 
cyst  IS  not  difficult.  A  crucial  incision  should  be  made  through  the  bodv  of 
the  tumor,  and  such  septa  as  exist  should  be  broken  up.  isTo  anxiety  need 
be  felt  concerning  hemorrhage.-  The  cavity  should  be  syringed  with  salt 
and  water,  or  other  slightly  stimulating  liquid,  and  stufied  withlint  saturated 
with  tincture  of  lodme.  This  will  cause  the  base  to  throw  out  granulations, 
and  the  cure  will  be  complete.  ' 

Dentigerous  cysts  are  compound  in  their  character,  showing  in  addition 
to  the  contents  of  a  simple  cyst,  elements  of  a  dental  nature,  and  owing  their 
origin  usually  to  an  impacted  or  otherwise  undeveloped  tooth  which  lies 
imbedded  in  the  jaw.  Every  impacted  tooth,  however,  does  not  lead  to  the 
formation  of  a  cyst.  Ihe  cause  of  this  condition  appears  to  be:  first  mis- 
placement or  diversion  of  a  tooth-germ,  so  that  in  its  growth  it  will  not 
emerge  from  the  gum;  and  secondly,  the  accumulation  of  serous  fluid  within 
the  dental  capsule,  which  thereby  becomes  distended,  and,  increasing  in  size 
involves  the  surrounding  tissues.  Generally  the  crowns  of  teeth  connected 
with  dentigerous  cysts  are  found  to  be  normal,  but  their  fangs  are  more  or 
less  abortive  and  defective. 

A  cyst  may  also  arise  from  an  unerupted  supernumerary  tooth.  The 
latter  can  generally  be  recognized  by  its  position  and  size,  being  seldom  larger 
than  an  ordinary  pea,  and  mostly  situated  in  the  palatine  process  of  the 
maxilla.  An  exploring  needle  will  readily  determine  its  presence,  if  used  by 
one  who  is  familiar  with  the  touch  of  tooth-substance.  Dentigerous  cysts 
sometimes  assume  a  most  formidable  character,  containing  as  their  germ 
abnormal  masses  of  dentine  and  enamel,  unrecognizable  as  belonging  to  any 


PEOTHETIC  DENTISTRY. 


955 


particular  tooth-the  distinguishing  feature  of  a  dentigerous  cyst  being 
siniDlv  the  presence  of  dental  tissue  in  some  torm  or  other 

These  cysts  may  occur  in  any  part  of  the  maxilla,  and  their  cause  and  cha- 
racter nay  be  Inferred  from  the  Absence  in  the  arch  of  a  tooth  winch  is  unde- 
veloped The  cases  are  very  rare  in  which  a  deciduous  tooth  becomes  encysted. 
The  teeth  most  frequently  found  in  this  conditio.i  are  the  superior  cuspidati, 
and  next  i^frequency  the  third  molars  ;  but  a  cyst  may  torm  about  the  crown 
of  any  impacted  and  unerupted  tooth.  The  treatment  ot  these  cases  is  sub- 
sLn  fally  ?he  same  as  that  indicated  for  a  simple  c>^t-opening,  evacu^u.ng 
the  contents,  and  removing  the  imbedded  tooth-substance,  which  is  hkcly 
to  be  foil  Kl  opposite  to  01- furthest  from  the  thinnest  part  of  the  expanded 
wall  Such  portions  of  the  bone  should  be  removed  as  may  seem  ncces- 
Tr  and  the  cavity  should  be  treated  with  tincture  of  lodme.  All  cutting 
should,  if  possible,  be  done  within  the  mouth. 


Prothetic  Dentistry. 


This  is  a  far  more  appropriate  term  to  apply  to  the  art  of  replacement 
than  the  des  tnation  of  "  michanical  dentistry"  which  this  branch  usually 
eceives  since,  strictly  speaking,  more  than  90  .1- "^^f  ^^l^^^: 
tions  performed  in  dentistry  are  purely  mechanical.  Ihe  tilling  ot  eveiN 
too  h  cavity,  with  no  matter  what  material,  belongs  to  the  art  of  replacement, 
and  l  as  much  a  mechanical  performance  as  the  construction  and  insertion 
o  artificia  teeth.  The  term  ''mechanical  dentistry;'  is  unfortunate,  too,  inas- 
mucl  as  t  mplies  that  the  requirements  for  its  practice  are  not  above  he  eve 
"f  ordinary  mechanics,  whereas  the  greatest  achievements  of  prothetic  dentistry 
demm  I  artistic  tastes  and  abilities  far  beyond  those  of  mere  mechainsm. 

Cons  dering  the  universality  of  the  need,  the  whole  range  of  medical 
science  Xd's  no  greater  boon  than  that  which  replaces  by  art  lost  organs, 
and  thus  enables  the  functions  of  the  human  economy  to  go  on  uninterrupted 
The  truth  of  this  proposition  can  only  be  realized  by  imagining  all  the 
artificial  teeth  now  worn  to  be  suddenly  destroyed,  and  the  art  ot  making 

^'^AJtifidirteeth  of  a  century  since  were  generally  carved  out  of  ivory ; 
po^ekin  teeth  were  then  unknown.  When  a  full  denture  was  requireJ,  he 
teeth  and  the  base  which  connected  them  were  carved  from  a  single  block , 
and  as  works  of  art,  in  imitation  of  nature,  some  of  these  dentures  have 
n  ler  blen  excelled.'  Another  plan  of  that  epoch  was  to  carve  a  base  o^^ 
plate  to  fit  the  gums,  and  upon  that  to  mount  the  crowns  of  i  atuial  teetii 
which  had  beeiTobtJined  from  other  sources.  Experience  soon  demonsti^ted 
that  ivory  was  subject  to  the  same  influences,  when  used  m  the  mouth,  as 
the  natural  teeth,  and  that  it  became  offensive  and  useless  from  deteriom- 
fon  and  decay,  'in  the  early  part  of  the  present  -ntury,  gold  a,ul  silver 
plates  were  substituted  for  ivory,  still  using  natural  crowns  for  teeth,  but^a. 
these  also  in  a  short  time  decayed  and  becan,e  useless,  porcelain 
introduced.  The  first  teeth  of  this  material  were  made  by  the  F'^i^^h  but 
were  exceedingly  rude  and  unsightly  ;  very  shortly  after,  that  is>.about  18.30 
American  dentists  began  their  manufacture,  and  to  day  the  art  is  carried  to 
ZosTabsolute  perfection,  and  the  American,  manutacturer  now  supplies 
almost  the  entire  demand  throughout  the  world.      ^    ,      .  ^- 

These  teeth  are  composed  of  "quartz,  feldspar,  and  clay  in  proportions  of 
about  five  parts  of  spar,  two  of  quartz,  and  less  than  one  of  clay  ground  nto 
:n  almost  Lpalpabi  powder,  mixed  mto  a  plastic  '-f' -f, 
carved  into  form.    Platinum  puis  are  inserted,  to  facilitate  then  ultimate 


V 


956 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


attachment  to  the  plates.    Teeth  and  gums  are  made  of  the  same  material 
the  difference  m  colormg  being  due  to  enamels.    These  moulded  forms  are 
subjected  to  a  heat  of  more  than  2000°  F.,  to  vitrify  them  and  develon  their 
colors.  ^ 

There  are  four  chief  varieties  of  artificial  denture,  according  to  the  prin- 
ciple upon  which  they  are  inserted  and  sustained,  viz:  (1)  Pivot-teeth; 
(2  Plates  with  clasps;  (3)  Plates  sustained  by  atmospheric  pressure;  and 
(4j  rlates  ot  simple  adaptation. 

A  PIVOT-TOOTH  is  a  single  artificial  crown,  secured  by  a  pivot  to  a  natural 
root,  and  only  applicable  where  the  crown  of  a  tooth  is  gone,  and  where  a  sound 
and  healthy  root,  to  which  the  artificial  crown  can  be  attached,  remains  in 
the  jaw.    ihe  use  of  pivot-teeth  is  of  very  ancient  date,  going  back  to  classic 
times,  and  possibly  earlier.    A  generation  since  they  fell  into  disuse  but 
withm  a  few  years  have  been  revived,  and,  under  a  score  of  different  names 
but  applying  the  same  princiji.le,  are  now  extensively  inserted.    Where  roots 
are  sound  and  in  a  perfectly  healthy  condition,  the  adaptation  of  pivot-teeth 
IS,  when  skilfully  executed,  without  exception  the  most  convenient  and  most 
useful  for  the  patient.    Formerly  the  tooth  was  simply  fitted  to  the  root 
which  was  cut  off  close  to  the  gum,  and  secured  by  a  pivot  of  wood,  gene- 
rally of  condensed  hickory.    This  plan  fell  into  disuse,  because  the  iunction 
was  never  so  perfect  but  that  the  fluids  of  the  mouth  would  act  upon  the 
root  causing  decay  and  loosening  the  pivot,  when  in  a  short  time  the  crown 
would  become  useless.    At  the  present  day,  there  is  one  plan  which  is 
entitled  above  all  others  to  a  claim  of  superiority.    It  is  to  fit  a  thin,  narrow 
band,  or  ferule,  accurately  around  the  stump,  and  to  push  it  just  under  the 
edge  of  the  gum,  and  to  this  ferule  to  attach  the  artificial  crown  by  solder- 
ing    The  ferule  protects  the  joint  and  prevents  decay.    Additional  strene-th 
is  also  given  to  the  crown  by  screwing  it  to  the  root.    Another  variation  of 
much  value  IS  to  make  the  entire  crown  of  gold,  hollow  like  a  shell  and 
fitted  to  and  over  a  stump.    This  method  is  not  applicable  to  the  front  part 
ot  the  mouth,  because  the  crowns  have  the  appearance  of  solid  gold  but  for 
the  bicuspids  and  molars  it  is  a  very  valuable  form  of  restoration  Still 
another  variation  of  this  plan  may  be  used  sometimes  with  excellent  results 
when  two  or  three  teeth  are  missing.    In  such  cases  two  crowns  are  secured 
to  the  roots,  as  above  described,  but  they  are  also  connected  with  each  other 
by  a  bridge  or  bar,  to  which  are  attached  the  other  missing  teeth.    Thus  two 
sound  roots  may  be  made  to  support  the  crowns  of  several  others.   The  advan- 
tages of  pivot-teeth  are  cleanliness,  security,  utility,  and  the  absence  of  any 
covering  to  the  natural  gums.  *^ 

Plates  with  clasps  are  applicable  to  either  jaw,  when  there  are  two  or 
more  remaining  teeth  separated  from  each  other  and  firm  in  their  sockets 
I  his  is  the  best  plan  (where  plates,  as  a  base  upon  which  to  set  the  teeth 
must  be  used)  that  can  be  devised,  wherever  admissible.  The  plate  which 
bears  the  artificial  teeth  is  sustained  by  clasping  to  the  natural  ones.  Objec- 
tions have  been  made  against  clasped  plates,  that  the  teeth  are  injured  which 
sustain  them,  but  this  objection  loses  all  its  force  when  the  work  is  skilfully 
executed.  It  is  only  bungling  and  ill-fitting  clasps  and  plates  that  do  the 
damage.  Ihe  advantages  are  that  greater  security  is  given  than  with  other 
forms  of  plates,  and  that  a  less  surface  of  the  gum  is  covered. 

Plates  held  by  atmospheric  pressure  are  the  last  resort  for  an  upper 
denture  when  all  the  natural  teeth  are  gone.  There  is  then  no  other  plan 
which  can  be  resorted  to  which  is  not  more  objectionable,  and  therefore  unne- 


PROTHETIC  DENTISTRY.  ^^"^ 


bone.  ^,,a  ^..catin-  a  detincd  cha.nbei-  ot  trom  one- halt 

trom  contact  witli  tue  '"'^'f";       ,.      ..        ^j-       ,,i.^te  were  accurately 

adapted  ^'  d      a'l  me  ^,  ^^^^  ,  would  be 

creatu.g  't.^uhe  jate  would  sustain  sucb  a  weight  betbrc  it  would  drop ;  but 
obtainec  a.    the  plate  adaptation  is  faulty  and, 

pheric  pressure  as  to  simple  adhesion. 

TTn.T  T,«.MTiiRBS  FOR  THE  LOWER  JAW  are  retained  only  by  the  accuracy  of 

of  .;ll'Tv.lm  ii,  uMms  to  the  comfort  ol  th.  p.t.ei.t. 

^^^^^^ 

have  been  tound  iisefu  .    Vulcainzed  ^ " ^^'^f Each  one  of 


958 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


or  platinum  he  only  m  cases  of  full  upper  sets,  generally  for  elderly  persons 
where  long  teeth  have  to  be  added  which,  together  with  an  artificid  gu^^ 
wh.Vh  -/-^  iF^^  weight,  and  liable  to  overcome  the  suction-powe?  by 
which  It  IS  held  in  place.  Excessive  weight  is  an  objection  in  upper  sete 
but  has  no  disadvantage  m  lower  ones,  except  for  very  old  people.^  There: 
fore  the  material  which  might  be  the  best  for  a  lower  set  might  be  the  worst 
for  an  upper  one.  ^  vvui&u 

W  cases,  save  those  named  above,  gold  or  platinum  is  much  the 

best,  for  either  partial  or  full  upper  dentures. 

Silver  possesses  some  of  the  advantages  of  gold  or  platinum,  and  is  much 
cheaper.    The  objection  to  it  is  that  it  is  not  as  strong,  not  as  durable,  and 
not  as  easily  kept  clean.    It  discolors  readily,  and  in  time  is  eaten  up  by  the 
acid  secretions  of  the  mouth.    Aluminum  is  rarely  used.    It  possesses  an 
advantage  over  other  materials  in  being  the  lightest  of  all  known  metals,  but 
there  has  not  been  sufficient  experience  with  it  in  dentistry  to  iustifV  its 
general  use.    Tin  is  a  very  valuable  metal  as  a  base  for  teeth,  especially  for  full 
lower  sets.    It  is  a  pure  metal,  not  easily  oxidized,  readily  worked,  aud  quite 
durable,    ^or  a  lower  set,  where  economy  is  necessary,  it  has  advantag-es 
over  any  other  material.    It  is  strong,  readily  repaired,  and  can  be  kept  clfan 
without  difficulty.    Since  the  discovery  of  vulcanite,  or  hard  rubber,  it  has 
been  extensively  used  as  a  base  for  artificial  teeth.    Its  popularity  has  come 
from  the  ease  with  which  an  unskilful  dentist  can  put  together  a  useful 
set  ot  teeth  upon  it  and  its  consequent  cheapness.    Its  advantages  lie  in  the 
readiness  v^ith  which  a  fit  can  be  obtained,  and  (when  not  too  clumsy  or 
bungling)  in  its  being  lighter  than  any  metal,  and  thus  admirably  adapted 
to  make  sets  for  the  upper  jaw.    The  objections  to  it  are  that  it  is  brittle, 
and,  except  when  great  thickness  is  used,  wanting  in  strength,  and  continu- 
ally  liable  to  break  down ;  that  it  is  impossible  to  repair  it  and  make  it  as 
good  as  new;  that,  being  a  non-conductor,  it  has  a  constant  tendency  to 
inflame  the  gums,  making  them  soft  and  spongy;  and  that  it  is  almost 
impossible  to  keep  it  sweet  and  clean.    The  advantage  which  its  lio-htness 
gives  It  for  an  upper  set  makes  it  equally  objectionable  in  most  easel  for  a 
lower  one. 

Recently  celluloid  has  become  a  rival  of  vulcanite.  Celluloid  is  a  com- 
bination of  cellulose  and  camphor,  and  is  of  about  the  same  strene-th, 
elasticity,  and  durability  as  vulcanite,  and  as  easily  worked.  The  onlv 
advantage  which  it  thus  far  seems  to  possess  over  vulcanite  is  in  its  translu- 
€ency  and  color,  which  is  a  close  imitation  of  that  of  the  natural  2:um :  but 
this  IS  offset  again  by  the  fact  that  in  a  little  time  it  loses  its  color  and  has 
a  dirty  look.  It  is  open  to  the  same  objection  as  vulcanite,  in  the  difficulty 
of  keeping  it  clean. 

Artificial  teeth  require  more  care  than  they  commonly  receive,  and  so  does 
the  mouth  while  they  are  being  worn.  The  idea  that  as  soon  as  the  natural 
teeth  are  gone  and  replaced  by  artificial  ones,  all  care  is  at  an  end,  is  a  falla- 
cious one.  More  care  is  required  to  keep  them  sweet,  and  the  gums  healthy, 
than  the  natural  teeth  would  have  demanded  from  the  same  person  They 
ought  not  to  be  worn  night  and  day.  Any  suction  plate,  whether  full  or 
partial,  will  injure  the  roof  of  the  mouth,  sooner  or  later,  if  constantly  worn. 
JNo  appliances  can  be  worn  in  air-tight  contact  with  any  part  of  the  human 
organization  continuously,  for  months  and  years,  without  producing  iniurions 
absorption  In  the  mouth,  the  gums  become  inflamed,  spongy,  and  diseased, 
as  the  result  of  such  contact.  This  state  of  things  is  aggravated  by  want  of 
cleanliness  on  the  part  of  the  patient.  ^        bt>  j  x 

Simply  rinsing  oft*  a  set  of  teeth  does  not  make  them  clean.    Particles  of 


PROTHETIC  DENTISTRY.  959 


food  will  accumulate  upon  the  plate,  and  in  the  crevices,  and  within  a  few 
hours  will  ferment  and  make  the  set  foul,  and  nothing  hut  a  liheral  scruhhmg 
with  a  brush,  and  often  with  some  alkaline  wash,  will  sweeten  it.  \\  itli  small 
plates,  clasped  to  adjoining  teeth,  constant  care  is  needed  to  keep  themsideot 
the  clasps  absolutely  clean,  and  also  the  natural  teeth  which  the  clasps  surround, 
or  the  teeth  will  rapidly  decay.  The  plates  which  are  least  liable  to  do  injury 
to  the  crums,  are  those  of  gold  and  platinum,  and  those  which  are  most  inju- 
rious are  of  vulcanite.  There  are  three  objections  to  vulcanite  plates,  viz. :  the 
character  of  the  material,  the  poor  workmanship  usually  employed  m  making 
them,  and  the  lack  of  care  which  is  taken  of  them.  Ihe  tirst  objection 
is  inherent  and  unavoidable;  the  second  shows  itself  m  all  cheap  work  the 
surface  which  comes  in  contact  with  the  gum  being  left  rough  and  unhnishecl ; 
and  this  makes  it  more  difficult  to  cleanse  the  plates  properly.  On  retiring 
at  nio-ht,  all  artificial  teeth  with  plates  should  be  removed  from  the  mouth 
and  tTioroughly  brushed  with  soap  and  water,  and  afterwards  scrubbed  with 
pulverized  chalk.  They  may  then  be  placed  in  a  glass  of  water  to  wliich  a 
little  common  soda  has  been  added,  and  left  until  needed  in  the  morning. 
Teeth  should  also  be  removed  and  brushed  after  each  meal,  it  the  wearer 
desires  to  meet  his  associates  without  a  foul  breath.  If  the  gums  are  inclined 
to  be  spono-y,  the  ball  of  the  thumb  should  be  wet  with  tincture  ot  myrrh, 
and  all  the'' spongy  surface  rubbed  daily  until  it  becomes  haixier. 

Bv  this  process  the  suction-power  which  keeps  an  upper  plate  in  place  will 
be  increased.  Artificial  teeth  will  not  last  a  lifetime.  The  average  period 
durino-  which  they  are  worn  without  renewal  is  but  a  tew  years,  ihis 
results  from  several  causes:  the  perishable  nature  of  the  materials  used; 
ordinary  wear  and  tear  ;  liability  to  accidents;  but  more  than  all,  the  constant 
shrinkage  of  the  gum,  which  goes  on  to  some  extent  as  long  as  lite  lasts,  and 
on  account  of  which  the  plate  loses  its  adaptation  and  usefulness. 

Methods  of  making  Artificial  Teeth.— An  impression  of  the  space 
desired  to  be  filled  is  taken  in  some  plastic  material.  Plaster  of  1  aris,  gutta- 
percha, beeswax,  and  some  composition  of  beeswax  and  various  gums,  are 
the  materials  commonly  used.  The  last  three  are  prepared  by  heating  until 
they  become  sufficiently  plastic  to  receive  an  imprint  without  disturbing  the 
soft  tissues.  Plaster  of  Paris  is  the  most  reliable  substance  for  the  purpose. 
The  best  method  of  preparation  is  to  take  the  desired  quantity  ot  water, 
and  to  drop  gently  into  it  all  the  plaster  that  the  w^ater  will  take  up.  ^  I3eat  it 
well  together  by  stirring,  thus  freeing  it  from  all  air-bubbles,  and  it  is  ready 
for  use."  If  it  is  da^irable  to  have  it  set  very  quickly,  add  a  teaspoontul  ot  salt 
to  each  pint  of  the  water  used.  Good  plaster  mixed  m  this  way  will  set  in 
about  sixty  seconds.  :  .    ^    w  -i  i? 

An  impression  made  of  plaster  of  Paris  shows  the  most  minute  details  ot 
structure.  Wash  the  impression  with  a  lather  of  soap,  rinse  it  oft,  and  pour, 
other  plaster  into  it;  an  accurate  model  of  the  parts  is  thus  obtained.  ^  W  hen 
metallic  plates  are  required,  such  a  model  is  duplicated  by  moulding  m  sand 
and  casting  zinc,  thus  making  a  die;  the  counter-die  is  made  of  lead,  and 
between  these  the  plates  are  swaged  with  a  heavy  hammer. 

A  plate  thus  made  should  fit  the  mouth  or  parts  required  accurately. 
The  teeth  are  attached  by  the  platinum  pins  which  were  baked  into  them 
at  the  time  that  they  were  made,  and  are  connected  with  the  base  by  linings 
and  solder.  A  set  of  artificial  teeth  mounted  skilfully  on  gold,  will  show  all 
the  artistic  finish  of  a  piece  of  fine  jewelry,  besides  being  so  nicely  adjusted 
to  its  place  that  it  can  be  worn  with  entire  comfort. 

The  highest  order  of  mechanical  and  artistic  talent  is  capable  ot  develop- 
ment  and  display  in  making  prothetic  apparatus  of  this  kind.    The  use  ot 


960 


SURGERY  OF  THE  TEETH  AND  ADJACENT  PARTS. 


vulcanite  or  celluloid  involves  but  little  exercise  of  the  same  abilities.  The 
method  used  for  those  substances  is  quite  difierent.  'No  dies  are  required, 
but,  instead,  the  teeth  are  arranged  upon  the  plaster  model ;  they  are  kept 
in  position  by  a  base  of  sheet -wax,  and  wax  is  also  used  to  build  up  the  form 
of  the  denture  desired.  This  form  is  inclosed  in  a  flask  and  surrounded  with 
plaster,  after  which  the  wax  is  removed  and  its  place  filled  with  rubber 
which  is  prepared  for  the  purpose.  The  rubber  is  vulcanized  at  about  320° 
Fahr.,  for  one  hour,  and  thus  becomes  a  permanently  durable  substance. 

Celluloid  is  treated  in  much  the  same  manner,  excepting  that  it  is  not  vul- 
canized, but  is  forced  into  the  shape  of  the  mould  under  great  pressure,  at 
about  the  same  temperature. 

Vulcanite  has  been  an  inestimable  boon  to  thousands  of  impecunious 
edentulous  people,  but  it  has  been  a  curse  to  "  dentistry  as  a  fine  art." 

Mechanical  Treatment  of  Lesions  of  the  Palate. 

Lesions  of  the  palate  are  either  congenital  or  acquired.  With  a  loss  of  any 
portion  of  the  palate,  whether  congenital  or  accidental,  sufiicient  to  make  a 
permanent  communication  between  the  buccal  and  nasal  cavities,  the  perfect 
articulation  of  any  spoken  language  is  impossible. 

The  chief  evil  arising  from  congenital  cleft  palate  which  demands  the  inter- 
ference of  science  and  art,  is  the  defective  articulate  speech.  The  efiect  upon 
the  speech  varies  much  with  different  individuals.  It  does  not  seem  to  depend 
upon  the  shape  or  the  extent  of  the  fissure,  or  upon  the  intellectual  status  of 
the  patient,  as  much  as  upon  some  other  influences  which  are  not  easily  deter- 
mined. No  physiologist,  however  large  his  experience,  can  tell  with  cer-« 
tainty,  by  simple  observation  of  such  a  fissure,  all  the  articulate  sounds  which 
will  be  defective. 

The  peculiarities  of  speech  shown  by  persons  with  cleft  palate,  form  a  very 
interesting  study.  In  most  cases  which  have  come  to  my  knowledge,  the 
sounds  of  K  and  G  have  been  wanting,  but  I  have  seen  other  cases  of  intel- 
ligent and  fairly  educated  people,  with  whom  every  consonant  sound  of  the 
English  language  has  been  defective  excepting  those  of  K  and  G. 

Aside  from  the  inability  to  articulate,  the  resonating  tone-power  of  both 
buccal  and  nasal  cavities  becomes  entirely  changed  by  their  partial  or  complete 
union,  or  by  the  change  in  their  form  or  dimensions,. so  that  the  speech  of 
a  person  with  cleft  palate  becomes  altered  in  tone,  indistinct  in  enunciation, 
difiSicult  and  sometimes  impossible  to  understand,  and  altogether  disagreeable. 
To  such  an  extent  has  this  condition  operated  on  sensitive  minds,  that  it  has, 
in  the  absence  of  relief,  sometimes  driven  the  sufterers  from  society,  and 
made  them  utterly  wretched. 

.  Such  an  afiliction  is  sufiicient  to  call  forth  all  the  resources  of  science  in 
producing  a  remedy.  The  only  thought  which  has  seemed  to  govern  surgeons 
in  adopting  the  operation  of  staphyloraphy,  has  been  that  a  roof  to  the  mouth 
of  natural  tissue  must  be  better  pej^  se  than  no  roof,  or  than  an  artificial  one, 
but  although  the  operation  has  been  tested  in  a  thousand  cases  by  the  most 
eminent  surgeons  of  their  time,  it  has  resulted  in  such  an  uniformity  of 
failure,  considered  as  a  beneficent  operation,  that  it  should,  in  my  judgment, 
have  been  long  ago  abandoned.  Without  a  complete  understanding  of  the 
physiology  and  function  of  the  velum  and  pharynx,  it  would  be  a  natural  sup- 
position, that,  as  there  are  evils  arising  from  a  fissured  palate,  if  the  cleft  could 
be  closed,  the  evils  would  pass  away ;  but  a  better  knowledge  of  these  functions 
in  the  mechanism  of  speech,  shows  that  it  is  impossible  to" correct  such  defects 


MECHANICAL  TREATMENT  OF  LESIONS  OF  THE  PALATE.  961 

„y  .argery,  and  a  lifetime  of  experience  has  demonstrated  tlie  correctness  of 

this  stateineat.  ^r^o^oh  \^  second  to  no  other  in  importance. 

The  ,ato.,as  a^^  ,,,,,      P      ,i  r 

It  IS  hinged  hke  a  vahe  to  ">e  e  g  i  nxnscles.    It  can  be 

border  may  be  elevated  or  JP^e-^^^^^  ^^.-^^^  ,,j,„s  of  the  pharynx, 
raised  until  it  ox.mes  i"*^  ^X^^Xtl^^^  ^aa-es,  or  it  can  be  depressed  until, 
and  thus  shuts  oil  f  P'J-^f^^*^^,  ^"ftji:^^^^^^^^^  mouth  is  stopped  ; 

meetin-  the  A^r.nm  oi  ^he  tongue  t^I      ,  ^^^^  ^^^^^^ 

or,  again,  it  may  hang  mi  W  ^^^^  j„^„th  and  nose, 

thus  sounds  emitted  from  the  ^rynx  may  p  „    ^^^^^^     ^.^.^^  ^.  .^^^^ 

But  for  the  Performance  of  the^^^^^^^^^^  ^^^^^  ^^^^^^^  ^^^H 

foration  or  fissure,  and  !»e^*^'^°,„^  ^ithout  a  cleft  lias  not  this  requ.re- 
the  pharyngeal  ^^jj'^^.  Suncl   of  articulation.    It  would  interfere 

raent,it  cannot  Pe'^o'™,;.'" '  |. 'fJ,eech  as  if  it  were  fissured,  perforated,  or  m 
as  much  with  pertect  ^^iculate  siH^ecli  a^^        dependent  in  its  perfection  not 

any  other  way  Ae  <^^^-    ^^f^tm  ""'^''^     '^'"^  ^^'V^"- 

only  upon  the  "2^«f >^  f^J^^f  ^^'eTo.terior  naiU  is  due  equally  to  the  eleva- 
geal  -^."f  '/Xand^to  ^'^^  pharyngeal 

tion  of  the  velum  palati  ana  .        ^usdes  of  the  pharynx  is  seldom 

wall.  This  ^^^^^l  ri  ^o  .^nt  oTgt  of  speec^^  nL.al  articula- 
recognized.  P£f  ^^/^^ kullte  with  abnormal  organs  it  develops  an 
tion,  and  in  the  ettoit  to  auicu  Indeed,  in  some  instances  the 

activity  and  ^  P~™;,  ^^^^  wi^h  the  tongue,  has,  i^n 

superior  constrictor  of  tlie  pnao  J    ^^.^^^^  to  make  many  sounds 

cases  of  absence  of  the  palate,  ena'ne  y  inteo-rity  of  the  latter, 

which  in  normal  articulation  'J';'^^  ^^If  the  edges  of  the 

The  failure  of  surgery  has  not  been     its  ^^^Yeen  in  the  fact,  before 

divided  velum  together,^nd  to  ge  — '       it       beei^^^^^^  .taphyloraphy 

pointed  out,  that  t^^*;  ^  cloes  not  and  cannot  be  made  to 

is  always  too  ^hort,  that  t.  P0»™  -  necessarily  be  defective,  in  spi  e 
reach  the  pharynx,  and  that  the  speeci  J  operation,  it  is 

of  the  opei-ation,^  s^^^^^  m  some  -  '-^i-^^^^^^ 

with  J^^t'fi'^b  ^ pride  hat  the  ai^^^^^        i  ^^^^^^^  including 

seeing  a  complete  f '^"f^  s^^^^^      where  before  was  a  gaping  orifice ; 

the  u  vula,  and  apparent  ^  n^^^^^^^^^         ^.^^^  ^^^^^  this  new.  palate  has  very 

and  thus  he  may  lose  sight  o  ,       ,  i  organ, owing  to  the  injury 

littlemuscularpow-erascompared  wnth  the  nm       oig    '     ^  S^j^^^ 

which  its  n--l- J^e     ver'was  Ssue  enough  to'  make  a  velum 

SXm^»cient  material 

JJrt|etit^^=a;S^ 

only  valueless  b>'.t  productive  ot  PO  t-e^  ^^^^       Jhe  ne^^_^^  ^^^^ 
rigid  curtain  which  splits  the  column  oi  soumi  lu  i 

,1„,,  h..  tee»  J«tr»Tf  by  accK 

,l„t  function  Mtoved  by  f^F''  "IffK*  ^^^^^^^         X  b..  M  it  tbvongh  . 


VOL.  IV. — 61 


9*^2  SUKGEKY  OF  THE  TEETH  AND  ADJACENT  PAKTS. 

perfect  speech  with  an  artificial  organ  upon  one  who  has  been  afflicted  from 
birth  with  the  absence  of  the  natural  organ,  and  has  grown  to  malur  tv  with 
out  the  abihty  of  distinct  utterance,  is  a  much  more  difficuuTrob^em  In 
acquired  lesions,  even  crude  appliances,  made  without  much  skil  or  ac^'racv 
are  often  beneficial ;  while  in  congenital  cases  the  full  resoui^ces  of  science 
and  the  nicest  adaptations  of  art  are  needed  to  accomplish  the  desired  i"suT 
The  partial  destruction  of  any  organ  of  speech  may  occur  after  The  acquire 

Tm    1   'r°^'  ^"'^  r*"*'  T^''       extraordinary  effort  to  overcome  the 
difficulty  by  increased  use  and  activity  of  other  or/ans  which 
supply  the  deficiency     Thus,  total  iLs  of  £echTi  itlW  th^  ~u" 
tion  of  the  hard  palate,  but  instant  restoration  will  result  upon  the 
introduction  of  proper  apparatus.    But  in  a  congenital  case  the  faculty  of 

molttk^fnll V  rr'f      ^^r'^'^'  '^^^  ^ft^'-      Introduct  on  onhl 

most  skilfully  constructed  and  scientific  appliance. 

Apparatus  fob  congenital  defects  may  be  of  two  sorts.    First  the  e-an 
may  be  filled  with  an  elastic,  movable  appliance,  so  constructed  That  it  liU 
grasp  the  remnant  of  the  velum  upon  each  side  of  the  fissure,  and  be  lifted 
depressed  by  the  movement  of  the  adjacent  muscles.  Such  an  nstrument  mu 
be  made  long  enough  to  reach  the  pharyngeal  wall  when  thaT^^n  s 
advanced  by  the  action  of  the  constrictors.  ^The  elevation  of  the  art^ficia 
palate  by  the  levatores  palati,  together  with  the  advance  of  tL  pha  ytea 
wa  1,  as  before  indicated,  will  form  a  conjunction  which  will  permit  the  per 
tect  articulation  of  oral  sounds,  while  the  nasal  sounds  will  be  heaM  whe^i'  he 
muscles  are  relaxed  and  the  voice  passes  by  the  nares.    The  second  foTin  of 

l^F^T'        TTf^l  ''''''  •^.^P^"'^^  "^•'ftl^ess  entirely  u  1  the 

ac  ivity  and  control  of  the  constrictors.  It  is  non-elastic  and  immovable  he 
par  occupying  the  cleft  is  made  bulbous,  and  with  this  bulb  the  pharyngeal 
wall  comes  into  contact  during  constriction  puaiyugeai 

The  first  form  is  applicable  to  all  congenital  clefts.  The  second  may  be 
used  where  he  superior  constrictors  are  well  developed  and  activT  ^ 

ihe  objections  to  the  first  form  are  that  the  movable  part,  being  made  of 
elastic  rubber,  must  be  renewed  from  tin>e  to  time,  and  that  tfe^.a  ien 

Ihe  objections  to  the  latter  are  that  it  is  not  always  as  certain  that  the 
IZ  J'\  'Ifl'J  '°,J'''r^'<'^^  ^-ith  it  as  with  the  elastic  instrument,  wh  ch 
ZfLX  V"-^  '  "^tural  organ  in  movement.'  With 

neither  kmd  will  perfect  articulation  follow  immediately,  but  must  be  acquired 
by  persistent  and  thoughtful  application  and  practice.  ^ 
the  intil         r  I*«/eriyed  from  the  use  of  an  artificial  palate  depends  upon 
the  intellectua  status,  the  application,  and  the  perseverance  of  the  patient 
The  responsibility  for  the  result  rests  solely  with  the  patient,  after  thi  app  : 

~teed  '^Al,  th";  ^""l  "^'''^  i"t.-oduc?d.    Results  cannof  be 

guaranteed     All  that  can  be  said  is,  that  appliances  can  be  made  which  can 
be  worn  with  freedom  from  discomfort,  and  that  a  large  number  of  person 
^Ilr^^^Z^^.^^-^  -      completely  hide^r  their  speeSi  any 

J^ttlZ!.'"''?'*'"-  ^T*"'  '■'^P'*^  '^"'^  remarkable,  in  other  cases  slow 

thtl^nTt'A  "^^''^      '^PPli^'^fion,  au  insensibility  to 

the  defect,  and  a  dulness  of  capacity  on  the  part  of  the  patient.  The  result 
must  be  accomplished  by  the  same  character  of  attention  and  training  as 
would  be  given  by  an  adult  to  the  mastery  of  a  foreign  language,  or  of  a 
musical  instrument.  &>    &  ? 

intl^nH,?„'f  ^,''1        '^"""S  ^^'"^  ^"'^'i  instruments  may  be 

introduced,  but  as  bad  habits  or  peculiarities  of  speech  become  more  and 


MECHANICAL  TREATMENT  OF  LESIONS  OF  THE  PALATE. 


963 


more  fixed  and  incurable  the  older  one  grows,  even  Avitli  normal  oro-ans,  it  is 
more  encouraging  to  begin  at  the  earliest  age  practicable.  But  little  will  be 
gained,  however," by  introducing  such  api)aratus  into  the  mouths  of  mere 
children,  before  they  are  of  an  age  to  realize  its  importance  and  to  cooperate 
with  the  efiorts  made  in  their  belialf.  As  a  general  rule,  it  is  quite  as  well 
to  await  the  eruption  of  the  twelfth-year-old  molars,  after  which  period  there 
is  but  very  slight  enlargement  of  the  jaws,  or  increase  in  the  size  of  the 
fissure. 

Acquired  lesions  of  the  palate  are  corrected  by  mechanism  far  moi-e 
readily  and  with  much  greater  certainty  than  are  the  congenital.  The  effect 
upon  speech  of  any  pertoration  of  the  palate  whicli  ])ermits  abnormal  escape 
of  sound  to  the  nasal  cavity,  is  disastrous,  but  the  remedy  comes  instan- 
taneously when  the  proper  apparatus  is  introduced.  Appliances  for  con> 
genital  cleft  tax  the  utmost  ingenuity  of  the  maker,  but  the  requirements 
for  acquired  lesions  may  be  of  very  simple  character.  Anything  which  can 
be  worn  over  or  in  the  orifice,  wdiich  will  interrupt  the  passage,  will  restore 
the  faculty  of  speech ;  so  that  the  instrument  may  be  made  of  any  of  the 
materials  used  as  a  base  for  artificial  teeth,  and  requires  to  be  but  a  coyer  or 
stopper  to  the  opening,  nicely  adjusted,  and  secured  generally  to  some  adjacent 
teeth.  In  all  lesions'of  either  the  hard  or  soft  palate  which  are  of  moderate 
extent,  and  which  do  not  reach  to  the  posterior  border  of  the  velum,  it  is 
unwise  to  permit  an  obturator  to  pass  into  tlie  opening,  thus  preventing  the 
diminution  of  the  orifice  and  its  possible  final  closure.  Small  openings  will 
sometimes  completely  close,  with  no  other  treatment  than  covering  the  orifice. 


V 


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